Preparing for Robotics: Flexibility is key to successful design of present and future cath lab space

Dan Rectenwald, AIA, ACHA, Senior Medical Planner HGA, Inc., Minneapolis, Minnesota
Dan Rectenwald, AIA, ACHA, Senior Medical Planner HGA, Inc., Minneapolis, Minnesota
Medical robotic equipment is emerging as a solution to this problem. The Siemens-designed digital imaging system (AXIOM Artis dFC Magnetic Navigation, Siemens Medical Solutions, Malvern, PA) can work with magnetic navigation systems to help cardiologists improve the ease and accuracy of catheter-based interventional procedures. Other systems, such as the da Vinci Surgical System and Zeus Surgical System (both by Intuitive Surgical, Inc., Sunnyvale, CA), are also making advances in robotic-assisted equipment for various types of minimally invasive surgery. With these tools, surgeons’ efficiency is intended to be improved by remote direction and digital control of catheter-based devices along the body’s complex paths. While robotics facilitate minimally invasive surgeries, at this point in time, the technology offers limited improved outcomes over traditional minimally invasive surgery (MIS). Robotics still represent a high cost with no significant reimbursement benefit. However, the opportunity to use this advanced equipment can boost recruitment of medical professionals. While the trend toward robotically-guided surgical assistance is just beginning, contemporary cath lab design must accommodate these and other evolving technologies in the future of this fast-changing medical field. Since current cath lab technology has advanced to the point of being useful for several different applications, flexibility is paramount in cath lab space and equipment planning. Three conditions determine the parameters of this flexibility: 1) Positioning and adjacencies of surgical and imaging spaces, facilitating collaboration among members of two or more different departments; 2) Use of mobile versus fixed equipment (sliding rails, floor and ceiling mounts); 3) Providing for ample and flexible space within the suite for positioning flexibility, storage and future technologies, such as robotic tele-surgery (in-room or assisted from remote sites). Positioning and Adjacencies To support the flexibility needed for current and future technology, the ideal departmental relationship diagram positions the surgery department adjacent to imaging rooms for catheterization, magnetic resonance imaging (MRI) and other special procedure suites. Bringing surgery and imaging together allows MRI equipment (and ALL equipment) to be easily used for both surgery and diagnostics. Furthermore, when a cath lab and other specials rooms are positioned between surgery and radiology, physicians from both departments can use them equally, as well as being poised to collaborate. In planning the contemporary cath lab or angiography suite, designers work to create a functional and pleasing environment for the physicians, support team and the patient. While collaboration among physician specialists is increasing, they may at first view a shared approach as threatening, especially regarding scheduling and reimbursement for a common cath lab. Placing the patient’s safety first in terms of design and operations allows everyone to succeed. Controlling access to the room is paramount. It may be left open for a catheterization, but must be closed and secure when immediate surgery is needed. Often, doors can be secured between rooms; vestibules create space breaks between surgical and imaging department sides of the space. Access from the imaging department may be from one direction, while access from the surgery department will need to come from a clean and controlled corridor. Often this means providing two access points into the room, which must be considered when sizing the space and reviewing equipment layout options such as fixed location and movement pathways for imaging, as well as support devices, including lights and medical gas delivery. A versatile cath lab should be planned for the right power, circuitry and low-voltage infrastructure to support such operational and procedural flexibility. It must also accommodate the great differences in air quantity, temperature, control, humidity and flow, as needed between the traditional imaging and surgical spaces. These mechanics can be adjusted at the flip of a switch if the cath lab is part of an infrastructure that has anticipated these scenarios (even with the vertical clearances necessary for more extensive systems). Air volume, temperature, humidity, and air delivery (as well as air return) is a challenging feature in special procedure rooms, since the equipment can tend to get in the way of proper laminar flow over surgical sites. Coordination of the ceiling devices, lighting and equipment slide rails is essential. Floor-mounted equipment can help alleviate ceiling conflicts, but must be tested for room layout options and not limit flexibility. Lighting, power and telecommunications present other challenges. Often during initial construction additional conduits are provided to allow for increased services in the future, even if the conduits are initially left empty. An example of flexibility in action, the new surgical suite at Benefis Healthcare in Great Falls, Montana, has special power boxes in each room allowing for a variety of power