The Software Hospital

Dennis L. Kaiser, AIA, LEED, AP Principal, Perkins & Will, Boston, Massachusetts
Dennis L. Kaiser, AIA, LEED, AP Principal, Perkins & Will, Boston, Massachusetts

Making the transition from “the way it’s always been” to the lower-cost, higher-efficiency, better-care alternative

Why should an operating room be like a desktop computer? A desktop computer can perform several functions because of its design. The installed software allows a user to run a word processor to draft reports, a mail service to communicate, a high-powered calculator to crunch numbers, and/or the Internet to research, read the news or just relax. Emerging hospital design concepts make it possible for hospital surgical suites and procedure rooms to function in a similarly efficient manner. Today, one specialized procedure room can offer balloon angioplasty and stenting, atherectomy, embolic protection, catheterization procedures and other minimally-invasive procedures — as well as more common invasive procedures. Imagine a series of 650-square-foot universal procedure rooms laid out in zones. One zone will handle cardiac catheterization procedures today, and a year later, robotic surgery. The design of these kinds of rooms enables change to happen inside the walls. Varying structural and infrastructure requirements can be anticipated and built in without adding significant first costs. In other words, the room, like the computer, stays. What changes is the “software”: the cardiac catheterization equipment makes way for new equipment, which handles open-heart surgery. In turn, advances in genetics might shift the room back to a new minimally invasive procedure. Individual ORs could thus morph back and forth, evolving with technological advances almost as easily as new plug-and-play software installed on a computer. Strength in Numbers Consolidating the number of hospital invasive and minimally invasive procedure departments into a single, well-designed interventional department with numerous shared spaces endows the new department with great strengths. The layout might look something like this: an invasive surgery zone or a minimally invasive procedure zone is adjacent to a recovery zone. Nearby is a single large locker room for all of the specialized as well as cross-trained staff members who work in the interventional department. Such centralized facilities encourage clinical collaboration and improve efficiency. Centralization can also make administrative initiatives such as infection control programs and policies easier to implement and monitor. Furthermore, a consolidated department cuts costs by reducing end-of-day support and resource requirements. In a decentralized setting, each department might serve only one or two patients; even so, it would be necessary for a full compliment of staff to cover each department. By contrast, a consolidated interventional department might serve many more patients, but with the same compliment of staff. Large centers as well as smaller community hospitals can benefit from this type of setup. The Way It’s Always Been While some hospital surgical units have consolidated into single interventional departments, most have not. They continue to operate in the traditional way because that is how they evolved. Over the years, interventional procedure areas within hospitals — general surgery, cardiac catheterization, interventional radiology, gastrointestinal and other specialties — have operated as individual dedicated departments, each with its own pre-and post-operative areas, staff stations and staff, lockers, support areas, utility rooms, public and non-public corridors, and entries. As technologies advanced, the separate disciplines — and associated procedures — grew out of the original specialties. The cardiology department, for example, accommodated cardiac catheterization and other minimally invasive specialties, which did not originally require the same level of infection control as more invasive surgeries. Thus, specific procedural rooms led to adjacent expansion by specialties across the facility. Cath labs, along with all the other minimally invasive specialties, got their own dedicated areas including procedure rooms, lockers, staff, entrances and other support areas. It is perhaps useful to recall that these minimally invasive technologies were developed for departments that were already in decentralized areas of the hospital. So when the new technology came to the hospital, it made some sense that it be placed with the department that was buying and using it. In recent years, however, revised regulations designed to improve infection control have been standardized around the more aggressive measures applied to operating rooms. As a result, hospitals have had to implement these controls in rooms used for catheterization and other minimally invasive procedures. It is, therefore, often much more efficient to move minimally-invasive procedures into the same kinds of rooms used for invasive surgeries. The New Regulations Based on current regulations and the trending to include a greater level of gowned/un-gowned traffic control and separate support space, the space efficiencies of combining multiple interventional services together are very real with resulting financial savings on facility development. Quoting from Guidelines for Design and Construction of Healthcare Facilities AIA 2006: 5.4 Interventional Imaging Facilities 5.4.1 Cardiac Catheterization Lab (Cardiology) Location. The cardiac catheterization lab is normally a separate suite, but location in the imaging suite shall be permitted provided the appropriate sterile environment is provided. Support areas for the cardiac catheterization lab (1) Scrub facilities. Scrub facilities with hands-free operable controls shall be provided adjacent to the entrance of procedure rooms, and shall be arranged to minimize incidental splatter on nearby personnel, medical equipment, or supplies. (2) Patient prep, holding, and recovery area or room. A patient preparation, holding, and recovery area or room shall be provided and arranged to provide visual observation before and after the procedure. Support areas for staff (1) Staff clothing change area(s). Staff change area(s) shall be provided and arranged to ensure a traffic pattern so that personnel can enter from outside the suite, change their clothing, and move directly into the cardiac catheterization suite. 5.5.2 Angiography General (1) Space requirements. Space shall be provided as necessary to accommodate the functional program. (2) Provision shall be made within the facility for extended post-procedure observation of outpatients. Scrub facilities. A scrub sink located outside the staff entry to the procedure room shall be provided for use by staff. Patient holding area. A patient holding area shall be provided. Culture Wars As architects have applied the revised AIA 2006 regulations for infection control to new and renovated hospital designs, it has become clear that building dozens of separate invasive and minimally-invasive procedure rooms to full infection control criteria spreads unnecessary costs throughout a hospital. But rather than a massive push toward a consolidated interventional department with a handful of adaptable procedure rooms, this kind of design has been slow to catch on. The reason is that people are slow to accept change. They resist that which might reduce their authority, influence, departmental cohesiveness or independence. Often a decentralized department has their own “sense” of governance and autonomy, which may be a primary barrier to change. These cultural barriers make it difficult to consolidate procedure rooms into one area of a hospital. Administrators may find that the underlying reasons to avoid change remain unstated and issues of staff morale, desire not to share staff and the desire to be adjacent to other non-invasive activities of the department may be presented. It is true that consolidation does have its costs. Physicians and nurses will probably lose the small departmental lounges and locker rooms they have used for years. Now they will share facilities with other departments and perhaps lose the sense of belonging to a tightly-knit group. But it seems a small price to pay for the improved quality of care and economies made possible by consolidation. The larger group also offers greater opportunities for collaboration — for taking advantage of the expertise available from other disciplines. Administrators and physicians who work in hospitals with consolidated interventional departments note the benefits of belonging to larger groups. Physicians indeed believe that collaborative expertise is available whenever it is needed. Nurses, meanwhile, report reduced levels of stress when they are able to share workloads across patient types through cross-training. Support functions such as anesthesiology, lab, central processing, PACU, etc. also benefit from the consolidation. Finally, administrators see positive results in the form of lower costs. Owners and administrators contemplating the switch to a consolidated interventional department are wise to visit facilities that have already made the change — and talk to the administrators, nurses, and physicians who work there about the advantages and disadvantages. The University of California, Los Angeles’ (UCLA’s) new Westwood Replacement Hospital (Los Angeles, CA), The Johns Hopkins Hospital (Baltimore, MD), Rush Presbyterian Hospital (Chicago, IL), Piedmont Newnan replacement facilities (Newnan, GA) and El Camino Hospital (Mountain View, CA) are all facilities that have adopted or are adopting various forms of a centralized interventional department. Their experiences will help smooth the transition from “the way it’s always been” to the potentially lower-cost, higher-efficiency, better-care alternative. Dennis Kaiser can be reached at: