Surgical suite talk

For a healthcare organization that is considering an OR renovation or a new build, what are the variables they need to be thinking about?

For renovation projects the main driver is usually new equipment. An increasing number of surgical cases require imaging equipment in the operating room which requires additional space and infrastructure. Robotics-assisted surgery is another growing trend that requires additional floor space so many hospitals are needing to increase the size of current operating rooms to accommodate this new equipment.

Organizations should begin by reviewing demographic and population data to see if there are measurable and sustained changes taking place that would influence the type of care and services patients will need. They should also try to answer these questions: Are cases being lost to other providers based on limited facilities? Is the financial impact associated with cases flat or declining despite population and demographic needs and demands? Understanding historical, current and anticipated cases and schedules for clinicians and surgeons will help determine what solution makes the best sense and the timing related to renovations.

In most cases we see the need for this type of renovation or expansion focused on improving throughput. The ability to accommodate more or different case volume.

Pamela Rockow, Director of Marketing, Surgical Workflows, Getinge

The timing of any renovation decision is greatly influenced by economic considerations, hardly surprising in light of the fact that up to 65 percent of a hospital’s revenue is generated in the OR.

In simple terms, the economic impact of maintaining the status quo in the OR needs to be weighed against the anticipated incremental return on investment if the decision is made to green-light a renovation project.

In many instances, project approval is preceded by a thorough analysis of the opportunity cost of channeling limited financial resources to upgrade the OR. This step is taken to determine if the earmarked funds can generate an even greater financial return or non-economic benefit if invested elsewhere in the institution.

However, as logical as this decision-making strategy appears to be in theory, in practice, hospital administrators often discover just how challenging it can be to quantify what are largely qualitative variables. After all, how does one accurately assign a monetary value to a patient’s quality of life or an institution’s reputation? Plus, there comes a time when the OR needs attention, regardless of what other worthy projects are competing for the same capital improvement dollars. Visit www.hpnonline.com/is-now-the-time-right-time/ for sidebar “Is now the right time? Important questions to ask before building a new OR.”

Frank DiLalla, Director, Marketing, STERIS

A facility can decide whether an operating room renovation is needed by looking at how their operating rooms are utilized today. Are these rooms incapable of supporting the number or complexity of procedures needed to meet the facility’s goals? Is the operative staff struggling to communicate effectively, access the information they need, or manage images and videos captured during a procedure? Is the operating room cluttered by cart-based equipment and difficult to navigate because of cables draped along the floor? Does the facility have or desire new video or imaging devices that cannot be connected to their existing OR integration system, such as 4K cameras or displays? Answering yes to questions like these indicates that a retrofit may be needed to improve the use of existing operating rooms.

What are the common concerns that you hear from surgeons, supply chain, nurses, schedulers, C-suite, etc. about taking this big step?

New state-of-the-art equipment requires additional space and upgraded power and cooling requirements. This equipment is often data driven and space must be available for multiple monitors. Additionally, the cost of upgrades (including phasing and downtime) versus relocating and avoiding phasing and downtime needs to be considered.

Most facilities can’t shut down an operating room and parts of the surgical suite to allow for an extensive construction project. They have an obligation to patients and need to maintain emergency services. Surgical procedures are also a prime revenue generator for the hospital, making prolonged downtimes a financial issue. It’s also very challenging to maintain the sterile environment that is required.

While all stakeholders tend to have their own concerns, the common concern is planning the construction in a way that minimizes disruption and potentially lost cases. This is where the Lean design methodology can come into play.

The decision to incorporate Lean design and practices into new construction projects can improve the efficiency of surgeons, nurses, scheduling staff and even supply chain; support the most efficient work-flow design and process.

Fear of change and the potential disruption to current workflows are shared concerns among all stakeholders. Surgeons and members of their surgical team, by their own admission, are creatures of habit. Many would acknowledge they function most comfortably in familiar surroundings, even under less than optimal conditions.

That’s why it’s important that surgeons and OR managers be well represented on any OR renovation planning team and be actively involved throughout the lengthy planning process to avoid unwelcomed surprises.

It’s equally important that training is scheduled for all members of the surgical staff prior to room commissioning and that additional support personnel are made available on-site once surgeries have been scheduled to deal with any issues in real-time during the transition period.

Schedulers will need to be sensitive to any variations in the rhythm of the surgical workflows to calculate any required modifications in OR turnaround times and CSD processing.

Senior hospital administrators will continue to be concerned in very broad terms until sufficient data has been accumulated to validate the business case for making the investment in the first place.

