By Don Sadler
Many hospitals and ambulatory surgery centers (ASCs) today look more like construction zones than health care facilities as they build new perioperative suites and renovate existing suites to keep up with patient demand and new technology requirements.
“Renovating and building perioperative suites has become one of the fastest growing skill sets for health care leaders,” says Aimee Watson, MS, CMRP, a senior manager in healthcare at St. Onge, an independent engineering firm that provides design, logistics and supply chain consulting to hospitals and ASCs. “But we never received a class on this in school.”
Aging Buildings and More
Watson says that OR suite construction and renovation is on the rise nationwide for several different reasons. “These include aging buildings, changes in reimbursement models, demands for specialty OR suites, outdated equipment, and the need to bring existing suites up to new codes and standards,” she says. “New and renovated suites can also help attract a more talented surgical team.”
Erin Kyle, DNP, RN, CNOR, NEA-BC, editor in chief, Guidelines for Perioperative Practice for the Association of periOperative Registered Nurses (AORN), concurs.
“Aging buildings and advancements in technology are two of the main reasons hospitals are building out new perioperative spaces,” she says. “Some hospitals need updates to support changes in the way care is delivered in procedural areas.”
Beverly Kirchner, BSN, RN, CNOR, CNAMB, also stresses the role of technology in the current wave of OR suite construction and renovation.
“For example, robots may require a larger room to be safe using advanced technologic equipment,” says Kirchner. “And ASCs are developing new service lines now that CMS has allowed them to perform more complicated cases. These include total joints, interventional vascular and cardiology, and more complex spine cases.”
Patients are also helping drive the need for more ORs.
“Most patients are unwilling to wait for elective, urgent or emergent surgery,” says Kirchner.
Kyle uses one word to explain the boom in OR suite renovation and construction. “Growth!” she says.
“Hospitals expand along with the communities they serve and their services grow to meet the community’s needs,” says Kyle. “This might be due to population growth or changes in the community’s health needs. For example, an aging population might lead to a need for more services for age-related health concerns.”
Competition is another factor. “Every hospital wants to emphasize in their marketing what their competitors do not have to help attract new patients and increase market share,” says Kirchner. “ASCs also do some of this kind of marketing, but not as much as hospitals.”
“Every Project is Different”
Kirchner has helped design and build more than 30 surgery centers throughout her career. “Every project is different,” she says. “We build our ORs to meet the needs of the specialties that will provide services.”
“For example, ortho, spine and robot rooms are not less than 600 square feet, and I prefer 750 square feet if possible,” says Kirchner. “Also remember that under federal regulations, the number of operating rooms in an ASC drives the number of preoperative and PACU bays or rooms.”
One of Kirchner’s most important success factors is being sure to work with an experienced architect who understands the complex federal and state regulations that govern the construction and renovation of OR suites.
“The architect must have a great engineering team to design the structural needs of the room,” says Kirchner. “This includes HVAC, integration of equipment through technology, and electrical requirements to accommodate the electrical loads that run to the equipment.”
Considering patient flow is also critical when building and renovating perioperative suites.
“You do not want to cross the fresh post-op with a patient in preop, and you want maximum privacy from the space you have been allotted,” says Kirchner. “Your ORs also must be central to where the dirty instruments go for reprocessing and the sterile instruments and supplies are stored.”
Erin Keeney, MSN, RN, CNOR, the director of perioperative services at AnMed,
has overseen a major OR construction and renovation project over
the past few years at AnMed in Anderson, South Carolina. This has included building two new operating rooms to support growing orthopedic volume and renovating two existing ORs to create four new endoscopy/bronchoscopy suites.
“In addition to orthopedics, the new ORs can be used by all surgical services if needed,” says Keeney. “We also built a new same-day surgery and a new post anesthesia care unit as well as new offices, staff and physician lounges, locker rooms and storage, and a new family waiting area.”
Keeney says the project has been much larger than what was
originally envisioned and won’t be complete until March 2023.
Early on, Keeney and her team held monthly meetings with the architects, design and construction team, infection prevention and engineering. “Those meetings became weekly once we got into the construction phases,” she says.
“We brought in physicians and key OR personnel to get input on the designs,” says Keeney. “And I met with sales reps to make sure that the standardization of what we currently had in the ORs would match the new areas.”
Working Around Obstacles
When it comes to unexpected surprises or obstacles, Keeney says there are always things that go differently than planned.
“When this happens, we regroup to go over the concerns and issues and develop a new plan to make sure we stay on track,” says Keeney. “Keeping an OR running while under construction definitely has some challenges, which makes being open and flexible to change extremely important.”
Keeney’s main advice? “Be patient and willing to think outside the box,” she says. “Prepare yourself and your team for change and engage the physicians and staff. And communicate regularly with the construction team and infection prevention to make sure that your other operating rooms are protected.”
“I also think it’s important to engage staff and physicians and ask them about any barriers in the current ORs,” Keeney adds. “Find out what their ‘wish list’ would be for the perfect OR and incorporate as much of this as you can into the design.”
