Planning for the Future Operating Theatre Planning for the Future Operating Theatre Kevin D. Crook, AIA, CHC & C. Joy White At the start of the new millennium, planning for the future seems more important than ever. In addition, with the high cost of building an operating theatre it is increasingly important for the design to provide flexibility to meet future needs. Although there is always a degree of uncertainty about the future, there are several key drivers that will continue to impact design needs in the operating theatre. What are these drivers or trends? And, what design responses are needed? Understanding and meeting these needs are paramount to effective, efficient healthcare design. Aging Population With the continued increase in life expectancy, the median age of the world population will be much higher in the next fifty years (See Figure 1). During the past fifty years the median age has increased 11% from 23.5 in 1950 to 26.1 in 1998. By contrast, in the next 50 years the median age will increase 45% to 37.8 by 2050. More importantly, the population that is the primary user of surgical intervention (age 65 and older) will increase almost 73% to a total of 35% of the population in developed nations (United Nations Population Division). Common sense tells us that the elderly will have a higher rate of surgeries than the young, healthier population. This is confirmed by looking at United States statistics, which indicate the surgery use rates per 1,000 population almost doubles in the 65+ age group (See figure 2). How will the increased elderly population affect the number of operating rooms needed in the future? Maybe not as dramatically as one might think. While the number of surgeries performed will inevitably increase, other factors such as new and improved technology are decreasing the procedure times of these same surgeries, so more cases are being performed per year in existing theatres. Of particular significance is the fact that less invasive procedures occurring in endoscopy, cardiac catheterization, and special procedure laboratories will shift procedures out of the standard operating theatre. However, there will probably be a net increase in OR demand. Consumer Preferences Especially in the United States, consumers are playing a more active role in their healthcare. With the vast amount of information now available through the Internet, patients are starting to make informed decisions about who will perform their surgery and where it will occur. Report cards are available that rate hospitals and physicians. While cost and quality of care will almost always tie for first in this decision-making process, other factors enter the consumers’ mind as well, such as: How flexible is the schedule? Will my surgery occur on schedule or will I be delayed due to an emergency case? What kinds of patient/family accommodations are provided? Do I have private accommodations or will I share space with another patient that I do not know? New developments in minimally invasive surgery have accelerated the growth in outpatient surgical procedures. Today, in the US, about 90% of cholecystectomies are performed laparoscopically. Minimally invasive techniques have been developed in other specialty areas as well, including cardiothoracic surgery, vascular surgery, gynecology and neurosurgery. It is estimated that minimally invasive methods may soon account for 20% of all surgeries in the United States (ECRI, 1999/2000). With the growth in outpatient procedures (see figure 3) more and more consumers are choosing Ambulatory Surgery Centers (ASC’s) for their elective and minor procedures. The atmosphere of an ASC is more conducive to the consumer, scheduling is more efficient and patient accommodations are usually more private. In 1997, while 72% of all surgeries were outpatient, 14% of all surgeries in the U.S. were performed in an ASC (see figure 4). Shorter average length of stays, efficiencies, technology and improved methods of surgical care will continue to increase the demand for ASC and hospital-based outpatient surgery centers. Advancing Medical Technology Medical technology is perhaps the most apparent and most rapidly changing phenomenon affecting the operating room of the future. Everything from the length of the procedure to the shape and design of the OR itself to the physical location of the surgeon relative to the patient will be affected by advancements in medical technology. These advances, while proving beneficial to the patient, do not come without an expensive price tag. Some emerging advancements today deal with improved anesthesia monitoring that greatly reduces recovery time after surgery. At the American Society of Anesthesiologists (ASA) meeting the fall, information on the Bispectral Index System (BIS) was presented. “BIS is a monitoring system that measures effects of anesthesia on patients’ consciousness. The system, by Aspect Medical Systems, Natick, Mass, consists of a monitoring unit and sensor placed on the patient’s forehead and temple. This allows the patients’ consciousness to be monitored as to regulate the amount of anesthesia given. So patients wake up faster (OR Manager, November 1999)”. Many patients using this system bypass Phase I Recovery (or Post Anesthesia Care Unit - PACU) altogether. In fact, the new Indianapolis Surgery Center East opened in April 1999 with no designated PACU areas at all. With the continuing changes and improvements in anesthesia and monitoring, it will be possible to perform many procedures traditionally done in a surgery suite right in the physician’s office. In an effort to increase the flexibility of an operating room (OR), many operating theatres are now replacing retractable columns with ceiling service pendants to accommodate a wide range of medical equipment and accessories. Traditionally, this equipment is located on the floor with cords and hoses frequently in the way of staff and physicians. The ceiling service pendant provides more flexibility, efficiency and improved productivity than carts and retractable ceiling columns. Most of these devices can be positioned at any point within a 330-degree arc with more than 600 interchangeable rail accessories available for specific procedures. This kind of flexibility will be imperative in the future and will also improve room cleanup and turnaround time. In the not-so-distant future the use of telemedicine and robotics will be common in the operating theatre. In 1999, patients in North America and Europe have received robotically assisted minimally invasive coronary artery bypass grafts on both beating and stopped hearts. Two companies lead the way in robotics, Computer Motion and Intuitive Surgical Systems. Intuitive Surgical System’s “daVinci” assisted in a closed chest single vessel coronary bypass graft on a stopped heart in Paris in June 1998. Computer Motion’s “Zeus” Robotic System was used in the first totally endoscopic robotic- assisted coronary artery bypass in October 1999. The patient was discharged only four days later from a hospital in Canada. Cost is still a major issue with these systems. Zeus is being sold in Europe for $750,000 and the cost to install daVinci is estimated at $900,000 (OR Manager, December 1999). While the initial capital cost is high, the benefits of coronary surgery without “cracking open a chest” may drive the demand upward just as with laproscopic procedures in the past. The combination of telemedicine and robotics will make it possible for a surgeon to perform an operation from a different location altogether, possibly from a different country. NASA has long been a supporter of telemedicine because the agency wanted the capability to perform surgery on a space station from a remote location on earth. Telemedicine will allow fewer physicians and caregivers to serve more patients scattered over larger geographic regions. This technology may even begin closing the gap in health care status between developed and developing regions of the world. True Non-Invasive Surgery¼The Merging of Radiology and Surgery “It has been suggested that laparoscopic surgery is merely a transition state between open surgery and truly noninvasive surgery, surgery without an incision, seamless surgery”, renowned laparoscopic surgeon, John G. Hunter, MD of Emory University School of Medicine, Atlanta states in the April 1999 World Journal of Surgery. Also, recent developments in imaging may have a greater impact on minimally invasive surgery than developments in new surgical tools. For example, the open MRI is already being used in surgery. An open MRI resembles a traditional MRI that has been cut in two, leaving room for the surgeon to stand between the gap and perform an operation while watching a live video image of the patient. A new piece of equipment called the “Venue” manufactured by Picker International, Cleveland, OH, allows patients to be examined radiographically, flouroscopically, and with CT. With this hybrid imaging system, physicians can perform biopsies or surgeries with real-time three-dimensional guidance (OR Manager, August 1999). This is only the beginning. Surgical and Radiology departments may eventually merge as the line between the types of treatments they perform begins to blur. In the future, imaging equipment may be located in a place that would permit access both by surgeons and radiologists in a room that is a cross between a radiology room and an OR. Flexible Design for the ORs What can be done today to ensure OR’s are designed for use tomorrow? First and most important is to design a multi- purpose OR. As surgeries become more and more specialized, rooms will need to be more and more generalized. It is inefficient to design a room useful only for a particular surgery that will occur a few times a week. While the average room size of an OR was 30 – 40 square meters (or 350 – 450 square feet) only ten or fifteen years ago, it is more typical to need 45 – 55 square meters (or 500 – 600 square feet) today for general OR’s and higher for some specialties. These increased room sizes are needed to accommodate the new equipment. Also, as surgery and radiology continue to cross paths, it will be necessary for imaging equipment to have its place in the OR along with all of the equipment being used today. Patient and Family Demands Not only are the OR’s themselves getting larger, the patient prep and recovery rooms are increasing in size as well. In a consumer driven market the customer is requesting more privacy and more space. Small cubicles enclosed by curtains are being replaced with four-wall rooms with doors or, at a minimum, three walls and a curtain. Often, a concern voiced by staff with private rooms is decreased visibility. However, when needed, visibility can easily be provided through view panels in the walls or with open doors. Using multipurpose rooms (See Figure 5) to integrate pre-admission testing rooms with outpatient preparation and outpatient stage two recovery is an efficient way to accommodate the differing staff, patient and family needs. This example uses private multipurpose rooms grouped in pods of six rooms for staffing efficiency. Also, in this design, it is possible for the patient to return to the same room after surgery. With family members becoming more and more involved in the recovery process, it provides a perfect place to wait and become familiar with surroundings before the patient comes back. Conclusion Beyond the future that has been discussed, we are on the brink of changes in the operating theatre that will result in almost non-invasive therapies. Miniaturization, pharmaceuticals, and gene therapy may eventually replace surgery as it exists today. However, in the near future, the gap between the inpatient and outpatient continues to widen, as inpatient surgery is increasingly limited to complex or life-saving procedures and outpatient procedures shift from invasive to minimally invasive. Accommodations must reflect that difference. Also, it will be more difficult in the future to integrate inpatient and outpatient procedures in the same operating theatre as consumers demand better scheduling, improved accommodations and shorter procedure times. Most importantly, the future operating theatre must be larger and more flexible to accommodate the changing technology. References 1. AHA Hospital Statistics, 2000 2. ECRI Health Technology Forecast, 1999/2000 3. Mathias, RN, J. Surgery beyond the laparoscope. OR Manager, August 1999. 4. Mathias, RN, J. Robots assist in bypass surgery. OR Manager, December 1999. 5. National Center for Health Statistics: National Hospital Ambulatory Medical Care Survey (NHAMCS): 1994-1997 6. OR Manager, November 1999 7. United Nations, Population Division, Department of Economic and Social Affairs About the Authors: Kevin D. Crook, AIA, CHC has been actively involved in the healthcare industry for 17 years. His consulting experience includes participation in more than 100 healthcare facility planning and development projects for teaching institutions, psychiatric hospitals, physician office practices, ambulatory care centers, and non-profit, federal, municipal, and investor-owned general hospitals. C. Joy White has been involved in the healthcare industry for four years. She has consulting experience in healthcare market research and strategic planning as well as facility planning and programming for many of the largest healthcare corporations in the United States. ©2000 Health Systems Direct