Today’s operating rooms are inefficient and overcrowded, and the turnover between cases is often lengthy and variable. New technologies and devices are often introduced haphazardly into an already technologically complex environment. This often leads to an HVAC system that is not equipped to handle these technological advancements. Adding these technologies over time will tremendously reduce the effectiveness of the HVAC system and its ability to meet the load and infection control requirements. This, in turn, potentially affects patient safety and hospital operating costs.

Surgeons are demanding very sophisticated operating rooms, larger ones, and more stringent temperature and humidity requirements. Existing operating rooms, because of age and changes in codes, will struggle to meet the demand of these surgical teams. Existing hospitals operating rooms are often in need of a major overhaul to meet these stringent requirements, and the luxury of new construction is rarely on the cards. So upgrading these operating rooms usually means very complex renovation projects in one of the most important spaces in the hospital. What can a hospital facility team do to make renovation and expansion of the operating suite efficient and cost effective? This article will address some of the key items that need to be addressed to ensure a successful operating room renovation project.

As project teams dissect and reassemble the most revered real estate in any hospital, utilizing technological advancement, portable technology, and the inclusion of hybrid operating rooms can all work to a facility’s advantage. Hospital facilities teams should be prepared for multiple project phases and disruption to their hospital operation. These intricate renovation projects can last anywhere from six months to five years, depending on finances and the level of renovation required.


Technological Advancements driving today’s Operating Rooms

Operating room technologies have change a lot over the years, mostly due to the advent of less invasive surgical procedures. Computer-assisted technology and highly specialized tools and instruments are used to assist the surgeons with visualization and control. The popularity of image-guided procedures have introduced the health care industry to hybrid operating rooms and tele-surgeries.

Procedures such as tubular ablation for cancer treatment and single-incision laparoscopy surgery are all conducted using image-guided three-dimensional videos images. Operating rooms are now being designed to accommodate machine intelligence and robotics. This process and innovation continues to enhance the human/machine interaction. The use of da Vinci and TransEnterix surgical robots are becoming commonplace for use in soft tissue surgeries. This is very beneficial to patient care and safety because they provide a number of benefits when compared to traditional surgical procedures; some of these benefits are smaller surgical incisions, reduced blood loss, lesser post-operative pain, faster recovery time, less scarring, and improved function.   


MEP and Structural Drivers

Operating room renovation projects often starts with the poor state of the existing space. However, there are a number of other factors that have to be considered before starting the design process. Usually some of these factors are not as visible as the surgeons need for space and better environmental condition. The most important of these considerations are the MEP and structural requirements of the new space. The facilities team is encouraged to conduct a full evaluation of the existing MEP and structural systems. The condition and capacity of these systems will play a significant role in the feasibility and phasing plan as well as the construction budget. MEP systems that are more than 20 years old are unlikely to meet the current code requirements.

The 2014 Guidelines for Design and Construction of Hospital and Outpatient Facilities now refer to operating rooms as a “wet room.” This means that isolation panels are required to be installed before any renovation of the existing OR spaces, which in turn increases the electrical requirements. This means that two isolation power panels will be required: one for normal and one for critical power. This could be two critical power panels with each panel coming from a separate automatic transfer switch (ATS). Electrical systems that are in excess of 15 years old are unlikely to meet these new guidelines.

This also means that the wall housing the isolator power panels will need to be a minimum of 12 in deep depending on the manufacturer of the panels. A possible solution to this wall depth requirement is to place the isolation panels in the corner wall of the duct chase. Sometimes the renovation involves the addition of a hybrid OR with fixed imaging and interventional equipment in the room — such as catheter lab equipment, these hybrid rooms usually require additional cables, power, integration, and HVAC.

Additional structural support will be needed for lights, booms, and monitors, and therefore the room will have to be expanded to accommodate this equipment. Operating rooms have become increasingly larger because of the equipment and code requirements. Older operating rooms are usually 350 to 400 sq ft, while new general ORs are between 500 and 600 sq ft. Neurosurgical and orthopedic operating rooms are between 600 and 800 sq feet, whereas a hybrid OR might be anywhere from 800 to 1,200 sq ft. Those upgrades to the MEP infrastructure systems, which are the first step in the renovation process, could be up to 50% of the construction cost.

