Surgical Suite Design guide

2010 2011 Operating Room Manual

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CHAPTER 1 THE DESIGN PROCESS

Lead Author: Cary Sweat; Architect Richmond, VA

The Mission At the core of any construction project are the issues and needs that the new facility is intended to address. This is often simplified to a statement such as an operating room (OR) suite capable of supporting a given number of cases, but the most thoughtful and effective facilities come from much more complex considerations. It is appropriate to think of a building as another tool of the health care professionals whom it serves. At its best, their facility can do much more than provide a roof under which to work. A great medical facility enables its staff, makes them more capable, and makes their work more effective. So, the most meaningful goals are essentially formalized thoughts of what is missing, broken, or inadequate in the status quo. The facility itself is to be a built response to what is limiting our medical professionals in their daily work, what new capabilities we can provide, and, certainly, how we can better address the health of our communities. Sometimes the issues to be addressed have a clear answer that simply needs to be built, but it is also perfectly valid to raise issues that have no foregone conclusion and ask that they be considered as part of the design process. In either case, the first step in responding to those needs is naming them, defining them, making them less amorphous and more tangible. Furthermore, the team members selected to fulfill the projectthe architects, engineers, interior designers, consultants, and construction contractorshave devoted their careers to understanding the myriad aspects of design and construction. They are instrumental pieces of the puzzle as translators, using their respective capabilities to turn the words of the owner into a built, real solution. And while they can propose possibilities, it is ultimately the owner who must determine the priorities. While many of the design and construction professionals have specialized expertise in medical facilities and larger trends, the health care providers themselves will have a far more intimate understanding of their own working patterns and methods. So, it is critical that each area of medical specialization be represented and involved throughout all phases of a project. Furthermore, the owner can be empowered in the process by understanding what information is most important as the project proceeds.


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Design Issues The following are some of the more common issues related to OR design. They can serve as a useful way for an owner to prioritize his/her own needs and gauge the success of built projects (both the owners own and case studies used in preliminary research). As a general statement, there is a famous axiom in the construction world: Cost, quality, time. Of these, an owner may prioritize any two, but never all three; the third will inevitably suffer for the sake of the others. That is not to say that the owner will have to accept one of these items being beyond any control; it is a three-way balancing act. While it is completely feasible to keep all three qualities in check, the owner should be aware that the degree to which one or two become extraordinarily important will have evident repercussions elsewhere. Beyond this acknowledgment, some of the more specific issues are aesthetics, design qualities, space assignment, microactivity assessment, flow, flexibility, and support. Aesthetics Aesthetics are the qualities of a project in which the value is intended to be psychological or emotional rather than directly functional (at least in any directly measurable way). Aesthetics are an admittedly tricky issue in health care work, being heavily subjective, and the ephemeral qualities of a place are often difficult to discuss in a way that can be shared and considered with the same clarity as physical fact. It is simple enough to describe the material reality of a placeits dimensions, colors, noisiness, and temperaturebut language fails when trying to describe how it feels. We are forced to speak in metaphors that are neither quantifiable nor reliable, often sounding more like a snake oil sales pitch (is there any definitive way to confirm that a given lobby is, in fact, gracious, peaceful, or inspiring?). Also, when considered strictly in the context of the core procedures being performed in an OR, aesthetic considerations can, understandably, be relegated to an unnecessary luxury (and a correspondingly difficult cost to itemize on a patients bill). Aesthetic Design Because of the issues mentioned above, aesthetic design is often limited to one of two functions: 1) decoration (e.g., a pattern in floor tile or an accent color for vinyl corner guards); or 2) marketing (e.g., the public face of a business, a built icon, etc.). But if approached with seriousness rather than frivolity, the results of aesthetics can be very real, meaningful, and even pragmatic (albeit difficult to measure). Increasingly, facilities are putting value in design qualities associated with emotional welfare, pursuing enriching environments for their patients and staff as part of an holistic approach to health care (with due care not to interfere with the professionals practice, of course). Consideration may be given to careful daylighting and connections to life outside the walls of the OR, often in lieu of luxury-priced interior materials. The degree to which an owner values these qualities has become an important factor in the selection of the design consultants and choosing where to spend the projects finances.


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Space Assignment There must be a proper assignment of spaces to support the mission of the facility. Effective space assignments must be predicated on a careful evaluation of the procedures to be performed, the projected volume of cases, and the equipment and staffing levels required. For preliminary planning, rules of thumb such as 1000 cases per OR per year or two-to-one recovery beds per OR may be used, but these should be tested against actual turnover rates and patient recovery times. Statistical databases should be used for projections if possible, but, more importantly, staff experienced in the specific operation proposed should be consulted. Microactivity Assessment The square footage, proportions, and ambient atmosphere of each space must be commensurate with the task to be accomplished in that space. This involves an analysis of the microactivity of each space and encompasses equipment; work space requirements; zoning; ergonomics; anthropometry staffing levels; patient and visitor volume; communications; life safety systems; occupational safety systems; heating, ventilating, and air conditioning systems; lighting; infection control; supplies; and maintenance. Flow There must be good flow. This is the vascular system of the facility. The importance of good flow cannot be overemphasized, and planning involves the acceptance, segregation, controlled interface, distribution, and discharge of patients, medical staff, paramedical staff, pharmaceuticals, equipment, sterile supplies, nonsterile supplies, normal refuse, biohazard (red bag) refuse, instruments, facilities engineering, and biomedical engineering. Flexibility The spaces and systems must be flexible and capable of responding to change with minimal disruption. Provisions must be made for modifications of the initial design resulting from fine-tuning, miscalculations, or medical practice evolution. Suggestions include:

Structural design to facilitate vertical or horizontal expansion Life safety design to facilitate occupancy and licensure upgrades Shell space within the facility for future internal expansions Soft space within the facility (i.e., spaces that can be used readily by adjacent spaces as

the need arises) Modular furnishings and partitions, as opposed to hard walls and millwork


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Support The design must maximize support at minimum staffing levels. With an emphasis on minimizing full-time employees and maximizing productivity, more patient and facility coverage per staff member will be needed. Centralizing functions and command points to the greatest extent possible will be mutually beneficial to patients and staff. Design suggestions include nurse station/bed station pods, shared preoperative/stage II recovery cubicles, adjacent centralized nurse work and administration stations, and computerized information transfer for charts, medical records, and supply tracking. The Players Once good design has been defined as it applies to the prospective project, consideration should be given to the entities required to plan the project. In broad terms, these are the owner, users, consultants, authorities having jurisdiction, and contractor. Owner Owner refers to the individual or collection of individuals for whom the project is being planned and constructed. The owner is the visionary who provides land, time, money, the design mission statement, and the method of project delivery. The owner may or may not be the user of the facility. Typically, the following are also included in this category, although they may be contracted to, rather than work in the direct employ of, the owner: attorneys, accountants, lenders, insurance carriers, security forces, and facilities maintenance. The owners influence and control over the planning and construction process is greatest at the projects inception and progressively diminishes over time as more and more people become involved in the process. Conversely, the owners vulnerability to cost is least at the projects inception and greatest as construction nears completion. Users Users are those individuals and groups who will occupy the facility that is to fulfill the mission statement formulated by the owner. They include executive management, administration, medical personnel, pharmacy, infection control, medical records, admitting and discharge, clinical engineering, biomedical engineering, and materials management. To fulfill the owners mission statement, the users must be committed to the project design. A communications system and incremental signoffs are crucial to progress and the users ultimate satisfaction. It is important that realistic expectations consistent with the owners original mission statement, schedule, and available resources be maintained within this group.