types to test lasers and other equipment in the future. This way, with very little work, new equipment can be trialed without disrupting other typical room functions. At Mercy Hospital in Cedar Rapids, Iowa, voice activation and picture archiving were added in the new surgery suites, but also added were conduits for future picture archiving and routing connections to other departments. The Hermes system (a robotic speech recognition system by Intuitive Surgical, Inc.) selected for this technology advanced through three different versions during the project, a result of evolving requirements and product development. Each version required the room to be adapted during construction, emphasizing the need for flexibility in infrastructure. Designing for Both Mobile and Fixed Equipment While the quality of mobile equipment for minimally invasive surgery is rapidly improving, its acceptance rate is still evolving. Advances in mobile C-arm technology offer great advantages for procedural efficiency and flexibility, yet fixed equipment still tends to better satisfy practitioners’ traditional paradigms or mindsets. In designing lab spaces for fixed equipment, adequate space is required for patient transfer between spaces and for surgery reconfigurations. The space in the room must allow staff to operate in various room/bed configurations within the sterile field. The anesthesia and other technologists’ circulation areas must be able to change depending on procedure type. When the space will be used for needs other than the cath lab, a greater amount of square footage is required. Advances in mobile equipment go beyond diagnostics and include the quality of ceiling or wall-hung booms that facilitate procedures. Columns for anesthesia gasses have been improved; once fixed vertically, they are now available as lightweight swing arms that provide clearance underneath lighting, are easily repositioned and allow for unobtrusive support within multiple configurations of the room. The space and equipment configurations must be tested for preferred set-ups for various procedural types. The room’s primary use should be a strong consideration, but adjustments for special case types will also influence design. Designing a room around mobile equipment requires considering not only how the table and patients will be positioned, but also how equipment will be maneuvered into the space. Door openings often need to be wider than the four-foot standard door, suggesting the use of multi-leaf swing doors and slides that allow major equipment to pass through without risk of damage. Providing access to several procedure rooms for mobile equipment is the key to its utilization. Where equipment will be stored and how it will move through the department and between various procedural rooms must also be considered. Finally, mobile equipment sensitivity requires that some facilities have dedicated rooms for equipment storage and repair. Depending upon the equipment’s cost and sensitivities, corridor or vestibule equipment parking can be considered, providing that it does not interfere with patient movement. Identifying dedicated storage, even in open corridors, is preferred. For the cath lab in particular, a storage room may also accommodate additional catheters and supplies. Enclosed lockers can provide shelving that is sterile, easily accessible and portable, as required. Cath Lab Robotics Medical robotics intelligent machinery that can be used in clinical practice is expected to improve procedure outcomes, as well as provide innovative new approaches. Robotic assistance can help physicians offer procedures to people in remote locations, or steady maturing surgeons’ hands. Robotics can also be used to teach medical students, enhancing their observational experience. While robotics has not yet achieved widespread use in the cath lab, principles of computer-guided probes are beginning to be applied. In the cath lab, magnetic navigation systems allow cardiologists to direct cath procedures from miles away. To support this direction, labs must include appropriate power and telecommunications connections for robotics. The ideal space diagram places dedicated rooms, which include connections to remote sites, immediately adjacent to the patient area. Other emerging medical technology includes voice-activated equipment, which follows verbal commands to control illumination, retrieve records and images, and other essential tasks. Designed to facilitate the physician’s work, such equipment also saves time for the circulating nurse and other staff. To accommodate this technology’s many features, additional connections to other areas within a medical center are needed, integrating many aspects of patient care throughout the facility. Flexibility, Flexibility, Flexibility Flexibility is paramount in space planning for surgery suites, special rooms or future cath labs to support an ever-increasing array of procedures being practiced in these rooms. With the delivery of more advanced technology just around the corner, these spaces must be planned to accommodate robotics and other new equipment with minimal disruption and without compromising patient safety. With an eye to the future, design and planning of space and infrastructure will help continue to provide the best patient care in the right location. Dan Rectenwald can be contacted at drectenwald@hga.com