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Section 2 Economic Considerations, Efficiency, and Design

Operating Room Design and Construction

Chapter

11 Technical Considerations
Judith S. Dahle and Pat Patterson

Contents Equipment Planning 116

Introduction 107 Infection Prevention during Construction 116
Strategic Program Planning 107 Interim Life Safety Measures 117
New Construction or Renovation? 108 New Technology/​Integrated ORs 117
The Planning and Design Team 109 Hybrid ORs 118
Phases of a Project 110 Design Considerations for Ambulatory Surgical
Considerations for Operational Processes 110 Centers 119
Design to Decrease Flow Disruptions 111 Summary 120
Design of Individual ORs 114 References 120

Introduction Design and Construction of Health Care Facilities from

the Facility Guidelines Institute (FGI) [1], Planning,
For most operating room (OR) leaders, the planning
Design, and Construction of Health Care Facilities by the
and design of a new surgical suite happen only once or
Joint Commission [2], and guidelines and standards of
twice in their careers. More than likely, these respon-
the Association for Professionals in Infection Control
sibilities will be added to their normal duties. These
and Epidemiology (APIC) [3], among others.
complex, multi-​ year projects are demanding, and
there is a great deal to learn and apply within a short
time. These projects call for a variety of strengths, Strategic Program Planning
including strong organizational skills, the ability to The building or remodeling of OR suites is a
collaborate with other disciplines, and the ability to demanding and expensive undertaking. Whether the
manage complex projects with deadlines. project is to renovate a current suite or build new ORs,
Surgery is always a team effort. That’s particularly it is important to think about the organization’s long-​
true for an OR design and construction project. The term direction and how that will influence the design
success of the entire project, from the initial meetings and efficiency of the surgical suite. The challenge for
to the final approval and move-​in, depends on the col- management and the design teams is to envision how
laboration among multiple disciplines. That includes surgery will be performed in the future. How will new
not only the clinical disciplines of surgery, anesthesia, and emerging technology affect the services provided?
nursing, and related disciplines but also the design How will work processes be affected by technology?
and construction professions. Working with a multi- What will the patient population be like within the next
disciplinary team can be a major benefit because it five to ten years? Will the hospital’s admissions have a
provides a support system for decision making and higher percentage of geriatric patients requiring com-
an educational opportunity for the OR manager and plex surgical care? Are there programs in the commu-
the entire surgical team. Whether the OR director is nity promoting diet and weight loss, which may bring
a novice or experienced, the key to staying organized a new bariatric program to the hospital? It is crucial
is to break the project into phases and to develop a for the organization to define its goals and strategies
checklist for each phase. clearly so the design team may plan for OR processes
Several essential resources can provide guidance that will support an efficient, safe, and cost-​effective
throughout the project. These include the Guidelines for care delivery system for many years.

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Section 2: Economic Considerations, Efficiency, Design

The first step in the planning process may be renovate existing space. Only altered, renovated, or
to conduct a needs analysis that will help drive modernized portions of an existing building system –
decisions throughout the process. In a needs ana- or individual components that have been altered,
lysis, all of the surgical, anesthesia, and support renovated, or replaced – are required to meet the
services identify goals and discuss their anticipated installation and equipment requirements in the FGI
needs for the future. Multiple meetings are needed to guidelines [1]. A list of exceptions to the guidelines,
gather input from each surgical specialty and anes- which apply as long as they do not reduce the existing
thesia providers. As part of the analysis, management level of health and safety in a facility, can be found in
must identify the reason for the construction: is it the 2014 FGI guidelines to help clarify when existing
to expand space for increasing surgical volume, to systems or building equipment must be updated.
redesign the facility for emerging technologies, to A variety of conditions affect the feasibility of
better compete with neighboring facilities, to antici- renovation such as:
pate new services, or to respond to changes in the • the amount and type of space available for
healthcare delivery model? renovation
The OR leadership team plays a crucial role • mechanical and electrical system limitations
in strategic planning. They will be asked for data • ability to work within the existing building’s
regarding types and volume of procedures. OR dir- boundaries
ectors experienced in this process also recommend • location of columns and structural walls
gathering detailed financial and market information,
• location of vertical penetrations, such as
including trends, projections for volumes, and case
mechanical shafts, elevators, and fire stairs
types as well as profitability information [4].
Many more questions need to be addressed during In some cases, organizations can renovate and
the planning phase such as: convert existing space for less money than they can
build new space. Often, however, renovation costs
• What are the market demographics?
may exceed new construction costs because of unfore-
• What will provide the competitive edge? seen conditions, phasing, scheduling, or logistical
• What level of technology will be required? complexities. There are several issues to consider:
• What are the pros and cons of the
• Converting existing space to new functions
technology costs?
frequently requires working with room
• How much functional space is needed for each dimensions, structural grids, and building
OR suite? configurations that force compromises to meet
• Will there be specialty rooms? the needs and goals of the project.
• How much storage will be required? • Remodeling often triggers the need to upgrade
• Where will storage be located? existing structures to meet current building
• What will the traffic flow be like and how efficient code requirements. This in turn increases
will it be? [4] construction costs.
Detailed questions for each area, specialty, and tech- • Renovation can cause disruption of ongoing
nology will be addressed later in the design process normal operations and require the relocation
when the master planning and design concepts are in of services. Coordination of temporary
place. An effective planning process is essential for the relocation of services and the sequencing
success of the completed project. A successful project of events on the overall time line may make
will have been designed to be flexible and adaptable remodeling more time-​consuming than new
for the future. Although trends cannot be predicted construction.
with certainty, detailed multidisciplinary planning • A renovation project may trigger correction of
can help to avoid major design mistakes. accessibility deficiencies in areas of the facility
remote from the proposed renovation.
New Construction or Renovation? • A partial renovation can result in the need for
As part of the planning process, management may dual systems, which may increase operating costs
want to evaluate whether to build new OR suites or and staff confusion [2].