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Consultants Consultants are individuals or groups who are directly retained by the owner or subcontracted to another consultant or contractor depending upon the project delivery method selected by the owner. Areas of expertise in which they furnish services include marketing (e.g., demographics, statistics, and preferences), facility analysis (e.g., utilization, efficiencies, resource assessment, and time/motion studies), predesign service (e.g., code compliance, code analysis, and space programming), cost control (e.g., budget formulation and tracking), regulatory assistance (e.g., Certificate of Need [CON] assistance, health department, zoning department, and building department), planning (e.g., facilities master plan, traffic, and environmental), surveying, architecture (e.g., building and landscape), interior design, graphic design, engineering (e.g., geotechnical, civil, structural, fire protection, mechanical, electrical, and plumbing), equipment planning (e.g., medical and food services), conveyances and material handling (e.g., elevators, dumbwaiters, and track cart systems), telecommunications, data systems, and audiovisual systems. Consultants are responsible for analyzing information furnished by the owner and users and transforming that information into useful documentation that is consistent with the owners mission, appropriate design practices, and all applicable laws. It is important to recognize that consultants are mechanics who are highly skilled in assembling the parts given to them by the owner and users. In the absence of specific information, they tend to rely upon their best judgment from previous projects, but those best judgments may not coincide with the owners and users perception of good design. Hence, it is important to define good design as previously discussed and track and comment on the consultants work at each increment of planning development. Consultants have a large amount of information to coordinate and, consequently, an enormous impact upon the functional and financial success of the project. Therefore, it is essential that they have substantive experience in the project types being proposed and demonstrate solid reliability through good performance references from previous project owners. Retaining local consultants will facilitate accessibility and reduce costs, but when local talent is not available and it becomes necessary to obtain out-of-town consultants, it is advisable that they have experience in the local code jurisdiction. It is a good idea to tour as many projects as possible and solicit recommendations from the widest possible spectrum: contractors, chief executive officers, administrators, users, and the facilitys personnel. Recommendations should speak not only to the design competency of the consultant but also to costs incurred as a result of errors and/or omissions. It is advisable to tour the consultants office to ascertain personnel and equipment resources, understand methods of project delivery and construction follow-through, and see examples of communication capabilities. Many owners and users do not understand blueprints but are reluctant to admit it. It is important that the communication skills of the consultant be compatible with the owners level of design and construction expertise so that there is mutual confidence in the appropriateness of the end product.


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Authorities Having Jurisdiction There are many authorities having jurisdiction over any single project. The list that follows will vary from state to state. For example purposes, the state of Florida is referenced here and excludes agencies involved in raw land development, which, in itself, is a very time-consuming process. Authorities having jurisdiction may include:

State CON program office (not required in all states) State health department (operational licensure, plans, and construction review and

approval) State insurance commissioner and/or fire marshal State department of environmental regulation (water, air quality, extension of sewer

systems, incinerators, gas-fired boilers, asbestos, and ethylene oxide sterilizers) Regional water management district office (protected waterways and wildlife) Local planning and development department (zoning) Public utilities (water, sewer, solid waste, and electrical) Public works (traffic, storm water, and solid waste) Local building department (local building code enforcement; local fire marshal; building

permits; structural; heating, ventilation, and air conditioning; plumbing; electrical; handicap accessibility; energy consumption; and elevators)

The above entities have direct legal authority with regard to all project reviews and approvals. Project circumstances will dictate compliance as well as, potentially, specific review and approval by agencies such as:

Public lenders (federal, state, and local grant and bond and tax authorities) Private lenders (endowments, trusts, and banks) Insurance carriers (factory mutual) US Department of Justice (Americans With Disabilities Act) US Department of Labor (Occupational Safety and Health Administration) US Environmental Protection Agency (asbestos, polychlorinated biphenyls, and

carcinogens) Federal and/or state energy efficiency agencies Federal building standards (Veterans Administration, US Department of Defense, US

General Services Administration, and US Department of Health and Human Services). Organizations that have no legal mandate but whose standards must be met for voluntary accreditation include Medicare/Medicaid, the Joint Commission on Accreditation of Healthcare Organizations, and the Accreditation Association for Ambulatory Health Care, Inc. The planning process will be greatly facilitated by meeting with all the various authorities having jurisdiction at an early stage of development and keeping them in the communication loop throughout the planning and construction process.


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Contractor The contractor, although referenced in the singular, is a conglomeration of many subcontractors, tradespeople, and vendors. Frequently, in order to simplify contractual ties and provide centralized management, a general contractor is retained; the owner singularly contracts with the general contractor, who, in turn, executes and manages all other subcontracts. This arrangement simplifies the owners task because the general contractor is the single source of delivery and liability in connection with the construction of the project. The general contractor is compensated for the assumption of overall management and liability by adding overhead and profit fees onto each subcontract and the work performed by the general contractor. Costs can be reduced in proportion to the degree the owner separately contacts, manages, and assumes liability for individual tradespeople and vendors. Selection of the delivery method is an important consideration in the planning stages because some methods introduce the contractor into the planning process as it is developed, and each method requires different methods of approach and documentation. The various project delivery methods are detailed later in this article. The contractor, as transformer of drawings and words into physical construction, has tremendous influence over the quality and cost of the project. Like the consultants, it is essential that the contractor have substantive expertise in the proposed project type, demonstrate solid reliability, and have experience in the local code jurisdiction. A careful investigation into the contractors track record, including financial history, bonding capability, and past litigation, is crucial. The Process The planning process is analogous to molding and then putting together a jigsaw puzzle, but with a systematic approach. Starting with a mission statement, individual pieces with amorphous edges are developed, each contributing a fractional element to the overall design. Once the elements are defined, their proximity and continuity to each other is tested and the edges are shaped, then a continuously interlocking picture is developed. With this as a mental picture, the process is systemized as follows. Strategic Planning Strategic planning in its purest form is a written and committed goal statement in which the owner identifies target markets, assesses the products and services needed to serve the markets, compares the required resources to the available resources, and develops a step-by-step strategy to invest the additional resources over set increments of time. The strategic plan should clearly itemize the objectives and remain consistent with the philosophy of the institution it serves. This level of planning is generally executed by the founding or executive management of the health care organization with the help of outside marketing, financial, and facility analysis consultants as required to supplement the owners expertise.


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Master Planning Master planning assesses the land and facilities available to meet the strategic plan and, by written and graphic means, projects the required land use and facility expansion over set increments of time. The expansions should be ordered and located in a manner that will not impede successive expansion yet will take advantage of and maximize the utilization of existing infrastructure and resources. The steps taken in master planning generally are:

1. Evaluate the physical condition of the existing facility and its suitability for current and future uses.

2. Analyze past utilization and volume from historic data. 3. Formulate future utilization and volume projections validated against the strategic plan. 4. Update the strategic plan, if necessary. 5. Identify major planning groups (e.g., surgery, radiology, laboratory, examination,

procedures, admitting, administration, etc.). 6. Develop a program for space, identifying the square footage requirements of each

planning group. 7. Determine phasing and land usage. 8. Develop graphic blocking plans that depict planning groups and phasing. 9. Evaluate infrastructure renovations and expansions.