According to Kyle, the foundation of a successful perioperative suite build is a solid understanding of the patients and population that the space will serve.
“Getting your arms around the patient population, anticipated services and the technology needed to offer the best care is no easy task,” says Kyle. “This is where the interdisciplinary team must come together to clearly define the strategic goals related to designing the anticipated build.”
Having the right people at the right time with the right authority is the strongest indicator of health care design success, Kyle adds. “Convening an interdisciplinary team with internal stakeholders can provide necessary insight into the best feasible practice design,” she says.
Remember the Five E’s
Mary Alice Anderson, Ph.D., RN, CNOR, senior perioperative practice specialist with AORN, stresses what she calls the five E’s when it comes to designing, building and renovating perioperative suites.
“First, every detail matters in the long-term strategic plan,” says Anderson. “The next E is efficiency: Designing the space to support efficient workflows should be a top priority.”
Ergonomics is also critical. “The space should be designed in a way that helps perioperative teams perform their best and be protected,” says Anderson.
The fourth E is emerging technologies. “Do what you can to anticipate how the perioperative environment will support what kinds of technology are next,” says Anderson.
Finally, you need to make sure that the perioperative suite’s electrical capacity can support all the equipment that will be running simultaneously.
“Also consider electrical and networking interference issues,” says Anderson.
According to Watson, building a cross-functional team is critical to the success of the design and operation of new perioperative spaces.
“This team should include representation from pre-op, PACU, sterile processing, anesthesia, support services and administration, cath lab, CV holding, and even infection prevention and environmental services,” she says.
“The goal of having a group like this come together is to establish the team’s goals, define roles, build trust and foster open communication,” says Watson. “Eventually perioperative team members should be able to simulate and practice within their new spaces before opening the new ORs.”
In her experience, Watson has seen a number of “oops” when it comes to OR suite design. These include kick plates installed too high to open doors, fire doors installed backward, access panels installed where carts will sit, a hand sanitizer dispenser installed behind the patient bed and an OR floor that did not meet infection prevention standards.
“These mistakes could have been avoided if the perioperative team had a voice and a seat at the table during the design and construction process,” says Watson.
Design and Construction Challenges
Supriya Patel, engagement manager with Surgical Directions, lists some of the biggest challenges when it comes to designing and building new perioperative suites.
“Appropriate block allocation, proper EMR integration, effective patient preparation and pre-admission testing processes, and standardization of ancillary department workflows are among the biggest challenges I see,” she says.
“These challenges make it critical to get staff and clinician input when designing new perioperative suites,” says Patel. “They understand the workflows and operational day-to-day challenges that occur.”
Block allocation is usually one of the most pressing concerns for OR leadership and physicians. “I recommend organizing a block subcommittee comprised of both physicians and OR leadership to review current blocks, forecasted data and best practice guidelines,” says Patel.
Pre-admission testing and patient preparation are other areas where Patel has direct experience in OR suite design. “These play a crucial role in operational efficiency,” she says. “The patient prep system should be redesigned with the correct players well in advance of the new build. Ideally, patients should be prepared for surgery at least three days prior to the procedure.”
Some of the biggest mistakes Patel sees hospitals make when designing and building new perioperative suites involve communication and planning. “Making sure staff and clinicians are involved in the design will go a long way toward the success of the new suite,” she says. “This is important not just for operational success, but also from a patient safety standpoint.”
Kirchner stresses the importance of looking ahead to what a surgical center will need to grow in the future. “For example, I always plan on an additional autoclave and washer decontaminator,” she says. “I have the plumbing put in and capped so it is almost plug-and-play when I need that autoclave or washer disinfector.
“The decision to design for the future is determined by strategically forecasting case growth from opening to five years out,” says Kirchner. “This process saves a lot of time, decreases disruptions and helps in constructing an infection prevention plan when new ORs are added.”
Kirchner also recommends creating a construction checklist identifying key phases. “Ask the architect and contractor for timelines,” she says. “Know the regulations that address and govern your project and make sure they are met.”
The Role of Hybrid Suites
Watson says that every hospital St. Onge works with is planning for flexible, or hybrid, OR suites. “This provides the opportunity to perform a variety of cases within that one suite – from OR to cath lab or specialty procedures,” she says.
Watson’s success tips for building and renovating new OR suites include making sure growth projections are accurate so as not to undersize the space and planning appropriately for which supplies and equipment will need to be in the room.
“Perioperative team members should grab a seat at the table wherever they can in the process,” says Watson “At the beginning during concept design is best. Identify someone as a dedicated liaison for the teams to work on the new project.”
It’s common for hospitals to partner with outside consultants who have operational experience and the industrial engineering skills to help with flow and design needs. “It can be difficult to juggle your day-to-day responsibilities while also trying to oversee a major new OR suite construction,” she says.
Anderson stresses that it’s critical to keep patient needs top of mind when designing new OR suites. “This means thinking about how the patient will experience the space and how the space supports the perioperative team in delivering optimal care,” she says.