The available ceiling height also affects the mechanical systems layout in operating rooms. Floor-to-floor ceiling heights of 15 ft are more are a dream for engineers renovating a surgery suite. If you have 15 ft or more from floor to floor, the mechanical ducts and terminal units or air valves are not limited in where they can be placed in the room. Floor-to-floor ceiling heights of less than 12 ft are a huge challenge for engineers because the mechanical ducts will not fit in the center of the rooms, making low soffits around the perimeter of the operating rooms necessary.  Lack of ceiling space can also affect ceiling-mounted booms that support medical gases, lights, power, data, monitors, and shelves for equipment. Locating the mechanical ducts and structural support for equipment booms can also be very challenging in low floor-to-floor heights.


Solutions for handling low ceilings heights

Renovating an operating room is often associated with complicated ceiling coordination. The structural supports for the booms can be located on the sides of the air distribution ductwork. For example, the engineering team was working on a project where there was a low structural beam in the ceiling which only allowed hybrid operating room equipment to pass but not the ductwork. The solution was to separate the terminal units and lights to operate on each side of the structural beam.

In another project, the ductwork could not be relocated so a ceiling-mounted monitor was located at the end of the operating room table with an extension arm. The only space available was for an anesthesia boom, so hose reels were used for electrical and medical gases, which required less space. Lights with extended arms can also be used to reach the surgical table and small monitors can be located on the same arm. When dealing with low ceiling heights, communication between the facility engineers, mechanical and structural engineers, and the architect is crucial as each situation will likely require a unique solution.


Streamlining the design and construction process

Operating room renovation projects often require multiple phases during the construction to keep the surgery suite in operation. These phasing plans will have to be documented in the architectural and engineering plans to ensure that the process of execution is well thought-out and communicated to the design and construction team. Phasing of the project should start with the design team; the mechanical engineer is usually a very important part of the process because phasing is usually based on the AHU zoning.

The construction team should then revisit the phasing plans and update it based on the surveyed existing condition. Phasing of the project should also be reviewed with the surgery staff, facility manager, and by the project team to ensure all parties understand what moves and the disruptions that will take place, the duration, and when they’ll occur. It is better to implement the pull planning technique for the scheduling of the tasks during these types of projects. Breaking down each phase and documenting it for the renovation phasing will setup the team for a successful project implementation.  

The control of dust and debris in operational operating rooms can be challenging during construction, and IAQ needs to be managed closely to ensure that it doesn’t become an issue for the surgery staff. The most import aspect of the renovation process is to ensure the sterility of the surgical suite at all times. Therefore, all work in the surgery suites should be constructed in compliance with local infection control risk assessment standards and the 2014 Guidelines for Design and Construction of Hospital and Outpatient Facilities. These standards are for the building and site areas that will be affected by construction and should include the determination of specific hazards and protection for each construction area.

Construction crews need to be flexible in their work hours because construction noise can be a dealbreaker for surgical procedures. If the noise cannot be contained, the construction team should conduct any noise related activities during evenings and on weekends. The noise related activities should be fully coordinated with the facility staff and the surgical team. The best scenario would be to block off an area of the surgical suite and create a separate construction entrance and egress for materials and debris. If this is not possible, the construction crew will need to be gowned with feet covered, and all material going in or out of the operating room must be covered.

During the construction duration, a TAB engineer independent of the construction team or hospital engineer should monitor airflow regularly to ensure negative pressure in the construction zone and to prevent contamination. One helpful approach is to find an adjoining soft space, such as an office or storage room, to explore an expansion.

For example, for the Carilion Clinic operating room expansion and renovation project, a storage and sub sterile space adjacent to an existing special procedure room was used to create a new minor procedure room and to avoid the shortage of space during renovation.


Keys to success

In the end, renovation and upgrading of the surgical suite can best be accomplished by using an integrated team and a collaborative process. This process requires successful communication between the surgical staff, the facility team, the commissioning agent, the contractor, and the architecture/engineering team. This communication should occur throughout the renovation process and into the initial operational phase. The more information the staff has, the fewer surprises there will be for the project team. It is also important during the initial operational phase to create a feedback loop so that issues can be resolved by the construction team during project close out.

When surgery suite rooms are upgraded to meet the new space requirements, MEP and structural requirements, this usually results in a surgery environment that consist of advanced technology integration. This will allow surgeons to be able to perform day-to-day operations for complicated procedures in the safest environment for patients and staff.