What are some of the misconceptions or unrealistic expectations you hear from various stakeholders when planning/designing a new surgical suite?

A misconception that we have encountered is that oftentimes the one controlling the dollars does not realize that to obtain the proper patient, staff, and materials flow requires additional square footage and other building requirements that add cost. This cost is realized in construction along with added square footage of the overall center.

Most end-users think that the project can be built in a short period of time. Healthcare design and construction is heavily regulated so it’s an extensive process that requires their participation at many points along the way.

Rodney Cadwell, Associate Principle, Vizient, Inc.

The most common misconception can be summed up from the famous line from the movie Field of Dreams, “If you build it, they will come.” This is particularly true when bringing in new technology. We have seen numerous hybrid operating rooms designed that do not function well because the input from various users was not blended. So the room may work well for one specialty but be a burden on another. These are not one-size-fits-all rooms. The advice would be make sure you have all potential users together during design so that each has a voice that is taken into consideration. Unless the design is specifically for one specialty, there will need to be some compromise.

When it comes to OR renovations — in particular, multidisciplinary hybrid surgica suites — managing expectations is just as important as managing each phase of the lengthy planning process. That’s because no amount of preparation can anticipate every workflow or equipment issue that could arise. That’s why it’s important that OR planners align themselves with highly knowledgeable and experienced partners who know what it takes to reconcile these unexpected problems and overcome the inevitable bumps in the road.

A big misconception is that retrofitting an operating room with integration is quite time-consuming. In reality, with the right vendor partner, the retrofit of an existing environment can be quick and seamless, getting the newly-renovated OR back up and running promptly. An efficient renovation can be key in allowing that operating room to start generating revenue again as soon as possible.

Have you noticed any trends in surgical suite builds/renovation in recent years? Are buyers more likely to upgrade or build from the ground up?

We are noticing that many hospitals are opting to take the less invasive surgical cases out of the main hospital surgery space. This allows for the use of hospital ORs for the more acute cases. Further, we are noticing that many of the outpatient Ambulatory Surgery Centers are geared towards quick turnaround cases. One of our latest projects, the Surgery Center at Shrewsbury, is a great example of a surgery center independent of a hospital campus that provides the same high-quality care but at lower costs and with improved efficiencies. To read the case study visit https://shields.com/surgerycentershrewsbury/.

The three big trends are imaging modalities embedded within the operating room, the use of robotics-assisted surgical procedures becoming more commonplace, and the shift of minimally invasive outpatient surgical procedures being decanted from the hospital to an offsite location that has more of a business structure rather than a healthcare structure.

What we are seeing with larger IDNs, as well as with physician/surgeon groups, is a trend toward locating new, stand-alone ambulatory surgery centers away from the critical/acute care hospital setting. ASC’s are performing more complex procedures now than ever before. Patients tend to have a better experience in this type of setting and recover better at home. What this does for the inpatient side is free up valuable OR time for more complex inpatient procedures that need hospital care following surgery.

As hospitals renovate existing spaces, the trend is toward flexibility. Generally speaking, they are not increasing the current building footprint but instead designing spaces that can be easily reconfigured for future demands. These flexible OR settings can be reconfigured for multiple cases or re-purposed for another use outside of surgery in the future (CCU/ICU space).

Build or upgrade? The answer typically reveals itself even before the planning process begins once the objectives of the project have been established. If a traditional OR is simply being re-outfitted with new technology (lights, booms, table, cabinetry, ancillary equipment) to re-establish a state-of-the-art environment, it’s highly likely the current OR footprint can accommodate these changes through a straightforward room renovation.

However, once it has been determined that image-guided procedures will be performed in a Hybrid OR setting, the need for ground-up construction increases exponentially for the same reason why it’s impossible to place ten pounds of sugar in a five-pound bag.

Space limitations become even more acute if the Hybrid OR is expected to be scheduled for multi-disciplinary use across an expanded list of specialties such as neuro, orthopedics, trauma, thoracic, oncology and urology — in addition to vascular, cardio and neuro-navigation procedures.

In the Hybrid OR, space truly is the final frontier that needs to be conquered, and current footprints are most likely too small to comfortably and safely accommodate additional imaging equipment, integration technology and staff.

New construction is also called for when hospitals need to add capacity to handle an increased OR workload. For example, since 2010, more than 75 rural hospitals have closed their doors, and it has been reported that nearly 700 additional rural facilities could soon be facing a similar fate.

In these situations, or when communities are experiencing explosive population growth, hospitals have little choice but to add brick and mortar to serve everyone in need.