Certificate of Need Not every state has a CON law, and not every health care facility is subject to CON review. The CON process is mandated by individual state legislatures. The intended goal is to maintain reasonable parity between health care services provided in a region and the needs of that regions population. The process is highly bureaucratic, at times unavoidably subjective, and often subject to political pressures and challenges from both opponents and proponents. Processing of CON applications varies, but a reasonable allowance would be 5 months. Generally, the process consists of:

1. Letter of intent 2. Application:

a. Site plan b. Small-scale schematic plan c. Code compliance data d. Space-to-workload ratios e. Building program f. Cost analysis (e.g., renovation costs, new construction costs, financial feasibility,

and source of funds) g. Project schedule, including design, construction, and operations

3. Submission fee


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A reasonable allowance for preparation could be a year to a year and a half. Typically, consultants specializing in CON regulations are retained and receive support from various other consultants, such as professional estimators, planners, programmers, and architects. Building Programming Building programming involves a written analysis of how each operation in a major planning group functions and a description of the space associated with that function. Each functional space is identified and described in detail as to the number of people, number of workstations, equipment, environment, material stored and processed, functional goals, and adjacency priorities. The floor area allotted to each space at this stage will be heavily based on assumptions of sufficiency. Because it is very difficult to enlarge the areas needed for spaces as the project proceeds, it is important to consider whether there is any reason to doubt that these initial assumptions will suffice. Spaces in a department are added together to establish the net department square footage. This is multiplied by a circulation and wall factor varying from 1.20 to 1.65 to yield the gross department square footage. Ultimately, the sum of all department areas is multiplied by a factor of 1.15 to 1.35 to include exterior walls and support areas, such as mechanical services spaces, elevators, and building structure. The circulation and wall factors are derived from historic design patterns. Under the most basic contract terms, the owner will be responsible for the majority of the effort with assistance provided by the design consultant (usually the architect), but it is often shifted more to the design consultant as an additional service. Project Budgeting and Scheduling At the conclusion of building programming, a construction estimate is prepared. Generally, this estimate is based on comparative costs for other facilities of a similar scope. By contract, the designer is usually required to provide this as a basic service, but only with a relatively low degree of accuracy. Therefore, professional estimators (who may be independent specialists, employees of construction management firms, or general contractors) are commonly hired as a worthwhile additional service. The resulting total project budget should include land acquisition; building construction; equipment (e.g., medical, nonmedical, fixed, and movable); data, voice, and video systems; conveyance systems; testing; jurisdictional fees; furnishings; graphics; art; the owners services (e.g., project management salaries, office expenses, and reimbursables); professional services (e.g., estimating, surveying, geotechnical engineering, design consultants, etc.); and reasonable contingency allowances for bidding, construction, and scope creep. In addition, a project schedule, incorporating all stages of planning, design, jurisdictional reviews, and construction, is prepared.


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Project Delivery Strategy and Consultant Design Team Selection The formulation of the delivery strategy and the selection of the design consultant must be in concert with the budget and schedule. In fact, the budget and schedule should be considered as tentative until consultant selection and the delivery strategy have been determined and reviewed by the owners project management and the consultant leaders. The method of project delivery will be influenced by the following:

The scale and complexity of the project The capabilities and availability of the owners in-house design and project management

resources The owners business plan The degree of control the owner wishes to exercise over the management of the project

and the corresponding degree of risk the owner is willing to accept The magnitude and breadth of input and options the owner wishes to consider The jurisdictional review process Government and/or finance-driven restraints

Methods of project delivery include conventional design/bid/build, fast-track design/bid/build, and design/build. Conventional design/bid/build. In the conventional method, the owner contracts with the design consultants, the project is completed through contract documents, and bids are solicited. Generally, the architect serves as the lead consultant, with many, if not all, of the consultants hired as subcontractors. The responsibility for design coordination is solely delegated, or single sourced, to the architect. Construction bids are submitted on a competitive basis, with the award going to the lowest-priced or highest-valued bid allowed for in the bidding documents. The owner contracts with the chosen general contractor, who in turn subcontracts with the tradespeople required to complete the construction. This single sources the construction, coordination, and liability to the general contractor. Professional cost estimators perform cost checks to meet the budget at the conclusion of programming, schematic design, design development, and document completion. This method of delivery is advantageous because it maximizes the potential for the owners input and control in the design process and allows adjustment of the project scope before committing to a construction contract. Success of this method is highly dependent upon a complete and well-coordinated set of contract documents. If the owners in-house level of design and construction expertise is limited, consideration should be given to the program management approach. In this permutation, the program manager provides all development, management, and design services for the entire project. Program management is offered by some architects but mostly construction firms. This method relies upon the program manager becoming intimate with and being committed to the owners philosophy and strategic goals. The owners confidence in the program managers understanding of the owners objectives is crucial.


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If the owner wishes to become more directly involved in the individual trade contracts and has in-house contract management resources, then consideration should be given to the construction management approach. In this plan, the owner contracts with a construction manager at the outset of the design process to act as an agent of the owner and make recommendations in the owners best interest. The construction manager provides continuous value and cost analysis of the design as it is developed. The construction manager then solicits bids from individual trade subcontractors and assists the owner in the analysis of bids, schedules, and contracts. This method is advantageous for large projects requiring multiple-bid packages for continuously phased construction such as may be encountered in existing facilities requiring renovations and/or additions with minimal disruption to ongoing operations. Fast-track design/bid/build. In the fast-track method, it is of prime importance to expedite the construction completion. The owner contracts with a general contractor on a fixed-fee basis for the general contractors services. The design and construction documents are prepared in packages consistent with the construction sequence of the project, and the general contractor bids the packages, which are then awarded through change order additions to the general contractors contract with the owner. A variation on this method of delivery is for the owner and general contractor to agree upon accomplishing the project for the sum of the cost of the individual scope packages plus the general contractors fee, with a guaranteed maximum price. This method relies upon the owner, designer, and contractor acting in close concert to negotiate and keep the quality and quantities included in the overall scope contained within the budget maximum. Design/build. In the design/build method of delivery, the owner and general contractor agree on a guaranteed price based on the description of the project scope set forth in an owners request for proposal. All design consultants and construction trades are subcontracted to the general contractor. The advantages of this method of delivery are that the contractor has direct control over the design product and can maximize economics and scheduling to meet the dictates of the owners request for proposal. The success of this method is highly contingent upon the development of the owners request for proposal and the owners corresponding ability to live with the quality and quantity of design elements included by the design builder when those elements are not specifically addressed in the owners request for proposal.


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Schematic Design Schematic design is the graphic transformation of the written building program into spatial form. It should communicate how the designer intends to meet the owners needs at a diagrammatic level, with realistic provisions for the building systems, equipment, structure, and furniture that will be designed and selected at a later stage. Before proceeding into this phase, it is essential that the building program and budget be revalidated through formal signoff by the owner and users. If the program and budget are not acceptable, they should be reworked before further design drawing proceeds. The detailed arrangement of equipment, furniture, and cabinetry within each space is not usually developed at this stage, meaning that the areas allotted to each function by the building program will be assumed to be sufficient. If the owner sees any doubt in this regard, either by past experience or knowledge of changing space needs, it may be preferable to confirm area requirements by additional detailed design for select spaces. While such reworking will cause a delay, it may result in time, coordination, and cost economies in the long run. Schematic design is begun by studying the relative sizes and adjacencies of the functional spaces to each other. Bubble diagrams allow arrangement of the spaces that are interconnected by lines of varying line weight to depict the hierarchy of interconnectedness and scale. As these interrelationships are validated, the forms of the bubbles are molded to approximate the lines and aspect ratios of wall construction, structural column grids, and functional space proportioning. The design multipliers for circulation and infrastructure support previously applied in the building program are translated into space geometries and distributed within the interconnected bubbles. The total is then transformed into block diagrams from which hard line overlays showing the spaces, corridors, walls, and openings of the building floor plan can be generated. From this floor plan, interior and exterior elevation studies are generated for concept review and acceptance. At the same time, the relationship of the project is evaluated against its existing context through the development of a small-scale site plan. Finally, the quality of the material and systems proposed for use are organized by narrative sections in an outline specification book. This schematic design package is validated against the building program and reviewed by the project team for the owners edification and satisfaction. The schematic design, at this point, is cost-estimated for comparison to the budget, still reserving all design, construction, and scope contingencies. Again, the owners approval should be formalized by signoffs. Jurisdictional review and signoffs are recommended and may be mandatory.


