Dirt and Aspergillious in Surgical Suite Renovation: Planning a"Clean" Fight

January 1, 2002

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Dirt and Aspergillious in Surgical Suite Renovation: Planning a
"Clean" Fight

By Bruce Knepper, AIA, ACHA

The renovation or expansion of an existing surgical suite is not a project to
be undertaken lightly. In general, facilities tend to put this off until the
need to expand or update can be financially justified. The surgical suite is
also extremely busy, making shut-downs and schedule restrictions difficult at

Reasons for Renovation

There are a number of reasons to alter the surgical suite. The first is to
add technology. As the technology explosion accelerates and changes the way
surgery is performed, the facility will need to change to provide support. A
second impetus is to increase the capacity of the suite, adding more ORs,
changing patient flow, and improving the "pit stop" time to increase
productivity. In some cases, facilities have simply outlived their useful
lifespan. Suites that are 30 years old can seldom support today's procedures.

Whatever the reasons or rationales, the journey from beginning to end can be
difficult. The key to any successful program is a clear and concise plan. This
is simple in concept; however, it is often difficult to achieve. There must be a
strategic plan to establish the goals and objectives of the program, and
facilities must plan to meet the needs of future changes. In an effort to keep
this article concise, we will not attempt to outline or identify the models and
methods of strategic planning. Suffice it to say that a strategic plan becomes
the foundation upon which all else is based, and a solid foundation is the key
to any successful project.

Implementing the Plan: A Problem/Solution Approach

After completing a balanced strategic plan (with buy-in and support from the
entire staff) it is time to map out the implementation. Step one is to find
competent help. Facilities can reap great benefits from the talents of an
experienced healthcare planner or healthcare architect. Find someone with broad
healthcare experience as well as a keen ability to build consensus among diverse
groups. With this accomplished, a facility can move to the facility
solution-planning stage, addressing the challenges and solutions needed to
satisfy the strategic plan. These can relate to anything from through-put,
dealing with increased capacity for pre-operative functions to decrease
preparation time before surgery, to increasing the capacity of the
post-anesthesia care unit to efficiently and safely recover patients. It may
address the types and features of the operating rooms themselves, i.e., Will
there be dedicated rooms for orthopedics, cardiovascular, etc.? Will ambulatory
procedures be performed in specific rooms? Will the rooms be universal, allowing
greater flexibility within the schedule?

A close look at infrastructure will identify various engineering systems that
must also be upgraded: do the air handling systems, medical gas systems and
data, and communications support the strategic plan? A comprehensive solution is
the best approach.

This is a critical portion of the project, as solutions developed here
translate directly into costs. Decisions made early can have the greatest impact
with the least expenditures of dollars. In essence, if it is decided during
construction that the renovation must include an additional operating room, the
cost at this stage will be overwhelming. If that decision is made early, the
costs will be manageable.

This is also a time to "think out of the box." People plan from the
perspective of their current working conditions; generally, it is their only
frame of reference. This is where a good planner earns his or her fee. Think
about how work flows through the department between patients, materials and
surgical staff. Improvements in any of these areas will impact the financial
success of the project. Remember the following objectives:

  • Manage the equipment; don't let it manage you. Plan for equipment, and
    keep it organized so that it can be brought to a room on demand, without
  • Evaluate the flow of patients into the suite, to induction, to the ORs, to
    recovery, and so on. Make these paths efficient.
  • Keep Phase I recovery as close as possible to the core operating rooms yet
    easily accessible to the anesthesia staff. Anesthesiologists often need to
    be in many places at once, such as pre-op, operating rooms, and recovery.
  • Manage the flow of clean and soiled materials.
  • Keep the surgical staff workflow organized and efficient.

The Renovation Process

After developing all of the proper adjacencies and defining a facility plan
to maximize the efficiency of the staff and provide a safe environment for
patients, it is time to plan for construction and implementation of the surgical

Construction is noisy, dirty, inconvenient, disruptive, and occasionally
dangerous. The facility plan must recognize that this renovation will occur in a
functioning surgical department, where quiet and sterility are the rule. Before
final plans are developed, work through the phasing of the construction
sequence. Enlisting the aid of a trusted contractor may be beneficial, as they
will have valuable insights into this phasing. There are a few colliding needs
at this stage. The first is to have little or no disruption. The second is to
complete construction in as short a time as possible. A third is to minimize the

Plan the renovation in blocks of time that will allow construction to occur
with access for the workers without entering the surgically clean areas. This
may be accomplished with temporary enclosures, temporary doorways and even
temporary access from the exterior. This will allow much of the work to occur
during a normal shift. Work hard to achieve as much daylight shift work as
possible, as this will reduce both the costs and the total time. Night shift
work is only 80% efficient, as the 8-hour shift is often reduced to 7 or 7.5
hours. Make the work time blocks as large as possible, as this will increase the
productivity of the workers, reducing construction time and costs.

In planning these initial blocks, don't make the fatal mistake of ignoring
the engineering portion of the project. Replacement, upgrades, and modifications
to mechanical and electrical systems often do not follow the same boundaries as
the architectural floor plan. Therefore, resolve these issues before defining
the phasing. This is an absolutely critical part of the phasing process.
Integration of new systems into existing areas while keeping old systems
operational can be a major complication--plan accordingly.

Phasing may add between 5 and 30% to the cost of actual improvements.
Obviously, the smaller the number of phases, the smaller the cost premium. This
may be an important decision point to review with the surgical group as less
work may be able to be accomplished if the phasing is very restrictive.