Many customers look to regularly augment their integrated operating room for years after the initial installation, without undergoing complicated or costly construction to do so. By investing in integrated solutions that offer scalability, facilities can add new capabilities to their existing systems as the operating room’s needs grow and change.

For example, with the enhanced detail of 4K resolutions now entering the healthcare space, it’s more critical than ever to ensure that the integration installed today can easily and quickly accommodate these signals when the hospital chooses to adopt 4K imaging devices. Likewise, because technologies are rapidly advancing, hospitals want to ensure that any renovations, updates, or upgrades done now will accommodate future technology with minimal disruption and expense.

How is traditional surgical equipment evolving to accommodate and facilitate use in a hybrid or integrated OR setting?

In most cases we see the operating room designs centered on multi-specialty use. This makes scheduling, set up and turn over much easier. In some cases, specialty rooms will come into play where volumes support the design. If, for example there is a growing heart program, you may see a cluster of rooms in the renovation design that will be specialized to support these cases.

Surgical equipment has been moving more and more into the dedicated room, ceiling mounted design. Equipment booms that allow for equipment to be off of the floor and that can easily be brought into the surgical field for use in a case or moved outside the field when not needed. The design needs to take into consideration patient positioning and be flexible enough to adapt. With more and more minimally invasive cases the expectation for video integration has expanded to allow visualization of the case throughout the room and often in offsite educational settings. Robotics also comes into play in the design as the robot has specific special needs that need to be coordinated with all of the ceiling devices.

How have booms/ceiling solutions advanced in recent years?

One of the most significant equipment-related discussions in operating room project discussions is around booms. The trend is to include booms to clear the floor of equipment and minimize the run of cords and tubes going to the patient. This allows staff to flow easily around the room, makes equipment more flexible in its positioning, and reduces tripping hazards. Although these are great outcomes of deciding to include booms in the project there is a significant cost for the equipment and structural support required to accommodate it. We have many clients that have to leverage the benefits of purchasing booms versus the cost.

Boom technology has evolved out of necessity over the past decade to accommodate multiple large flat screen monitors and associated cabling that serve at the heart of image guided surgery and OR integration. At the same time, ceiling supply unit arms and distributors are now being designed to be even more robust and adaptable, consistent with the widely-established preference to de-clutter the OR floor.

The Maquet Moduevo ceiling supply unit is distinguished by a number of performance, productivity and risk management advantages with the goal of making equipment management extraordinarily simple. The advanced design of our Moduevo units reflect an understanding that in a patient-focused environment, professional staff doesn’t have a moment to spare to give a second thought about the equipment and devices they’re using.

Getinge has closely examined the ways in which staff members work together in a clinical setting, and how they access the boom-based equipment and utilities they use. In turn, Getinge’s evidence-enriched approach has resulted in the creation of one of the industry’s most user-friendly ceiling supply unit. For example, easy grab-and-move positioning features human-touch-sensing technology that automatically releases the unit’s brakes when the handle is gripped to help speed repositioning in rapid response situations. This is accomplished with minimal physical effort and smooth, highly controlled movements.

In addition, Moduevo’s exclusive distributor design is equipped with our company’s exclusive Ergonomic Positioning System (EPoS) that lets staff quickly attach and position any component or accessory — even brake handles requiring a power supply — without constraint on any mounting position on the distributor at any selected height.

Recent trends demonstrate that hospitals are considering pre-fabricated, modular ceiling solutions such as the CLEANSUITE Ceiling System for placement above the sterile field. The CLEANSUITE Ceiling System integrates laminar flow air delivery, LED ceiling lights and also serves as a structural steel, space-frame for mounting lights, booms, monitors and C-arms. (CLEANSUITE is a registered trademark of Nortek Air Solutions, LLC.)

Since the product is produced and validated in a factory, it helps reduce change orders and project delays that are often associated with traditional “stick-built on-site” ceiling systems. This can help ORs get back up and generating revenues faster than traditional construction. Another advantage is that the CLEANSUITE Ceiling System delivers ISO Class 5 cleanroom level of air quality to the OR space, which greatly exceeds industry air-handling standards (ASHRAE 170). The end result is a modern installation which delivers a healthier environment for patients and clinical staff.

Aside from being able to support modern procedures, what other benefits do OR upgrades provide to patients, surgical staff and others?

If done properly a calming effect can be created for the entire experience of both patient and staff. This allows for greater staff retention as well as better patient recovery experience.