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The Planning and Design Team be weekly, and distributes them to members of the
planning and design team. In addition, the architect, in
The planning and design team should consist of a
collaboration with the organization’s representatives,
core group that will remain consistent throughout
develops and maintains an organizational tool such
all phases of the project. The team needs a level of
as a project evaluation and review technique (PERT)
ownership and commitment to the project. The
chart. A PERT chart diagrams the project activities
organization’s representatives should be a multidiscip-
and identifies critical tasks, milestones, projected
linary group from the relevant areas of the facility. The
timelines, and primary responsibility for each of the
professional consultants on the team include those
activities. This tool is helpful for the entire team to
who will execute the planning, design, and construc-
identify delegated tasks, tasks not assigned, and tasks
tion. The size of the team varies with the complexity
that may delay the project.
of the project. Additional members function in an
The organization develops a budget as part of
advisory role and may attend only certain meetings
the initial preplanning that is revised as the project
that require their expertise.
moves forward and changes are made. The budget is
Core members include:
developed in several segments: construction costs,
• a representative from administration equipment costs, professional fees, escalation fees,
• physicians and contingency costs. The nurse leader is the clin-
• nurses ical expert on the team. All team members look to the
• infection preventionist nurse leader for recommendations and input about the
• facilities planning/​engineering appropriateness of the design with respect to regula-
• architects tory requirements from accrediting bodies, state health
• engineers departments, and others; space allotment; patient
• finance safety; and interdepartmental functions, to name a few
Members who provide additional input at times areas of expertise. It is nursing’s opportunity to design
throughout the project include: an environment that is safe for patients and staff, is effi-
cient, meets the needs of the physicians, and meets the
• contractor
mission and vision of the organization.
• equipment/​technology planners
The nurse leader has a prominent role as a
• physicists/​hybrid rooms
member of the planning and design team. Initially,
• materials management this may seem like a daunting task that adds to an
• laboratory staff already full workload. Although the project may
• support services seem overwhelming to a nurse leader who is not
• pharmacy staff familiar with design and construction, it provides
• interior designers a great leadership opportunity. Involving everyone
• landscape designers for new facilities who will be directly affected by the construction
An empowered leader from the organization needs and will be working in the new or remodeled area
to be selected and given the responsibility to keep the is essential. Collaborating with staff members in the
process moving forward, on time and within budget. process allows them to feel a sense of ownership in
The leader will establish the communication process. the building effort [5]. Communication about the
This person needs to have facilitation skills and to be project with nursing, physician, and support staff
flexible, a good manager of people, and responsive to helps decrease the staff ’s stress about the project and
sudden changes. brings helpful ideas to the design process. The staff
One person from the consultant role, usually an can provide valuable ideas in relation to storage and
architect, will take the leadership for coordinating the supply access, types of case carts, OR furniture, and
members representing consulting services. Frequently, cabinets as well as the location of electrical outlets,
this person is helpful in determining when to ask the data ports, and other design items that affect patient
advisory group or additional members to participate flow. Direct care providers can provide the best
in meetings. input regarding design aspects that will improve
A representative of the architectural firm usually safety and efficiency. Nurses who are participating
takes the minutes of each meeting, which initially may in design and construction for the first time will find

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Section 2: Economic Considerations, Efficiency, Design

that the design team members are willing to share

their expertise.
Construction Documents
During the construction documents phase, all aspects
of the design are converted into building plans that a
Phases of a Project contractor can use to estimate costs, identify issues,
Design and construction projects typically follow and plan construction activities. These documents
these six phases: will be used throughout the construction phase and
are used to obtain building permits for the project.
Planning At this point, the organization discusses contract
conditions with the contractor and the architect. Roles
The planning phase includes wish list considerations,
and responsibilities of all participants are defined.
master planning, setting the vision, and needs ana-
During this phase, the design team does not meet as
lysis. This is the time to gather input from each spe-
often, and there may be less communication between
cialty and to hold meetings with the staff to find out
the architect and other team members. At this time,
what they envision for the new OR and what the posi-
the architectural firm is detailing the drawings in
tive and negatives of the current OR may be.
preparation for the bidding process with the builders.
Site visits to other facilities are helpful because
they provide OR leaders with an opportunity to see
completed ORs and talk to the personnel to learn what Construction
works well in their facility and what they would have During the construction phase, the OR suite is actu-
done differently. It is helpful to take a multidiscip- ally built. Before the construction begins, the design
linary group on the site visit. team should meet with the contractors to discuss final
preparation. These discussions need to include site
security, contractor education, storage of materials,
Schematic barrier placement, infection prevention, and the
The schematic phase involves drawing a rough outline communication process to be used during the pro-
of the project, including a preliminary room layout, ject. Frequent visits to the site, when appropriate, by
structure, and scope of the project. At this time, the planning and design team members are advisable. It is
architect begins to prepare diagrams that display the important to ask questions. Sometimes what the team
major functions, the structural components, and the saw on the drawings does not look the same during
approximate size needed for the various functions. The construction. Ask for clarification and explanation
planning and design team members provide important of the construction process. Weekly construction
input at this time. There are frequent meetings during meetings provide an opportunity for effective com-
this phase, with brainstorming and probing discussions munication and education throughout the project.
with the architectural firm. A detailed list of ideas is
collected, and the architect will develop more in-​depth
drawings from each of these sessions. Commissioning
Before taking ownership of a building, project, or
renovation, the organization must make sure all
Design Development specifications are met; all requirements are in order for
In design development, details are added to the design licensure; and all systems, components, equipment are
drawings, including electrical outlets; data ports; furni- operational [2]. Plumbing; electrical systems; heating,
ture location; fixtures; and details regarding casework, ventilating, and air conditioning (HVAC) systems; fire
hardware, and décor. This phase takes several meetings alarms; and safety systems will be tested at this time.
with frequent revision to the plans. The design team
should ask many questions and review the plans closely.
Every detail of the finished facility needs to be included Considerations for Operational
at this time. The final design is reviewed by the planning Processes
team. Then the key decision makers from the organiza-
tion approve and sign the final plans before they are General Considerations for OR Suites
converted to construction documents. Once this phase The size and location of the surgical suite will be
is completed, making revisions incurs additional costs. determined by the level of care provided. The number