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Design Development The design development fleshes out the schematic design through the creation of more numerous and larger-scale floor plans, elevations, wall sections, system details, and expanded specifications. By the end of this stage, the design team should be able to answer all questions related to how the building will be built and function, with only specific details and product selections remaining to be fulfilled. Layers of added information and coordination include:

Construction systems (e.g., foundations, superstructure, code classifications, load classifications, vibration isolation, wind, seismic resistance, and special construction)

Civil systems (e.g., utility grid, infrastructure expansion, drainage, grading, excavation, roadways, sidewalks, exterior lighting, and other site features)

Life safety systems (e.g., occupancy loads, exiting and egress, stairs, compartmentalization, fire extinguishing, alarms and initiating devices, flame spread and smoke ratings, wall construction types, and fire ratings)

Architectural systems (e.g., doors and hardware; windows; millwork; casework; plumbing fixtures; fixed equipment; movable equipment; owner-provided equipment; finishes; furnishings; ceiling materials and layout; special construction features, particularly those requiring coordination by other consultants; acoustical treatment; elevators; and conveyance systems)

Mechanical systems (e.g., heating, ventilating, and air conditioning systems; pressure zones; fire and smoke dampers and detectors; ductwork; equipment; smoke control systems; and operation sequences)

Electrical systems (e.g., fire and smoke detection, activation, and alarm systems; electrical riser and diagrams; service voltages and conductor systems; equipment; audiovisual equipment; data and telecommunications equipment; normal and emergency power systems; and lighting)

Plumbing systems (e.g., life safety fire protection equipment, plumbing equipment, risers and distribution, medial gas systems, and waste systems)

Special systems (e.g., food service, radiation protection, and owner-provided equipment)

In many instances, a book is prepared with a section devoted to each room of the building. In each section, a floor plan, ceiling plan, and all wall elevations are shown with all equipment, cabinetry, furnishings, lighting, critical dimensions, etc. In addition, a checklist of features is itemized along with special notes. Just as in schematic design, this package must be reviewed, priced, approved, and given a formal signoff. Again, jurisdictional reviews are advisable and may be mandatory.


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Contract Documents The contract documents are the legal attachments to the contract for construction between the owner and the constructor. They must fully define the scope of the work to be provided in accordance with all applicable laws and commonly accepted engineering practices and are composed of the drawings and specifications prepared by the design consultants. The drawings are organized by design discipline; the specifications are organized by a 16-division industry standard developed by the Construction Specifications Institute. These divisions are only for reference convenience because the integrated sum of the drawings and specifications represent the scope of the work. This is particularly important when the project delivery method utilizes packages, by which cost and contract aggravation can become significant owing to the increased potential for gaps in coordination responsibilities between packages. By the commencement of the contract documents phase, all of the basic design and component selection decisions should have been made. This phase represents an exponential increase in the complexity of coordination, documentation, and production work hours from all previous phases. A single sheet of drawings on average represents a minimum of 40 work hours. A single change affects an average of 20 sheets of drawings and their corresponding specifications. Changes in design during this stage can be expected to have a significant impact on corresponding costs and schedules. This being said, however, it is significantly less costly to make changes at this stage than to wait until construction. It is important that the owner remain involved in the review of the contract documents, although the emphasis will move away from the medical design team to the owners project manager and facilities and technical staff. At the conclusion of the contract documents phase, the owners technical department heads and each department to occupy the facility should receive the documents, be given ample opportunity to review them, and then review all comments or questions with the project management and consultant teams. Only with final approval of the owner should the documents then be released for final bidding and construction.


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Hints for Success

1. Become involved in the design process as early as possible, even as early as the strategic-planning phase, in order to maximize your influence.

2. Put a project manager in place as early as possible, but absolutely no later than the programming phase. It is imperative that a single source who has a detailed understanding of the owners goals and is the full-time advocate is in place.

3. Interject the right types of thinkers at the right moments of development. Basically, use your global thinkers when the process is global and your detail thinkers when the process is in its detail phase.

4. Put your managers and staff who will run the proposed facility in place as early as possible. People who will actually work in the facility will have the commitment that comes from being given a charge and knowing that they will have to live with and in it. People who do not actually have to work in the facility tend to interject their expertise from a more political and detached perspective.

5. Share concepts with and get to know jurisdictional authorities as early as possible. They are far more cooperative with teams that include them than those that regard them as an impediment or necessary evil.

6. Investigate case studies. Chances are very likely that your projects needs have already been considered by other facilities, with varying degrees of success. Learn from their experience, and pass that knowledge to the design team by either your own input or including them in the research itself.

Organize the unresolved issues as the design work proceeds from schematic to detail so that they can all be addressed and incorporated when their time comes. Doing this, the owner and users can gain confidence in the final success to come from the process. Bibliography American Institute of Architects Academy of Architecture for Health. Guidelines for Construction and Equipment of Hospital and Health Care Facilities. Washington, DC: AIA Press; 2010. Dickerman KN, ed. Florida Project Development Manual: A Guide to Planning, Design & Construction of Healthcare Facilities in the State of Florida. Jacksonville, FL: Health Facility Publishers Inc.; 1993.


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CHAPTER 2 THE ANESTHESIOLOGISTS OVERVIEW OF THE OPERATING ROOM

Lead Author: Jan Ehrenwerth, MD; Professor of Anesthesiology; Yale University; New Haven, CT

Checklist

1. A single anesthesiologist should be designated to consult with the architects throughout the design and construction process.

2. The operating room (OR) should be designed to facilitate the flow of patients, family, staff, and equipment.

3. The ORs must be large enough to permit the procedures that will occur therein. 4. The OR lighting design should consider the specific requirements of surgical procedures,

surgeons, nursing, and anesthesia personnel. 5. Adequate storage space for present and future equipment is crucial.

Security measures to control access to the operating suite and the sterile area should be considered as part of the design process. Introduction Many health care facilities are currently in the process of building new ORs, remodeling old ones, or converting existing space into general work areas (such as one-day surgicenters). Anesthesiologists are frequently called upon to participate in the design and development of the new ORs. This is important for both safety and practical reasons. Unfortunately, most anesthesiologists have little or no experience in working with architects, interpreting blueprints, or designing new ORs. It is, therefore, imperative that the anesthesiologist obtain as much advice as possible before assisting in this process. By the time the anesthesiologist is asked to participate in such a project, it is likely that many of the preliminary decisionssuch as the size of the project, the site, the budget, and selection of the architectwill already have been made. Nonetheless, it is extremely important that the anesthesiology department be prepared to participate from the outset. To facilitate that process, the department should select one of its members to represent it at the various meetings and grant to that individual decision-making authority. Although several members of the anesthesiology department may be involved in various aspects of the project, it is vitally important that one person be the spokesperson and decision maker for the entire project. That person must be aware of what is happening in every subcommittee and must be provided with the time away from clinical duties to attend the numerous meetings.


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The architects and administrators will be present at all meetings, and if a member of the anesthesiology department is not present at each meeting, decisions will be made without the departments input. Because many changes will take place during the design phase of the project, it is necessary to carefully assess and understand the impact of the changes so that any problems arising from them can be corrected at the next meeting. The anesthesia representative should have a long-term commitment to the institution because the time from the initial meeting until the completion of construction will be at least 2 and possibly as many as 8 years. Architects If possible, the spokesperson for the anesthesiology department should meet with the hospital administration prior to the selection of the architectural firm. The architect who is selected should have experience and expertise in the design and development of health care facilities, especially ORs. Because there are particular challenges unique to OR design, it should not be assumed that architects who have previously built health care facilities are capable of designing an OR. The OR is completely different from other hospital areas, and it must be designed with particular regulations and requirements in mind. It is also crucial to review the architectural firms prior work. For example, the anesthesiology department representative should speak with and/or visit members of the anesthesiology department in facilities where the architect has previously designed and built ORs. The architectural firm that is selected should have expertise in all aspects of OR design. This includes the initial planning (e.g., schematic and design development), drafting of the blueprints and room layout (e.g., floor plans, electrical, heating, ventilating and air conditioning, and plumbing coordination), and the development of the construction documents (especially development of the specifications). The firm should be able to provide examples of previous ORs it has designed and make recommendations about what has worked well in the past. The architect must deal with an additional set of problems if the existing ORs that will be used during construction are adjacent to the construction zone. The operational part of the OR must be isolated from the construction area, and plans must be made for infection control, dust containment, noise abatement, and establishment of negative pressure in the construction zone.