The phasing plan then needs to be folded into the final architectural plan,
reflecting the compromises made to achieve the renovation. There will almost
certainly be compromises; however, if the surgical staff is part of the
solution, they will not become part of the problem when construction begins. The
"buy in" to this final plan is critical.

Keeping it "Clean"

Every construction project has a few things in common: noise, dirt, odors,
and disruptions. These are unavoidable, so developing a plan to manage them is
crucial. Noise is a generally a major problem if heavy demolition is necessary.
Night or weekend shift work will most likely be the preferred solution. Keep in
mind that while noise may be limited to an immediate area, vibrations will often
carry throughout the building. Consider implementing a plan to communicate
information about the project to all patients, family members, and staff. There
will undoubtedly be emergency situations when work must stop. This is to be
expected and must be clearly communicated to contractor(s) before they submit
bids for the work in order to avoid future change orders. "Marathon"
weekend shifts are often good solutions, as a great deal can be accomplished
between 5pm Friday and 4am Monday.

Dirt creates some of the most dangerous problems for renovations.
Aspergillious is the prime villain. It resides everywhere, and is transmitted
via air. Taking a few careful steps will minimize patient exposure to this
potentially fatal fungus. Isolate the work area(s) with temporary partitions
consisting of studs, drywall, or fire retardant plywood, polyethylene (fire
retardant) and miles of duct tape. Do not allow temporary walls to be
polyethylene sheeting alone, as this will not withstand the abuse of
construction and may fail.

A second measure is to provide for negative air pressure within the work
area. This will further reduce the chance that airborne dust will migrate into
clean areas. Adding devices to monitor the pressure relationship is highly
recommended. Record the findings daily at the beginning and end of work shifts;
this record may become invaluable evidence in the future. Negative pressure can
be achieved by installing a fan and exhaust it directly to the outside. If this
is not possible, exhausting air into the building system is acceptable if it is
filtered first with a HEPA-style system. This can be a high maintenance option,
and should be considered only if discharge to the outside is prohibitive.

Educate workers about the dangers of spreading aspergillious. If they
understand the danger, they are more apt to exercise the extra care necessary.
Some institutions have required workers to attend classes to fully understand
the importance of containment as well as the exposure risk to themselves.

Clean Finishes

Select finish materials that comply with the Volatile Organic Compounds (VOC)
regulations. If products do not meet the standards (indicated by the
manufacturer), do not allow their use. With current specifications and product
labeling requirements, this is relatively easy to achieve. In a renovation where
dust is difficult to control, facilities may choose to construct the walls with
gypsum lath and plaster in lieu of drywall. In general, there is little dust
created with plaster, while drywall requires sanding of the seams. The cost of
plaster is higher, but may be offset by a reduced need for dust control. Each
facility must evaluate the conditions and make an informed choice.

Flooring is one of the most hotly debated finishes in a surgical suite
project, as it has to perform in many contradictory ways. It must be seamless
for infection control and aid in maintaining the sterile environment. It must
resist the absorption of a wide variety of fluids. Flooring must also withstand
static build-up, while not to the level necessary when flammable anesthetics
where used, it must be adapted to the OR's increasingly electronic environment.
It must also be slip resistant.

A common flooring material is a homogeneous polyvinyl chloride (PVC). The
installation is generally flashed up the wall and all seams are welded to
provide a monolithic floor surface. One drawback is that this material tends to
be slippery when wet. However, slip resistant varieties with a metal oxide
impregnated into the PVC are available. The seams can be the weak element in
either choice, as they are only as good as the craftsmen who assemble them.

Latex has recently become a problem for many people and care should be taken
to reduce the exposure. The common source for latex odors in construction is
paint. A few of the major paint manufacturers have developed a hospital-grade
paint for such use. If a negative pressure enclosure is maintained, odors will
be manageable. However, it is advisable to allow at least two weeks before
moving into a recently completed area to allow for the normal out-gassing from
flooring products, adhesives and other odors to dissipate.

Mishaps During Construction

Beyond the physical challenges in construction, there are also concerns that
are not visible to the naked eye. Radio frequency interference (RFI) is
invisible and may cause major disruptions to sensitive electronic equipment such
as patient monitoring systems. RFI interference is generally the result of
electric arc welding. Special considerations need to be undertaken to provide
for proper grounding and isolation of the electrical system from welding

Assume that the project is now proceeding beautifully. The contractor has
kept noise to a minimum, has kept the facility wonderfully clean and is ahead of
schedule. Then, a tradesman accidentally cuts the power to the entire suite.
Developing a plan to deal with the immediate and accidental loss of building
utilities is prudent. Work with the surgical staff to develop plans to deal with
the loss of medical gases, electricity, water, or even the loss of the HVAC

As with any construction within a healthcare facility, if the OR project
disrupts any life safety features as required by the Life Safety Code, a plan
must be prepared to deal with these issues during construction. The common
problems to be addressed are obstruction of the egress corridors or exits,
interruption of the fire alarm system, or modifications to the sprinkler
systems. The rules for this plan are defined in the JCAHO requirements as well
as the life safety code. Each condition, or "temporary code
violation," requires a solution.

Bruce Knepper, AIA, is a principal with Burt Hill Kosar Rittelmann
Associates, an architecture and design firm with offices in Butler, Pittsburgh,
and Philadelphia, PA; Boston, MA; and Washington, DC. He has specialized in the
design and planning of healthcare facilities for 23 years, and is a founding
member of the American Academy of Healthcare Architects. He can be reached at [email protected].