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semirestricted area. Traffic in semirestricted areas

Box 11.1. OR Design: General Principles
is limited to authorized personnel and patients.
• Make each OR at least 600 sq ft (55.74 m2), Personnel in these areas are required to wear
larger for cardiovascular, orthopedic and other surgical attire and cover head and facial hair.
complex procedures. The Guidelines for Design • The semirestricted area may contain entrances to
and Construction of Healthcare Facilities [1] locker rooms, the PACU, and sterile processing
recommend a minimum of 400 sq ft (37.20 areas. Sterile processing is a semirestricted
m2) of clear floor space for general ORs, with a environment but can be entered directly
minimum of 600 sq ft for ORs performing surgical from the unrestricted area or from another
procedures that require additional personnel and/​
semirestricted area.
or large equipment, such as some cardiovascular,
orthopedic, and neurosurgical procedures. • The restricted area is a designated space in the
semirestricted area of the surgical suite that can
• Make the ORs identical to avoid staff having to
adjust to new positions and item locations.
be reached only through a semirestricted area.
The restricted access is primarily to support a
• Install adequate wiring, ventilation, and structural
high level of asepsis control, not necessarily for
reinforcement to accommodate equipment.
security purposes. Traffic in the restricted area
• Design ORs for multiple uses because caseloads
is limited to authorized personnel and patients.
and surgical techniques may change.
Personnel in restricted area are required to wear
• Include communication tools such as wall surgical attire and cover head and facial hair.
monitors and e-​mail stations in OR design.
Masks are required where open sterile supplies or
• Make storage space adequate and rapidly scrubbed persons may be located [1].
accessible; avoid distant storerooms, or expect
more onsite hoarding of supplies.
• Design logistics for smooth supply transport and
Design to Decrease Flow Disruptions
protection of sterile items. Investigators have used human factors analysis to
identify and classify flow disturbances during surgery.
• Design patient transport routes and waiting
locations to provide comfort, privacy, and The analysis looks at any factor, specifically human
the growing trend toward presence of family factors, impeding work or communication during
members. surgery. Studying cardiac surgery, researchers from
the Medical University of South Carolina, Charleston,
Reprinted with permission from OR Manager. 2011; 27(5):13.
Copyright 2011 Access Intelligence. All rights reserved.
found that one-​third of the disturbances were related
to OR physical layout and design [6]. With techno-
logical advances in equipment and procedures, the
OR has become more complex, potentially disrupting
of ORs and postanesthesia care unit (PACU) beds workflow and affecting patient safety. The researchers
and the size of the support areas are governed by the have also developed a taxonomy to describe the nature
expected workload. Current and future workloads by of flow disruptions during cardiac surgery.
specialty should have been determined during the Six categories of flow disruptions were identified
preplanning and planning phases (Box 11.1). and analyzed in each phase of surgical care (preopera-
The surgical suite will be divided into two tive, operative, and postoperative) with more detailed
designated areas –​semirestricted and restricted –​ descriptions within each category.
defined by the activities performed in each area. The main categories were:
• The semirestricted area includes the peripheral • communication (verbal and nonverbal)
support areas of the surgical suite, including • usability (computer, equipment, packaging, etc.)
storage areas for clean and sterile supplies; sterile • layout (equipment, connector positioning,
processing rooms; scrub stations; and corridors furniture, visibility)
leading to restricted areas of the surgical suite. • environmental hazards (slipping, falling,
• A central control point may be established to crushing)
monitor the entrance of patients, personnel, and • interruptions (phone calls, nonessential
materials from the unrestricted area into the personnel, shift changes, etc.)