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Initial Planning Once the scope of the project has been defined, the initial planning can begin. The size of a project can vary from the remodeling of a few ORs to the building of new ORs, delivery rooms, and ambulatory surgical centers. If there will be multiple new or remodeled areas, it is crucial that the same architect be responsible for designing all of them. The importance of this cannot be overstated. Dealing with two or three different architects means having to reinvent the wheel with each one. This wastes time and leads to costly mistakes. The members of the anesthesiology departments design team and the architects will have a great deal of interaction. They must learn from each other, and they will have to set standards and make compromises throughout the project. The initial phase of the project will consist of having all of the users submit: (1) a list of their needs; (2) the amount of space required for those needs; and (3) projections for future needs. Each user should state how he/she will function in the space and what the anticipated flow patterns will be within the space. Projections about future needs are difficult because needs can dramatically change over time. The percentage of outpatients can change, equipment can change, and even changes in managed care can impact future needs. For example, it would have been difficult for anyone to have predicted the development of the surgical robot, which occupies a very large amount of floor space. However, if an architect who previously designed an OR had considered the possibility that future developments in technology might require the use of significant amounts of floor space, the introduction of this type of technology would not have been a problem. Indeed, changes in technology, or anything for that matter, only become a problem when the design fails to account for future needs. This list is essentially a wish list; rarely will all requests be fulfilled. One should, therefore, not underestimate his/her needs at this stage. After all lists are completed, an initial plan will be devised and the cost of the project estimated (some projects will have the cost predetermined). The plan will then be scaled back so that it comes within the projected budget and available space. Once the initial plans are drawn, it is vital to determine exactly how much of what was initially requested remains in the plans. This will be the best and probably the only opportunity to reinsert into the budget something that was removed. The architects initial drawings may consist of several designs with different ideas on how best to satisfy everyones needs and stay within the allotted space and budget. Space for future expansion must also be included at this time. Key representatives from anesthesiology, nursing, surgery, biomedical engineering, and administration must work with architects to create a space that will best meet the needs of all groups and the proposed budget. Compromises will be necessary.


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Anesthesiologists must ensure that adequate space is allotted for the department to carry out its functions. In particular, space must be allotted for an anesthesia workroom and storage (for bulk supplies and spare equipment). At this time, there should be agreement as to the total number of ORs and postanesthesia care unit (PACU) beds that will be developed. In addition, space must be allotted for a preoperative holding area, locker rooms, call rooms, lounges, offices for the nursing and anesthesia staff, storage areas, waiting rooms, a control desk, and, possibly, a biomedical repair shop. At this stage, all desired space must be designated in the plans. Failure to do so will result in severe space constraints when the final compromises are made. This is also an excellent time to discuss general design principles with the architects. An often-overlooked principle is the overall flow of patients, staff, and materials into and out of the OR. A good example of efficient design is illustrated by a theater. There, action takes place on a stage and is visible to the entire audience. This corresponds to areas that are utilized by patients and their family members. Also, an enormous amount of activity takes place backstage and is not visible to the audience. This corresponds to areas that are used primarily by staff that patients and their families normally do not see. There should be a method to bring materials into the OR and remove trash and soiled linen without these items coming in contact with the public. Also, the physicians and staff should be able to enter and leave the OR without having to encounter the families in the waiting area. Security is also a major issue today. If the space is not going to be used on a 24-hour basis, there must be a way to easily secure it when the schedule is finished. It is also essential to have a method of controlling access to the ORs so that unauthorized personnel do not intentionally or unintentionally wander into the sterile area. Cameras in the front desk area and waiting room are an important part of any security plan. Similarly, hallway surveillance may be indicated. Finally, it is important to remember that most anesthesiologists are not familiar with the construction process and will, therefore, require on-the-job training. One has to work with tiny diagrams in which one-quarter of an inch represents a foot, and it is very hard to visualize from a two-dimensional drawing exactly how the facility will look when completed. It is very helpful if the architects can provide some kind of mockup of the space before the plans are finalized.


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Operating Room Size A general-purpose OR must have a minimum of 400 square feet, and a special procedure room (e.g., a heart room) must have at least 600 square feet. Although 400 square feet may seem like a large room, in many instances it is inadequate for contemporary surgical and anesthetic practice. Ideally, the minimum size room should be 600 square feet, with special procedure rooms sized at 800 to 1000 square feet. There is more equipment in ORs now than ever before, and the process is not slowing down. The result of more microscopes, x-ray machines, video carts, surgical robots, etc., being introduced into the room is that the anesthesiologist is crowded into a continuously decreasing amount of space. Be wary of the argument that a room can be designed to be small because it is just for outpatients or pediatric patients. There is a common misconception that pediatric patients need smaller ORs or that ambulatory procedures require less equipment. The equipment used for arthroscopy can occupy more than one-third of the available floor space. The fact that the room is intended to be used for only one purpose at the time of the design phase does not reflect the fact that needs might change or that the room will be used for many functions and surgical services over time. Obviously, the larger the room, the easier it is to work in it (Figure 1).


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Figure 1

Figure 1 depicts a large multipurpose OR that is designed for special procedures, such as cardiac surgery. The room is large enough to accommodate any equipment that is needed. Note the extra gas and electrical drops for use by the pump team. Because the amount and size of equipment that is brought into the OR is ever increasing, building a larger room today will undoubtedly pay dividends in the future. The size of the door to the OR is of particular importance. Very large items, such as specialty beds, orthopedic fracture tables, and heart-lung bypass machines, must be brought into the OR. It is, therefore, advisable to have a large main door and a second, smaller door that can be opened when needed (Figure 2).


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Figure 2

Figure 2 depicts a two-part OR door. The main part is used for regular stretchers, while the additional section can be opened to accommodate special OR tables or extra-wide beds. Note that the wooden doors have no protection from damage by stretchers and movable equipment. The two-part door works very well because the entryway can be enlarged when needed, but it does not have to be opened for regular beds. If windows are going to be placed in the doors, then provisions should be made to cover the window with a shade. Also, when using wood doors, the lower door panels and edges should be protected with a stainless steel overlay or a kick plate with edge guards (Figure 3). Otherwise, the movement of beds in and out of the room will damage the wood.


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Figure 3

Figure 3 depicts a two-part OR door with the addition of stainless steel overlays to protect the doors. Another consideration in new construction is patient movement. How patients are going to be moved on and off of the OR table should be considered in the design phase. Because bariatric patients are an increasingly large segment of the patient population, consideration should be given to installing some mechanical lifts in some of the ORs. Heating, Ventilation, and Air Conditioning The number of air exchanges in the room must be at least 20 per hour; at least four of these exchanges need to include fresh outdoor air. Relative humidity can be as low as 30% but cannot exceed 60%. It is best to have a separate system for scavenging that is independent of both the ventilation and vacuum systems. The air return ducts should have a HEPA filter built into the system.


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The ability to change the room temperature easily is very important. As recent studies have shown, keeping the patient warm is highly beneficial during most types of surgery. The heating and air conditioning systems must allow the individual room temperature to be raised or lowered rapidly as needed for patient and surgeon comfort. This must be accomplished without large overshoots in the desired temperature and can be accomplished by using individual reheat coils in each OR. Also, it may be beneficial to have the temperature sensed at several different points in the room. Lighting Often, the architects are very concerned about the amount of room lighting. However, excessive fluorescent lighting can be problematic. With the vast increase in the amount of endoscopic surgery, the entire concept of room lighting needs to be carefully planned. It makes more sense to have lights on dimmers or provide separate switches for different lights so that some can be turned off during a procedure. In rooms where all the lights must be turned off (e.g., when the operating microscope is being used), special procedure spot lighting can be installed for both the anesthesia staff and the scrub nurse (Figure 4). This lighting can be directed at areas that need illumination, such as the instrument table or the drug cart. Figure 4

Figure 4 depicts a special procedure light (spot light) that can be adjusted for use by the scrub nurse or anesthesia staff.