Upgrading the operating room has tremendous benefits in the sense that the facility can install state-of-the-art equipment, which allows the surgical team to provide improved care to the patients. There are also opportunities to improve the staff flow within the room, which is critical in reducing the number of steps for staff and reducing hazards that staff face in a surgical environment.

The benefits that OR upgrades can provide to clinicians and their patients include:

• More efficient throughput of cases — meaning the ability to turn a room around from one case to another in a more efficient manner, saving time
• Adjacencies to central sterile that can increase productivity and turnaround of critical instrumentation
• Improved environment and acceptance from staff and surgeons
• The right technology in the right place and at the right time
• Basically, creating an efficient environment will tend to create a better experience for surgeon, staff and patient

Rockow:

Every successive medical discovery and advancement throughout the course of history has in some small or large way helped humankind enjoy longer, healthier lives. Patients who enter the OR — as well as their friends and family members who anxiously await word of the surgery’s outcome — will always be comforted in knowing the surgical suite is provisioned with the latest and greatest iterations of medical technology.

Even more importantly, surgical staff can enter the OR with full confidence they have the most advantageous equipment, resources and workflow strategies at their command to help achieve the positive, life-sustaining outcomes they seek.

From an administrator’s perspective, there are a number of ways for hospital leadership to calculate the benefits of an OR upgrade. But perhaps none are more compelling than taking stock of the look of relief and gratitude on the faces of patients and their loved ones because everything went as planned in the OR.

OR upgrades can increase the OR’s safety, efficiency and even improve patient outcomes by enhancing the complete continuum of care. Modern OR integration connects the OR with clinical teams, information systems, and other resources outside the OR’s walls, making every procedure a cooperative opportunity.

For example, through an integration upgrade, the clinical team within the OR has instant access to the patient medical record to ensure informed treatment and can conference with a remote specialist during the procedure for instant consultation. Throughout the procedure, information about case progress can be captured on a dashboard, helping to improve room turnover and utilization. These are simply a few of the ways that an upgrade to modern OR Integration can help the hospital facility be more effective.

What should healthcare product/service evaluation and purchasing teams know about your company? Why are your services a good investment?

We make use of specific tools and methods when designing a space that show how to effectively use the space more efficiently — and more efficient use of space saves dollars and staff and reduces materials and the cost of space itself. Using these tools, we can also assist in understanding how much of the space is required based on expected patient volumes.

Vizient can support providers in all areas of capital and construction investment in their facilities. Our capabilities and consulting expertise includes:

1. Analytics and expertise to help accurately anticipate critical health care trends and understand unique, local market dynamics
2. Lean-led design that identifies and integrates opportunities for operational efficiencies that increase throughput; thereby expanding capacity
3. Capital equipment services, including medical equipment planning, Revit/BIM design, procurement, project management, logistics and installation coordination and capital equipment lifecycle management
4. Subject matter expertise in facilities and construction to identify opportunities for process improvement and standardization/aggregation and savings on day-to-day facilities, plant operations and related services
5. GPO agreements to support all aspects of capital and construction projects, as well as day-to-day maintenance, repair and operations of facilities

More than anything else, OR integration technology should make it extremely easy for staff to access and orchestrate the overwhelming flow of live/archived images and patient data in a Hybrid or traditional OR while managing key equipment/room functions from a single point of control.

Today, many OR integration systems overcomplicate what absolutely needs to be easy, creating a degree of uncertainty and confusion among OR staff members who need to access information and modify settings without hesitation or delay.

Getinge’s Tegris OR Integration System features a highly intuitive touchscreen interface and scalable/upgradeable system architecture that dramatically simplifies total connectivity inside and outside of the surgical suite. Tegris is designed to interface with leading HIS, RIS, OR planning and PACS systems to seamlessly integrate into existing IT environments.

Scalability and upgradability make it possible for Tegris to protect an institution’s initial investment by supporting the ever expanding and changing needs in the OR as standards and technology such as 4K video routing continue to evolve.

STERIS Harmony iQ | BDV Integration Systems are designed to fit into today’s environments with tomorrow’s needs in mind. Our OR integration systems offer a unique, minimally disruptive approach to installation, easily fitting within the design and infrastructure of an existing OR. Because our systems are card-based and extremely flexible and upgradeable, once the OR integration system is installed, facility staff can enjoy these systems for years, quickly adding new capabilities and connections as needed, with minimal OR downtime. These upgrades can range from adding our SignatureSuite solution for patient relaxation, to a simple card-based 4K upgrade to allow connection of the latest 4K imaging devices, and much more.