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Section 2: Economic Considerations, Efficiency, Design

• equipment failure (surgical, anesthesia, etc.) [5] OR suite, and into the PACU depends partially on
Under layout, the researchers described six subcat- an efficient facility design. The planning for patient
egories of disruptions or areas of interest: flow should consider the experience not only of
• Connector positioning –​wires and tubes patients but also of family members who accompany
entangled or misplaced, which can hinder the patient on the day of surgery. Patients need to be
movement and continuation of a task. prepared and wait for surgery in a private environ-
ment where the family may stay with them until they
• Equipment positioning –​machines and tools may
are taken into the OR. There also needs to be a quiet
restrict or prevent the movement and actions of
area where medical staff can discuss medical issues
the staff.
with the patient and a quiet, comfortable area where
• Furniture positioning –​chairs, OR bed, and desk
families can wait during the procedure. New facilities
can cause OR staff to deviate from their original
are often designed with family waiting areas that have
movement.
features such as natural light, comfortable furniture,
• Permanent structures positioning –​doorways
data ports and wireless internet access, and play areas
are frequently used in the OR during surgical
for children.
procedures, preventing continuous movement
The decision for private rooms or bays in the pre-
and possibly causing injury.
operative area is influenced by the size of the area,
• Inadequate use of space –​surface and floor the ability to provide patient care efficiently, and the
space are used inappropriately through clutter, impact of the choice on staffing levels. A common
untidiness, congestion, and blockage. design for patient cubicles is three walls with a cur-
• Impeded visibility –​the staff may have objects tain across the foot of the bay. This allows patient
that obstruct their ability to see at important privacy but provides efficiency and visibility for the
times in the procedure [6]. nursing staff.
Methodology is being developed to help researchers The immediate preoperative area (holding area)
understand the impact of each type of flow disruption. needs space to accommodate both patients on
stretchers and ambulatory patients who are seated.
Evidence-​Based Design This area needs to be under the direct visual control
of the nursing staff. Provision needs to be made for
Evidence-​ based design (EBD) is a recent concept
patients with transmissible infections, developed in
fostered by the Center for Health Design (www
collaboration with the infection prevention depart-
.healthdesign.org) [7]. In EBD, design and construc-
ment. Consideration also needs to be given to the
tion are based as much as possible on research evidence,
patient mix and the surgical program. Space may be
with the goal of producing the best possible outcomes
needed for additional equipment, depending on the
for patients, families, and staff while improving the
surgical program planned.
process of care. The evidence suggests that standard-
The planning phase for the preoperative space is
ization is one aspect of design that improves patient
an opportunity to evaluate spaces that may be used as
safety by reducing the risk of errors. For example,
cross-​functional areas during the day. For example, a
when multiple facilities such as ORs are oriented
portion of the PACU may be used as part of the pre-
the same way, the staff knows where equipment and
operative holding area during the first part of the day.
supplies are kept. The surgical team knows how the
This arrangement can contribute to efficient staffing,
patient will be oriented in the room, reducing the
particularly if the staff is cross-​trained for both pre-
risk of wrong-​side surgery. Less time is spent looking
operative and postanesthesia care, and may decrease
for supplies and equipment, which reduces rework,
the amount of space required for the preoperative
minimizes fatigue, and allows caregivers to focus on
holding area.
direct patient care. Standardization also improves effi-
The planning phase is also the appropriate time
ciency and productivity and lowers costs [7].
to design the communication and documentation
systems for the new area, which can have a positive
Patient Flow Considerations impact on efficiency, safety, and patient and staff satis-
The smooth flow of patients from the admitting area faction. The use of information technology can make
to the preoperative holding area, to the individual for a quieter work area, fewer interruptions, and an

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Chapter 11: OR Design and Construction

opportunity for more efficient patient flow. These are a nurses’ station, charting facility, and storage
examples of how information technology may provide allocations [1]. Involving the PACU staff in planning
for an improved environment: this area is beneficial because they can provide valu-
• Airport-​style tracking systems enable the staff to able information about what functions well in the
see the status of individual OR suites, help the staff current facility and what does not. The design of
to anticipate the patient flow, communicate with the PACU also depends on the functional program.
other departments such as the critical care unit, Examples of issues to be considered are whether the
and keep families informed of patients’ progress. PACU will accommodate pediatric patients, intensive
• Wireless communication systems using small care patients, and family visitation and whether the
phones or badges may be installed to facilitate area will care for inpatients as well as outpatients.
communication among the nursing staff.
• Audiovisual systems allow surgeons to Materials Flow
communicate with the radiology and pathology Surgery consumes a large volume of supplies and
departments more efficiently and clearly. instrumentation. How these materials are supplied
and distributed through the facility has a major
Design of Postanesthesia Care Areas bearing on the surgical suite’s overall efficiency and on
the cost of care.
There are specific space requirements for both phase
The flow of materials needs to be planned so
I and phase II postanesthesia recovery areas. A min-
the movement of clean and sterile supplies and
imum of 1.5 postanesthesia patient care stations per OR
instruments is separated from contaminated items
is required. When designing the recovery area and deter-
and waste by space or traffic patterns [9]. The
mining the number of recovery positions required, the
clean storage space needs to be in a moisture-​and
project team should consider the types of surgery and
temperature-​controlled area that is free from cross-​
procedures performed, types of anesthesia used, average
traffic. The soiled area cannot have direct connection
recovery periods for patients, and the anticipated
with the ORs. Involving the staff from materials man-
staffing model. Special consideration is needed if pedi-
agement and sterile processing as well as the OR staff
atrics is part of the functional program [1].
who are most directly involved in supply distribution
The phase I level of care applies to patients in
is important to planning a successful materials flow.
immediate postanesthetic recovery in which a 1:1 or
There are several issues to consider for surgical
1:2 nurse–​patient ratio is maintained, depending on
supplies:
the patient’s status. This phase lasts until the patient
meets the “critical elements,” as recommended by the • How will supplies be received in the surgical
American Society of Perianesthesia Nurses. During suite? Is there a separate area outside the suite to
phase II, care focuses on preparation of the patient break down shipping containers so only the clean
and family for discharge to home or extended care [8]. inner packaging enters the suite?
The FGI guidelines [1] recommend a separate area • What supply chain system will be used for
for phase I and phase II postanesthesia care, such as a delivery, control, and replenishment of supplies?
separate step-​down area, but this is not always possible • How will supplies be transported to the surgical
because of space. The first concern is to follow the appro- area and to the individual ORs?
priate level of care while maintaining patient privacy. • How much and what type of storage will be
Maintaining privacy in the preoperative and needed to accommodate this system, both in
postoperative areas is a challenge because of limited the suite and in the individual ORs? Where will
space. Many facilities have cubicles with three walls sterile supplies be stored so their sterility is not
and a sliding glass door or a privacy curtain. Others compromised?
provide separate enclosed patient rooms for pre- • After surgery, how will soiled trash be removed
operative care and discharge preparation, but this from the suite and stored so patients and
design does not provide the flexibility required for clean areas are not exposed to contaminated
efficient patient flow and presents a staffing challenge. materials?
General requirements for postanesthesia care • There are several issues to consider for surgical
include medication stations, hand-​washing stations, instrumentation:

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Section 2: Economic Considerations, Efficiency, Design

• Where will instrumentation be processed? In a lounge for breaks and lunch. The changing areas
some hospitals, sterile processing is performed are required to have lockers, showers, toilets, hand-​
within the semirestricted area of the surgical washing stations, and space to change clothing [1].
department. In this case, the size and location The lounge area is intended to minimize the need
of the clean and soiled workrooms will be for staff to leave the surgical suite for breaks and meals
determined in the functional program. In other and to provide convenient access for both the OR and
hospitals, sterile processing is performed outside the PACU staffs. The decision about whether to have
the suite. In this case, direct but separate paths a combined or separate lounge for physician, nursing,
should be planned between the surgical suite and or ancillary staff usually depends on the amount of
sterile processing area for both clean and soiled available space and the philosophy of the organiza-
instrumentation. For example, the surgical suite tion. There are also regulations for these areas that
may be on a floor above the sterile processing vary by state and locality.
area, with dedicated clean and soiled elevators Though much of the surgical suite design focuses
connecting the two units. on functionality and efficiency, the design of staff
• Will the surgical suite perform sterilization on support areas should also consider comfort and
an emergency basis? If so, sterilization facilities aesthetics. The staff ’s participation is essential in
need to be provided in an area readily accessible planning an area that will suit their needs. A com-
to the ORs that complies with guidelines for bination of eating area, lounge, and kitchen is most
immediate-​use steam sterilization (formerly called desirable. If there is an opportunity, the lounge should
flash sterilization). Immediate-​use sterilization have windows to allow for natural light and an outside
refers to the processing of items intended to be view. Selection of furniture is important for comfort
used immediately and not stored. This process and function. Color selection should consider gender
requires the same critical reprocessing steps as as well as generational, cultural, and geographical
any other sterilization cycle, including cleaning, preferences.
decontamination, and transport of sterilized
items [10]. Ancillary Department Coordination
The physical relationship between the surgical suite
Equipment Storage and supporting departments is an important con-
Equipment storage is always a challenge. Today’s sideration. The planning team needs to consider the
surgical procedures require a variety of large, port- surgical program and identify all of the services that
able pieces of equipment such as x-​ray equipment, may be required for each specialty. Generally, the ORs
stretchers, fracture tables, and warming devices. All of should be located close to the emergency department,
these must be stored in locations that are convenient to radiology department, cardiac catheterization labora-
the ORs but must be kept out of corridors and traffic [1]. tory, and clinical and pathology laboratories. The
If the surgical suite will be large with specialized ORs, PACU should be located so patients can be transported
the storage spaces should be readily accessible to the easily to the intensive care units. Representatives from
specialized rooms. In new construction, recessed space pharmacy, interventional radiology, and any depart-
is frequently planned outside each OR for the storage of ment that routinely provides services to the surgical
a stretcher. Other areas may be designed for large items department should be included in discussions about
such as x-​ray equipment. In developing the functional location and information technology that may assist
program, the planning and design team should list all in the coordination of care.
of the equipment the surgical suite is likely to include
and how frequently it is used. That list should be avail- Design of Individual ORs
able for reference as the design is developed.
Space Requirements
Staff Support Areas A general OR is required to be at least 400 sq ft
The design of staff support areas can have a major (37.20 m2) with a minimum clear dimension of
impact on staff satisfaction. These areas include places 20 ft between fixed cabinets and built-​ in shelves,
for changing from street clothes to surgical attire and according to the FGI guidelines [1]. ORs for surgical

