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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 tobe undertaken lightly. In general, facilities tend to put this off until theneed to expand or update can be financially justified. The surgical suite isalso extremely busy, making shut-downs and schedule restrictions difficult atbest.
Reasons for Renovation
There are a number of reasons to alter the surgical suite. The first is toadd technology. As the technology explosion accelerates and changes the waysurgery is performed, the facility will need to change to provide support. Asecond impetus is to increase the capacity of the suite, adding more ORs,changing patient flow, and improving the "pit stop" time to increaseproductivity. In some cases, facilities have simply outlived their usefullifespan. Suites that are 30 years old can seldom support today's procedures.
Whatever the reasons or rationales, the journey from beginning to end can bedifficult. The key to any successful program is a clear and concise plan. Thisis simple in concept; however, it is often difficult to achieve. There must be astrategic plan to establish the goals and objectives of the program, andfacilities must plan to meet the needs of future changes. In an effort to keepthis article concise, we will not attempt to outline or identify the models andmethods of strategic planning. Suffice it to say that a strategic plan becomesthe foundation upon which all else is based, and a solid foundation is the keyto any successful project.
Implementing the Plan: A Problem/Solution Approach
After completing a balanced strategic plan (with buy-in and support from theentire staff) it is time to map out the implementation. Step one is to findcompetent help. Facilities can reap great benefits from the talents of anexperienced healthcare planner or healthcare architect. Find someone with broadhealthcare experience as well as a keen ability to build consensus among diversegroups. With this accomplished, a facility can move to the facilitysolution-planning stage, addressing the challenges and solutions needed tosatisfy the strategic plan. These can relate to anything from through-put,dealing with increased capacity for pre-operative functions to decreasepreparation time before surgery, to increasing the capacity of thepost-anesthesia care unit to efficiently and safely recover patients. It mayaddress the types and features of the operating rooms themselves, i.e., Willthere be dedicated rooms for orthopedics, cardiovascular, etc.? Will ambulatoryprocedures be performed in specific rooms? Will the rooms be universal, allowinggreater flexibility within the schedule?
A close look at infrastructure will identify various engineering systems thatmust also be upgraded: do the air handling systems, medical gas systems anddata, and communications support the strategic plan? A comprehensive solution isthe best approach.
This is a critical portion of the project, as solutions developed heretranslate directly into costs. Decisions made early can have the greatest impactwith the least expenditures of dollars. In essence, if it is decided duringconstruction that the renovation must include an additional operating room, thecost at this stage will be overwhelming. If that decision is made early, thecosts will be manageable.
This is also a time to "think out of the box." People plan from theperspective of their current working conditions; generally, it is their onlyframe of reference. This is where a good planner earns his or her fee. Thinkabout how work flows through the department between patients, materials andsurgical staff. Improvements in any of these areas will impact the financialsuccess of the project. Remember the following objectives:
The Renovation Process
After developing all of the proper adjacencies and defining a facility planto maximize the efficiency of the staff and provide a safe environment forpatients, it is time to plan for construction and implementation of the surgicalsuite.
Construction is noisy, dirty, inconvenient, disruptive, and occasionallydangerous. The facility plan must recognize that this renovation will occur in afunctioning surgical department, where quiet and sterility are the rule. Beforefinal plans are developed, work through the phasing of the constructionsequence. Enlisting the aid of a trusted contractor may be beneficial, as theywill have valuable insights into this phasing. There are a few colliding needsat this stage. The first is to have little or no disruption. The second is tocomplete construction in as short a time as possible. A third is to minimize thecosts.
Plan the renovation in blocks of time that will allow construction to occurwith access for the workers without entering the surgically clean areas. Thismay be accomplished with temporary enclosures, temporary doorways and eventemporary access from the exterior. This will allow much of the work to occurduring a normal shift. Work hard to achieve as much daylight shift work aspossible, as this will reduce both the costs and the total time. Night shiftwork is only 80% efficient, as the 8-hour shift is often reduced to 7 or 7.5hours. Make the work time blocks as large as possible, as this will increase theproductivity of the workers, reducing construction time and costs.