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Another technique is to install two banks of fluorescent tubes in each fixture. A separate wall switch would control each bank so that half of the lights can be turned off while the other half remains on (Figure 5). Figure 5

Figure 5 depicts special fluorescent lighting whereby half of the lights can be turned on or off as needed. Note that excessive lighting causes glare on the remote monitor, making it difficult to see. Some of the newer OR integration systems have lighting controls that can be configured for different lighting schemes; these schemes depend on which light fixtures are switched together as one unit and which are switched separately. In addition to light intensity, glare on monitor displays from room lights can be a major issue. The greater the individual control over different lights, the more adjustable will be the work environment. The downside is cost and complexity of use. A battery-powered source of emergency lighting must also be installed. Lighting can be dealt with in many innovative ways during the design phase, but if it is not planned, it is difficult to add later.


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Fire Safety Fires continue to be an ever-present danger in the modern OR. This is true even though virtually all ORs in the United States are designated as nonflammable anesthetizing locations (i.e., no flammable anesthetic agents or medications are allowed). The ECRI Institute estimates that there are between 500 and 600 OR fires each year in this country. The combination of three factors commonly found in the OR can easily result in a fire: (1) an oxidizer, such as oxygen or nitrous oxide; (2) a flammable substance or fuel, such as paper drapes, plastics, alcohol-based prep solutions, or gel pads; and (3) a heat source, such as electrosurgical pencils or lasers. When designing or remodeling an OR suite, fire safety should always be considered. This includes locating fire extinguishers and fire alarm boxes near each OR. In addition, zone valves to shut off medical gases and electrical panels should be conveniently placed outside each OR. Space for storing numerous compressed gas cylinders needs to be provided. These cylinders must be in a proper holder because rupture of a tank can flood an area with an oxidizer, such as oxygen, and create a hazard from high-velocity metal projectiles. Depending on the size of the OR suite, compressed gas cylinders may need to be stored in multiple areas. Gas storage areas have specific fire-rating construction needs. While every OR will have a smoke detector and sprinkler system, the location of these items is important. Because a fire is most likely to start in the vicinity of the patient, the smoke detector and sprinkler should be placed as close as possible to the OR table. Fires in the OR frequently produce a lot of smoke and toxic fumes but not a lot of heat. Therefore, if the sprinkler is placed in the back of the room, it may not activate until very late in the course of the fire. The National Fire Protection Association (NFPA) provides many other useful ideas and guidelines regarding fire safety in its publication NFPA-99: Standard for Health Care Facilities. Substerile Areas (Scrub Rooms) There are four basic items that will occupy the substerile area: sinks, an autoclave (note that newer recommendations suggest that all autoclaving be done in a central sterile area, which may greatly reduce the need for autoclaves in each OR area), storage for supplies, and a telephone/intercom. Other possible items include a blanket/fluid warmer, ice machine, and refrigerator.


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Scrub sinks are not of equal quality. Some are far better at containing the water in the sink, which avoids a wet and slippery floor. Many surgeons are used to having a window above the scrub sink so they can watch the patient while scrubbing. While this may seem like a good idea, the reality is that the window occupies a large amount of valuable wall space. Often, it will not be possible to place all the necessary cabinets, electrical panels, etc., in the walls and still have a window. In addition to the autoclave, some ORs need a warming cabinet for solutions and blankets. There may also be a sink for decontaminating instruments prior to autoclaving, but having the autoclaving activity in a central location may obviate the need for a decontamination sink adjacent to the OR. Most substerile rooms will have some storage space. This can be used for general supplies or equipment unique to that OR suite. If a pass-through cabinet is going to be installed, then sliding doors should be avoided. Although they do not require swing-out space, sliding doors tend to come off the tracks, and oversized items will inhibit the ability to open or close the doors. Storage Rooms Storage space is one of the most important requirements for the modern OR. However, it is often overlooked or reduced in the cost-cutting phases of the project. The amount of equipment that is in the OR today is probably double that of 10 years ago. The introduction of video surgery has resulted in numerous television monitors, carts, and videocassette players that have to be stored in and moved to different rooms. There are specialized OR tables, microscopes, instrument carts, lasers, coagulators, and a host of spare devices (e.g., anesthesia machines, monitors, and electrosurgery units) that need storage space. This does not include the supplies and materials that are needed on a daily basis, as well as setups for emergency cases. Future storage needs are difficult to predict; the more storage space that is planned, the less likely the hallways will be jammed with equipment and supplies 2 or 3 years later. Because OR space is very expensive, it may be possible to provide some storage room in close proximity to the operating suite. In addition, some services that are traditionally in the OR may be moved to create additional space. For example, the area for processing and sterilizing instruments can be located outside of the operating suite. That area can be on a different floor (above or below the OR) and have two dedicated elevators to bring in sterile supplies and take out dirty supplies. This would allow one central processing area to serve several of the inpatient and outpatient ORs as well as the labor and delivery rooms. It is best if the OR and the anesthesiology department have separate storage areas. There may need to be one or two large areas and several smaller areas spread around the OR suite. If there is a room for large movable equipment, provisions need to be made for easily getting equipment into and out of the room.


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Communication Communication is another important aspect of OR design. Telephones, intercoms, and computers are all necessities for any modern OR. Also, television cameras and monitors may be used for teaching or teleconferencing. The amount (and location) of each of these devices should be determined by the nursing, surgical, and anesthesia staff. There are many different ways to design a communication system. An effective communication system can greatly enhance the safe and efficient running of the OR. Every hospital has unique needs, and the system for a particular OR requires careful planning to achieve the desired goals. Well-designed information technology is essential for the efficient operation of the modern OR. Robust wireless and wired networks are needed for communication, access to the Internet, cell phones, and various patient management tools. Some sort of electronic patient management system (e.g., NaviCare) can greatly enhance the timely coordination of patients and staff. In a large OR, it may be preferable to have a dedicated OR intercom as well as a telephone in each OR and one on the anesthesia machine. The communication system must provide for a simple and reliable way to obtain extra help in an emergency. This can be accomplished with a dedicated OR page system or a separate alarm system. Materials Management One often-overlooked aspect of OR design is materials management. This encompasses all sterile and nonsterile supplies, dirty instruments, trash, and any materials to be recycled. The OR should be designed to allow the smooth flow of materials into and out of the area. If possible, clean and dirty supplies should not mix, and the delivery and removal of supplies should not interfere with patient movement. There needs to be space to unpack crates and boxes of supplies as well as storage for enough supplies until the next delivery. This is true for OR as well as anesthesia supplies. Complete isolation of pathways is impossible, but careful planning can minimize the interference. Special Functions There are a number of special functions that may require space in or near the OR. These include space for the pathologist to do frozen sections; an area for the perfusionists to assemble, clean, and test the cardiopulmonary bypass machines; and space for blood bank refrigerators. It may also be advantageous to have a laboratory to perform a selected number of tests and a dedicated area for a biomedical technician. Space may also be required for a drug dispensing machine(s), a narcotics return lock box, and a scrub suit distribution system. These functions must be considered during the design phase, or something will have to be deleted later to make room for them. Other support functions, such as call rooms, locker rooms, lounges, and offices, are covered in other chapters of this manual.