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Chapter 11: OR Design and Construction

procedures requiring additional personnel and/​

large equipment, such as cardiovascular, orthopedic,
or Configuration of the OR
During the design process, it is helpful to create a
and neurological procedures, require 600 sq ft (55.74
schematic drawing of the individual OR and trace all
m2). Many hospitals are designing all of the ORs to
of the paths personnel may travel during a procedure.
accommodate the latest technology and equipment,
The room plan should be evaluated for how it will
allowing for flexibility in scheduling procedures into
function during the set-​up phase of surgery as well
any room. The larger rooms, in addition to accommo-
as when the sterile back table has been moved into
dating the many pieces of equipment today’s surgery
place during the procedure. Scenarios should also be
requires, provide adequate room for the staff to move,
created for other mobile equipment that comes into
allowing for better staff circulation and greater effi-
the room during surgical procedures. This same pro-
ciency. Larger rooms also allow clearance for patient
cess should be used to plan the placement of storage
transport and the movement of portable equipment.
cabinets, workstations, wall-​ mounted view boxes,
In addition, they provide space for a sitting worksta-
white boards, and other stationary devices.
tion where clinicians can document care electronic-
Door placement should be designed to maintain a
ally and manage controls for digital imaging and other
sterile work zone in relation to the OR bed. There are
technology.
two doors, one for transporting the patient and per-
sonnel and the other for access to the substerile area
Ceiling-​Mounted Booms or central core. The main door should be located to
facilitate the transport of the patient by stretcher or
The use of ceiling-​mounted booms in ORs enables
by patient bed. The most efficient door placement is
equipment and related cords to be kept off the floor,
to the left of the patient’s head. It is also advisable to
decreasing clutter and allowing for safer movement
design all of the OR rooms so the approach to each
around the room [11]. In new construction, the space
room is the same. Consistency in design improves
above the ceiling can be designed to include conduit
safety and efficiency.
to accommodate utilities and the necessary cabling
Placement of electrical and data outlets is crit-
for equipment mounted on the booms. If the ORs are
ical for the OR’s functionality and efficiency. Even if
being remodeled, engineers must assess the ceiling
there are ceiling-​mounted booms, additional outlets
structure to determine the weight-​load capabilities
are required throughout the room. The architect and
before planning to install ceiling-​mounted booms. It
electrical engineer can provide guidance to the design
is a good idea to provide additional capacity to meet
team about electrical loads per outlet and the types of
future needs.
outlets required. Outlets that will be used in the event
Retractable utility columns for anesthesia
of a power failure when the OR is on an auxiliary
providers provide an efficient, well-​ organized ser-
system are required to be clearly marked. The clinical
vice area at each end of the room. The columns house
staff on the design team can provide valuable infor-
medical gases, phone jacks, and data connections. The
mation about the location of these emergency outlets.
columns do not eliminate the need for a small anes-
It is convenient if electrical outlets can be placed at
thesia cart but provide another means to keep the
a higher-​than-​normal elevation on the wall. Despite
floor free of cords.
wireless technology, hardwiring is still necessary for
Proper placement of ceiling-​mounted equipment
backup data access. It is a good idea to plan for the
booms is critical. Booms should be placed on the
future during the construction process by providing
side of the room away from the OR door where
for additional electrical and data capacity. It is less
patients enter the room. The articulating arms need
expensive to run additional conduit at the time of con-
to move freely and not interfere with movement of
struction than to add it a few years later when it may
the surgical lights. Physicians and staff who per-
require taking an OR out of service for upgrading.
form minimally invasive video-​guided surgery can
provide valuable insight on placement of booms and
should be involved in site visits to view established Substerile Space Requirement
facilities. Computer-​aided design and simulation In many OR suites, a substerile room is located
are also helpful in visualizing the placement of between each two OR rooms and enhances the rooms’
booms. function. Substerile rooms, used for immediate-​use

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Section 2: Economic Considerations, Efficiency, Design

sterilization, are typically equipped with a steam ster- level of services to contract for with the equipment
ilizer, a countertop, and built-​in storage for supplies planners, weighing the cost of these services against
[1]. The substerile area may also be in the clean core the hospital’s own resources for equipment planning.
if the clean core is directly accessible from the ORs. There are several options when using an equipment
In this case, the substerile area needs to be accessible planner. The planner can collaborate with the team to
without traveling through any ORs. identify all of the equipment, from large equipment
such as sterilizers, x-​ray units, lasers, and OR lights
Interior Finishes to smaller items such as carts and stools. The planner
researches product availability and costs and obtains
Interior elevation drawings will include information
product information and installation details for the
about design elements such as cabinets and other
contractors, and then assembles the information in
casework, wall service details, equipment mounting
a binder or reference file. In addition, the equipment
locations, sinks, plumbing fixtures, and other details
planning firm can either purchase the equipment itself
[12]. The purpose for cabinets needs to be defined.
or coordinate with the hospital’s purchasing depart-
What will be stored in the cabinets? Do the cabinets all
ment. The equipment planner can develop a timeline
need to be built in, or should some storage be mobile?
with the vendors and schedule deliveries according to
Cabinet surfaces need to be chosen keeping in mind
the construction timeline.
the surface’s durability and ability to withstand fre-
quent cleaning.
Wall finishes must also last through rigorous Purchasing Protocol
cleaning and be smooth and seamless. The color Whether or not an outside equipment planner is used,
needs to be pleasing and relaxing. Floors must be dur- the hospital’s materials manager needs to be an advisor
able, nonskid, capable of handling the movement of to the design team, and a decision-​making protocol
heavy equipment, and ergonomically comfortable for needs to be established for the project. An effective
staff. Many flooring options are available, including method is needed for evaluating equipment and deter-
terrazzo, tile, sheet vinyl, and newer products. The mining its value related to improvements planned in
design team’s interior design representative can pro- areas such as patient and staff safety, patient outcomes,
vide samples of materials and discuss the pros and best practice, and regulatory requirements. Decisions
cons of each product. are needed early in the design process about whether
to acquire new or refurbished equipment, purchase
Equipment Planning equipment through group purchasing contracts, and
who will be responsible for each element of equipment
Outsourced Equipment Planners planning and acquisition.
A data sheet for each room is used to identify and
Equipment planning is an essential and time-​sensitive
record types and locations of all necessary room elem-
element of the planning, design, and construction
ents and systems. The data sheet may also indicate
process. Timing for equipment delivery should be
who will be responsible for purchasing and installa-
planned so equipment arrives at the correct time for
tion of each element, or this may be completed on a
installation and so unnecessary storage is not required
separate document. Data sheets also can function as
because equipment arrives too early. To determine
checklists to confirm all details have been completed
the equipment space, design needs, and budget, an
prior to the room being used.
equipment list should be developed as part of the
planning phase. The equipment list is necessary not
only for the design process but also as a budget guide.
Infection Prevention during
Researching equipment options, cost, and avail- Construction
ability can be time-​consuming. One option is to hire a Part of the planning for construction includes plans
company that specializes in planning and purchasing for managing potential risks to patients, staff, and the
equipment for healthcare facilities. The equipment public during the project [12, 13]. At the beginning of
planner then meets with the project representative to the planning phase for a construction project, the hos-
learn about the needs of the project and propose the pital needs to plan for infection control by conducting
role the planner can provide. The hospital decides what an Infection Control Risk Assessment (ICRA) [1]. The