In planning these initial blocks, don't make the fatal mistake of ignoringthe engineering portion of the project. Replacement, upgrades, and modificationsto mechanical and electrical systems often do not follow the same boundaries asthe architectural floor plan. Therefore, resolve these issues before definingthe phasing. This is an absolutely critical part of the phasing process.Integration of new systems into existing areas while keeping old systemsoperational 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. Thismay be an important decision point to review with the surgical group as lesswork 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 almostcertainly be compromises; however, if the surgical staff is part of thesolution, 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 iscrucial. 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 inmind that while noise may be limited to an immediate area, vibrations will oftencarry throughout the building. Consider implementing a plan to communicateinformation about the project to all patients, family members, and staff. Therewill undoubtedly be emergency situations when work must stop. This is to beexpected and must be clearly communicated to contractor(s) before they submitbids for the work in order to avoid future change orders. "Marathon"weekend shifts are often good solutions, as a great deal can be accomplishedbetween 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 transmittedvia air. Taking a few careful steps will minimize patient exposure to thispotentially fatal fungus. Isolate the work area(s) with temporary partitionsconsisting of studs, drywall, or fire retardant plywood, polyethylene (fireretardant) and miles of duct tape. Do not allow temporary walls to bepolyethylene sheeting alone, as this will not withstand the abuse ofconstruction and may fail.
A second measure is to provide for negative air pressure within the workarea. This will further reduce the chance that airborne dust will migrate intoclean areas. Adding devices to monitor the pressure relationship is highlyrecommended. Record the findings daily at the beginning and end of work shifts;this record may become invaluable evidence in the future. Negative pressure canbe achieved by installing a fan and exhaust it directly to the outside. If thisis not possible, exhausting air into the building system is acceptable if it isfiltered 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 theyunderstand the danger, they are more apt to exercise the extra care necessary.Some institutions have required workers to attend classes to fully understandthe 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 themanufacturer), do not allow their use. With current specifications and productlabeling requirements, this is relatively easy to achieve. In a renovation wheredust is difficult to control, facilities may choose to construct the walls withgypsum lath and plaster in lieu of drywall. In general, there is little dustcreated with plaster, while drywall requires sanding of the seams. The cost ofplaster is higher, but may be offset by a reduced need for dust control. Eachfacility must evaluate the conditions and make an informed choice.
Flooring is one of the most hotly debated finishes in a surgical suiteproject, as it has to perform in many contradictory ways. It must be seamlessfor infection control and aid in maintaining the sterile environment. It mustresist the absorption of a wide variety of fluids. Flooring must also withstandstatic build-up, while not to the level necessary when flammable anestheticswhere 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). Theinstallation is generally flashed up the wall and all seams are welded toprovide a monolithic floor surface. One drawback is that this material tends tobe slippery when wet. However, slip resistant varieties with a metal oxideimpregnated into the PVC are available. The seams can be the weak element ineither 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 takento reduce the exposure. The common source for latex odors in construction ispaint. A few of the major paint manufacturers have developed a hospital-gradepaint for such use. If a negative pressure enclosure is maintained, odors willbe manageable. However, it is advisable to allow at least two weeks beforemoving into a recently completed area to allow for the normal out-gassing fromflooring products, adhesives and other odors to dissipate.
Mishaps During Construction
Beyond the physical challenges in construction, there are also concerns thatare not visible to the naked eye. Radio frequency interference (RFI) isinvisible and may cause major disruptions to sensitive electronic equipment suchas patient monitoring systems. RFI interference is generally the result ofelectric arc welding. Special considerations need to be undertaken to providefor proper grounding and isolation of the electrical system from weldingequipment.
Assume that the project is now proceeding beautifully. The contractor haskept noise to a minimum, has kept the facility wonderfully clean and is ahead ofschedule. Then, a tradesman accidentally cuts the power to the entire suite.Developing a plan to deal with the immediate and accidental loss of buildingutilities is prudent. Work with the surgical staff to develop plans to deal withthe loss of medical gases, electricity, water, or even the loss of the HVACsystem.
As with any construction within a healthcare facility, if the OR projectdisrupts any life safety features as required by the Life Safety Code, a planmust be prepared to deal with these issues during construction. The commonproblems to be addressed are obstruction of the egress corridors or exits,interruption of the fire alarm system, or modifications to the sprinklersystems. The rules for this plan are defined in the JCAHO requirements as wellas the life safety code. Each condition, or "temporary codeviolation," requires a solution.
Bruce Knepper, AIA, is a principal with Burt Hill Kosar RittelmannAssociates, an architecture and design firm with offices in Butler, Pittsburgh,and Philadelphia, PA; Boston, MA; and Washington, DC. He has specialized in thedesign and planning of healthcare facilities for 23 years, and is a foundingmember of the American Academy of Healthcare Architects. He can be reached at firstname.lastname@example.org.