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Security Security is a subject that has increased in importance in recent years. It is important that only authorized personnel gain access into the OR suite, especially the sterile areas. There needs to be a means to ensure that visitors and family members do not wander into sterile areas. Also, the OR personnel need to feel safe during nights and weekends. In addition, family members will want access to the front desk personnel. Controlling who has access to the OR area should be part of an overall security plan. Quality of Materials It is important to consider what types of materials will be used. This should be determined during the planning process because higher quality products will be more expensive. A good example of this are OR cabinets; stainless steel cabinets with glass windows are more expensive than laminated particle board with plastic windows (Figure 6). Over the life of the OR, the stainless steel will be the better value. Figure 6

Figure 6 depicts stainless steel OR storage cabinets with glass doors. These cabinets are easy to clean and will last for many years. Also, any supplies stored in them are easily accessed from the swing-out doors. Other equipment must be kept far enough away from the doors to allow access to the supplies.


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The materials for the OR walls and floor are also important. They should be easy to clean, blood and stain resistant, and able to maintain their appearance for many years. Also, the floor and the wall should not meet at right angles, as this creates an area that is difficult to clean. Rather, the floor should seamlessly continue up the wall for 4 to 6 inches (Figure 7). Figure 7

Figure 7 depicts an example of an OR floor that extends several inches up the wall. This floor is easy to clean because dirt cannot collect at the junction of the floor and the wall.


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Construction Documents Once all of the different components of the room have been determined, the architects will prepare the construction documents. These are the detailed plans that show exactly where everything will be in the walls, ceiling, and floor. At this time, the nursing, surgical, and anesthesia staff should carefully examine each OR to determine if the placement of the OR table, the cabinets, and any special equipment makes sense. Even though many rooms are the same, each one must be inspected because important components may be left out or changed. The nurses need room to set up their sterile tables in a location that does not interfere with the patient entering the room or the staff members obtaining supplies from the cabinets (Figure 8). Figure 8

Figure 8 depicts a room that has the anesthesia supply cart located in front of the storage cabinets, making it difficult for the nursing staff to access the supplies. The room should have been designed so that movable equipment was kept away from the supply cabinets.


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It is advisable not to place OR supply cabinets behind the anesthesia team; however, if it is unavoidable, then the anesthesia gas drops should not interfere with obtaining supplies from the cabinets. It is desirable to have a mockup of the OR so that people can walk through and actually see where the architect has located the various components. A full- or small-scale wooden mockup can be done. Alternatively, the room can be laid out with chalk on the floor and the actual pieces of equipment brought into the area. Cardboard cutouts can be used to represent various pieces of built-in equipment. It is much easier to visualize the setup in three dimensions rather than the two dimensions of the blueprints. Using computer software, the architect may be able to simulate the three-dimensional aspects of the space. This may provide additional insight into the future function. Potential mistakes and conflicts can be resolved before construction is actually finished (or even started). One place where this is particularly important is in a room where there is a fixed piece of equipment, such as a microscope. Having a microscope mounted and fixed to the ceiling markedly limits the function of the room. If a microscope is going to be mounted to the ceiling, it should be on a track so that it can be moved aside when the room is used for other types of cases. This takes a lot of planning so that the microscope, OR tables, and anesthesia machine are all in the best position to minimize congestion and interference with other equipment and to facilitate transporting the patient into and out of the room. All of these basic principles should be applied to all other areas of the OR. The preoperative holding area, PACU, locker rooms, lounges, and offices should all be scrutinized for appropriate size, setup, and flow. If the facility being built has special needs, such as a labor and delivery suite, a pediatric suite, or an outpatient surgicenter, then the previous discussion can be applied and tailored to that specific area. For instance, a pediatric operating suite may require several different preoperative holding areas so that children of different ages can be segregated. Outpatient surgicenters have unique requirements, including modifications for recovery in order to ensure that the patients are able to ambulate before being discharged. Construction Once all of the design and construction drawings are finished, the actual work will begin. This is not a time to sit back and hope everything will go according to plan. It is vitally important that members of the anesthesiology department and nursing staff make frequent and comprehensive visits to ensure that the construction is proceeding according to plan. It is also a time to resolve minor problems and add forgotten items before the suite is finished (Figures 9 and 10).


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Figure 9

Figure 9 depicts automatic doors leading from the preoperative holding room into the OR that require a plate to be pressed in order for the doors to open. The plate was originally located on the wall next to the doors (note the blank cover plate to the right of the doors). This made it impossible for a person pushing a stretcher to open the doors.


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Figure 10

Figure 10 depicts how the plate to open the doors has been relocated to approximately 8 feet in front of the doors. This allows a person pushing a stretcher to operate the door control without having to leave the patient It is important that the people who helped during the design phase stay active with the project during construction. It is almost impossible for someone else to take over at this phase. There needs to be an agreement between all the parties that any changes will be presented to and agreed upon by the group. Agreed-upon changes need to be put in writing and distributed to the group. The meetings need to be scheduled (so that everyone has a reasonable opportunity to attend) and should be long enough to get the necessary work done. The representative from the anesthesiology department needs to realize that this will entail being out of the OR for many hours during the day.


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No matter the similarity of some rooms, they must be treated as individual projects. One cannot assume that all of the rooms will be correctly done just because two or three rooms are correct. For instance, our project involved building three new delivery rooms. All were supposed to be done the same way. However, we found that one room had no suction for the surgeons. If such a mistake is identified early, it is easy to fix; if it is discovered on the final inspection, it is very costly to rectify. Conclusion Once the construction is finished, the anesthesiologists should do a final checkout and safety inspection. The gas lines should have a certified report of testing. Ideally, this is part of the gas piping installation contract. The contractor must provide a test of both proper installation (i.e., brazing and purging of impurities) and proper function (i.e., correct gases in the correct pipelines). Numerous disasters can occur if this has not been done. The anesthesiology department should also perform its own check to be sure that oxygen is in the oxygen lines and nitrous oxide is in the nitrous lines. A complete test of all systems must be done before the room is used for patient care. A tremendous amount of work is required in order to have an excellent (functional) finished product. The difference between an operating suite that is workable and usable and one that is not frequently depends on how much attention is paid to small details. As always, a vigilant anesthesiologist (as well as nursing, surgical, and OR staff) is required in order to have a satisfactory outcome.


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CHAPTER 3 ERGONOMICS AND WORKFLOW

Lead Author: Robert Loeb, MD; Associate Professor of Anesthesiology; University of Arizona Tucson, AZ

Contributors: Ramon Berguer, MD; Clinical Professor of Surgery; University of California, Davis; Davis, CA

Checklist

1. Have end users considered how patients, supplies, and equipment will move through the planned facility?

2. Have end users considered the workflow of tasks they will repeatedly perform in the planned facility?

3. Will there be adequate technology and access to technology for communication within the facility and to the outside (considering telephony, intercoms, information displays for schedule, laboratories, radiology, etc.)?

4. Will lighting be adequate for the tasks to be performed in the facility? 5. Has the facility been optimized to control noise pollution, provide different temperature

zones, and distribute electrical power and compressed gases? Introduction Ergonomics is the field of study of the physical and psychological relationships between working humans and their tools and environments. The purpose of ergonomics is to promote efficiency of operation and decrease human error and stress and strain on the user. Ergonomics should be an early consideration in the design of any new or retrofitted surgical facility so that the interactions of workers with their coworkers, equipment, and facilities can be studied and the resulting data can guide the design of better policies, procedures, equipment, and facilities. Early attention to ergonomics is increasingly applied to the design of medical instrumentation. In 2001, the American National Standards Institute and the Association for the Advancement of Medical Instrumentation published the Human Factors Design Process for Medical Devices, which describes how ergonomics and human factors should be applied to the design of medical devices. The intention is to help equipment manufacturers develop safe and effective medical devices. However, no such document describes the application of ergonomics and human factors to the design of operating suites and other health care environments, even though these facilities greatly influence the safety and efficiency of the processes within. The process of facility design has already been covered in Chapter 1, The Design Process, but the key ergonomic considerations will be highlighted here. Facility design begins with an analysis of needs and a clearly defined objective. From this, an overall concept for the facility is formulated. This leads to the development of the functional criteria and requirements for