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Chapter 11: OR Design and Construction

goal of the ICRA is to mitigate the risk of harm to the particularly patients who are unable to leave their
patients, staff, and others within or near the construc- beds, the OR, or the hospital [16].
tion project. Depending upon the scope of the project, During the project, part of the planning team’s
some potential risks are dust and fumes, mold, fungi, responsibility is to plan for compliance with Interim
water contamination, hazardous material, noise, and Life Safety Measures (ILSM). The National Fire
vibrations. Protection Association 101 (NFPA 101) is part of
The ICRA is a multidisciplinary, documented the interim life safety measures [17]. The NFPA
assessment process to identify and mitigate risks of 101: Life Safety Code is used in every US state to
infection that could occur during construction. This address minimum building design, construction,
assessment is part of the integrated facility planning, operation, and maintenance requirements necessary
design, construction, and commissioning activities. to protect building occupants from fire, smoke, and
The ICRA team consists of members with expertise in toxic fumes. Life Safety Code is a registered trade-
infection prevention and control; direct patient care; mark of NFPA. The Life Safety Code can be used in
facility design; construction; HVAC; and plumbing conjunction with other building codes or alone in
systems. The scope of the project dictates whether jurisdictions without a building code. The Centers
other members are needed [1]. for Medicare and Medicaid Services and the Joint
In addition, patient safety has come to the forefront Commission refer to NFPA 101, as do federal, state,
of hospital design. The 2014 FGI guidelines added a and local fire officials.
safety risk assessment (SRA), which combines with Among life safety issues that may need to be
the ICRA. The purpose of the owner-​driven SRA is to considered during construction are the need to
foster a proactive approach to patient and caregiver redirect occupants because of blocked exits, to alter
safety by mitigating risks from the physical environ- fire safety systems temporarily, and to construct fire
ment that could directly or indirectly contribute to barrier walls altering traffic patterns. Plans to miti-
harm. The project team must identify through the SRA gate these and other hazards need to be developed and
risks involving infection control, patient handling, communicated throughout the affected areas of the
falls, medication safety, psychiatric injury, immobility, hospital. Plans for managing emergencies also must
and security [1]. be established before construction begins.
The OR manager on the design team is respon- Throughout project planning and construction,
sible for participating in both the ICRA and SRA and the OR manager needs to anticipate potential safety
monitoring adherence with the plans and regulations. hazards that may surface. An unexpected utility shut-
A challenge is to make sure the staff understands these down, for example, is a serious safety concern. As part
risks and that the contractors understand how to work of the ILSM plan, the manager should be prepared to
safely in the hospital environment, especially when educate the construction team about the importance
close to patient care areas [12, 14]. of planning for and communicating about any type of
Important resources are the Centers for Disease event that could potentially affect patients, families/​
Control and Prevention’s Guideline for Environmental visitors, and staff.
Infection Control in Health-​ Care Facilities [15],
the FGI guidelines [1], the Joint Commission’s New Technology/​Integrated ORs
book, Planning, Design, and Construction of Health Advancements in technology have allowed ORs to
Care Facilities [2], and the APIC standards and integrate systems that manage information, audio-
guidelines [3]. visual signals, and radiographic imaging inside and
outside of the OR suite. There is some indication that
Interim Life Safety Measures integrated technology can enhance the efficiency of
In addition to infection prevention, the team needs certain aspects of surgical procedures. Small studies
to assess and manage other risks that may arise have found that compared with a conventional OR,
during construction, such as protecting patients intraoperative efficiency was improved in a dedicated
from fire, smoke, and toxic fumes. They must also minimally invasive surgery (MIS) OR with perman-
consider risks that may arise after the structure is ently fixed equipment [18]. Researchers have also
occupied. Healthcare must meet the needs of three found neck flexion and surgical spine rotation for
populations: families/​visitors, patients, and staff, surgeons and nurses were significantly reduced in a

