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 best.
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 waiting.
- 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 suite.
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 costs.
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.
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 equipment.
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 system.
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 firstname.lastname@example.org.