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specific areas of the facility. Thereafter, a schematic design of the facility is produced. Finally, construction of the facility begins. But, ergonomic-guided design is an iterative and cyclical process wherein the steps from overall concept to schematic design are repeated and refined based on the feedback of owners, end users, consultants, and customers until all the major design flaws have been fixed. Techniques such as task and workflow analysis, site visits to similar facilities, building mockups, cognitive or computer-based walkthroughs, and interviews and surveys are used to obtain feedback on the proposed designs. Such a design approach requires the early involvement of experienced users who have time allotted to help with the design process. As stated in Chapter 1, the design team must include people who will actually work in the facility. Ergonomics Factors to consider under the heading of ergonomics include medical teams in the operating room (OR), lighting, noise, temperature, work-related injuries, and workflow and task analysis. Medical Teams in the OR

Different needs of surgical, anesthesia, and nursing (including ancillary) teams Patient safety, communication, and shared data: Universal Protocol, World Health

Organization checklist, time out, and information displays (e.g., x-ray, vitals, etc.) Communication into and out of the OR and case scheduling Simulation for OR emergencies Communication skills: teamwork training

Lighting

Sufficient light is needed for works-specific tasks Surgeons need the brightest light Anesthesiologists and nurses need bright light Hazards of colored lenses (e.g., need for laser safety goggles) Interference of ceiling-mounted light booms with other equipment (e.g., video

monitors, drop down gas sources, and intravenous poles) Local-field lighting: headlights

Noise

ORs are noisy Noise is reflected; thus, the localization of sounds is difficult High noise levels interfere with communication and alarm perception American Society of Anesthesiologists standard requires being able to hear the pulse

oximeter variable pitch tone above the background noise Causes of OR noise (e.g., hard surfaces, suction, room ventilation, conversations, alarms,

pagers, overhead pages, and music) Room and furniture design to decrease noise levels


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Temperature Comfortable temperature increases efficiency and safety Patient and staff are insulated to various degrees Patients tend to become hypothermic Surgeons tend to become uncomfortably warm Personal cooling and warming devices Need for rapid changes in room temperatures

Work-Related Injuries

Lifting Needlesticks and sharps injuries (including exposure to blood-borne pathogens) Repetitive motion injuries, static posture injuries, and wrist/forearm injuries from the

use of heavy or awkward instruments/devices Physical fatigue and OR seating Different user shapes and sizes (e.g., small female vs. large male) and the effect of sizes

and shapes of medical device handles and controls. Workflow and Task Analysis

Use of simulation in the design phase Location of supplies, medication, and instruments (e.g., in vs. out of room and free

access to supplies vs. electronic inventory control systems) Planning for sequential vs. parallel patient flow (e.g., block rooms and induction rooms) Equipment storage, work surfaces (e.g., setting up and supplies), and writing surfaces

(usually minimal) The integrated OR concept: Endosuite, integrated room/procedure video, and

telemedicine/telementoring systems Team-Specific Issues Anesthesia: The Anesthesia Cockpit

Machine size and orientation: o Typical anesthesia workstation and medication cart dimensions o Anesthesia machines are generally configured so the patient attachments (e.g.,

the breathing circuit) are located on the left-hand side of the machine o The anesthesia machine is best positioned to the right side at the head of the OR

table or in a less desirable location behind the anesthesia provider o In some surgical procedures, the anesthesia machine may be located at the

patients side or at the patients feet Suction:

o Suction canister and controls should be located in the anesthesia cockpit within reach and view of the anesthesia provider

o Height of suction canister should be below the level of the surgical table (to decrease effect of hydrostatic pressure)

Monitor, computer, and phone:


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o Access to patient data in the Electronic Medical Record (EMR) in real time o Access to help materials (e.g., internet) in real time o Wired and/or wireless access o Portable vs. fixed computers with keyboards and mice; where will the mouse be

located? o Use of alternate screen-pointing devices (e.g., touch screens, trackballs, and

knobs) o Glare, spillage, and infection control considerations o Food and Drug Administration Human Factors Design guidelines o ECRI Institute resources

Power management: o Electrical, phone, network, and compressed gas outlets should be located near

the anesthesia cockpit and not across major pathways into and out of the room o Multiple network ports may be needed because monitors, anesthesia

information systems, hospital EMRs, and general intranet and internet usage may require separate networks

o Can be located on the ceiling or on ceiling-mounted booms Hose cord and cable management:

o Hoses, cord, and cables on the floor can be a trip hazard and can interfere with positioning of wheeled equipment.

o Wheel protectors can be used to push cables away Surgery

Cleaning and sterility Patient support and positioning systems: adequate table height adjustments during

surgery Video-endoscopic surgery:

o Integrated equipment towers (e.g., booms vs. carts) o Display locations and adjustability o Communication systems (e.g., video, audio, images, picture archiving and

communication system, etc.) o Surgeon-controlled systems (e.g., computer interface and voice activation) o Management of multiple cables/tubes from multiple pieces of equipment (e.g.,

OR spaghetti) Sharps injury prevention: double gloving, blunt suture needles, hands-free zone, and

engineered sharps injury prevention devices OR documentation: paper vs. computer Interruptions: personal communication devices (e.g., pagers, cell phones, and cameras),

overhead pages, and in/out room traffic Workflow aids for best practices (e.g., antibiotics, deep vein thrombosis prophylaxis,

beta blockers, etc.) Physical safety and comfort: gowns, cooling systems, and eye/face protection


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Nursing Preference cards or the electronic equivalent and their use and location Standardization of supplies


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CHAPTER 4 ENVIRONMENTAL SUSTAINABILITY: LIMITING IMPACT ON THE ENVIRONMENT Lead Author: Susan Ryan, MD, PhD; Professor, Department of Anesthesia and Perioperative

Care; University of California at San Francisco San Francisco, CA

Checklist

1. Sustainable sites: Are the architect/construction teams, materials, and site choice geared toward low environmental impact?

2. Water: Are fixtures and systems designed for maximal water efficiency? 3. Energy: Is energy efficiency a consideration in lighting, heating, and design choices? Can

green energy be purchased by the facility? 4. Indoor environment: Are interior materials eco-friendly and recyclable? Is

environmental sustainability a factor in operating room (OR) surgical and anesthesia equipment evaluation?

5. Innovation and design: Can operative and perioperative spaces be proactively designed to accommodate recycling programs and other features that lower environmental impact?

Introduction The imperative to limit environmental impact extends to the health care industry, which is very high impact and energy consuming. However, this imperative presents many special challenges given the needs for patient safety, infection control, and cost containment. Fortunately, with some specific guidance for the industry, green design and green operations in health care may work in concert with health cares goals and challenges by improving building efficiency and cost and providing safer, more pleasant surroundings for patients and employees. The Leadership in Energy and Environmental Design (LEED) program of the US Green Buildings Council offers guidance and certification for new and remodeled building projects and currently has over 350 health care construction projects registered. The LEED for Healthcare system, a more specialized version tailored to the challenges of health care, is under final review and expected to be available by mid-2011. This more specific guidance, along with the currently available Green Guide for Health Care (www.gghc.org), will enable implementation of many low environmental impact solutions.


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A LEED certification involves accumulating points in at least six areas of evaluation: sustainable sites, water efficiency, energy and atmosphere, materials and resources, indoor environmental quality, and innovation and design. Based on the degree of compliance in these areas, projects can be deemed LEED certified, silver, gold, or platinum. Each of the areas of LEED certification will be briefly addressed, with comments about how they generally pertain to a health care facility and might more specifically pertain to ORs and perioperative areas. Sustainable Sites First, consider what it means to have a sustainable site and whether the other green plans for the project fit into this location. The ultimate goal is to minimize impact on the surroundings while choosing a location that best serves the intended patient and employee populations.