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Section 2: Economic Considerations, Efficiency, Design

dedicated MIS room [19]. Some of this technology with a fixed and dedicated imaging system, are
not only enhances efficiency but also improves patient intended for complex surgical and interventional
safety through improved and timelier communication procedures that require advanced imaging. Examples
among care providers. are hybrid coronary revascularization procedures,
Questions that arise during the planning and percutaneous cardiac valve replacement, and complex
design of a new suite include how much technology is brain and spine cases [21]. Industry experts estimate
needed in every room, how much of this technology that by 2018, 75 percent of cardiovascular surgeons
needs to be integrated, and whether the technology will be working in a hybrid operating suite, ECRI
installed today will be compatible with the next phase Institute reports [22].
of technology [20]. To answer these questions, the OR Evidence on clinical benefits is limited, but some
planning team needs to perform extensive research, reports indicate that advantages may include shorter
make site visits, interview other clinicians who have patient recovery time due to less physiological stress
developed integrated ORs, learn from their experi- because multiple procedures can be performed in the
ence, and develop a list of pros and cons. same episode, streamlined care delivery, better cross-​
General questions for planning for new tech- specialty communication, and potential for revenue
nology include: growth as conventional ORs and interventional rooms
• Will the technology integrate with the hospital’s are freed for other procedures [22, 23].
systems? Because hybrid rooms are not only technologic-
• How will the technology affect existing processes? ally but operationally complex, planning requires
• Will automation actually be more efficient or will the collaboration of multiple disciplines. This
it add unnecessary steps to an existing system? includes not only the surgical and interventional
• How many ORs need an imaging system? disciplines but also administrative and clinical staff,
• What types of procedures will be performed in facilities personnel, biomedical engineers, informa-
these rooms? tion technology specialists, and equipment vendors.
Also important to include are others who are crit-
• Is an anticipated new service or procedure
ical to the room’s functioning, particularly anes-
volume driving the design plan?
thesia providers, imaging support personnel, and
• Should the rooms be flexible or specific for
perfusionists [21].
certain types of procedures?
There are several general questions to address in
• Are all the rooms equipped to handle the new
the decision-​making process about whether to include
technology?
a hybrid room(s) in the operating suite:
• If a robotic surgical system is a potential addition,
how many surgeons will use it, and will it be • Will a hybrid OR be supported by existing
cost-​effective? interventional and surgical caseloads?
• Will technology be ceiling mounted or floor • How will a hybrid OR affect the utilization of
mounted? other interventional suites and ORs?
• Will the equipment be wired or wireless? • Can a hybrid OR be installed in existing space or
Hospitals that decide to build integrated ORs should will substantial renovation or new construction
involve stakeholders to identify the goals and desired be needed?
outcomes of the project to achieve and determine the • Is the hybrid OR best located in the interventional
best return on investment. They also often decide or surgical departments? Generally, interventional
to engage the advice of an unbiased consultant. suites do not have the required ventilation, scrub
Organizations that subscribe to services offered by the area, sterilization area, or access to surgical
nonprofit ECRI Institute (www.ecri.org) can seek its equipment and instrumentation. It may be less
advice for objective technical information. expensive and easiest to install the hybrid OR in
the surgical suite where those support services are
Hybrid ORs already in place.
The hybrid OR is a rapidly evolving surgical environ- • What infrastructure will be needed? Consider in
ment. These technologically advanced rooms, which particular the size of the room, ceiling height, and
combine surgical equipment and instrumentation weight-​bearing capacity of the ceiling and floor.

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Chapter 11: OR Design and Construction

• How will the room’s space be organized? Consider A hybrid OR with intraoperative magnetic reson-
the positioning of equipment and lights, air flow, ance imaging (iMRI) must be designed so the doors
and the pattern of movement for patients and swing outward from the room to prevent them from
personnel. It is helpful to construct a mockup becoming inoperable in the event of a magnet quench
of the room to allow clinicians to test the [1]. In an MRI magnet quench, all of the electrical energy
configuration of space and equipment. Planning in the superconducting wire is dissipated as heat, rap-
teams often also choose to visit existing facilities idly boiling the liquid helium keeping the magnet cold,
to learn what works well and doesn’t work well for turning it into helium gas. The equipment needs to be
them [21, 24, 25]. properly vented to provide for the escape of helium in
Once the decision is made to include hybrid rooms case of a quench. The consequences of unvented helium
in the facility design, early in the planning the pro- are that it can burn. If helium fills the room, displacing
ject team should ensure that all members thoroughly the oxygen, unconsciousness can quickly result (www
understand how the hybrid OR is intended to function. .mriquestions.com/​what-​is-​a-​quench.html).
Many manufacturers offer highly specialized, pro-
prietary imaging systems that can be permanently
integrated into the OR. Intraoperative CT, MRI, and
Design Considerations for Ambulatory
vascular imaging technologies are common. In many Surgical Centers
cases, these modalities can be moved into and out In an ambulatory surgical center (ASC), where patients
of the surgical field via floor or ceiling assemblies, arrive soon before surgery and are discharged soon
allowing for a clear zone when imaging technology after, the admission process and patient flow are prime
is not needed. Hybrid OR imaging technologies pre- considerations. The facility needs to be planned so the
sent additional spatial, structural, patient, and staff admission process is convenient for the patient and
safety issues that must be addressed by the entire efficient for physicians and staff. Surgical scheduling
team. Representatives from the imaging equipment and the preoperative assessment program need to be
manufacturer need to be involved early in the planned so procedures can be scheduled easily, the pre-
planning phase and throughout the project [1]. In operative assessment is safe as well as convenient, and
the design of an MRI room, specific requirements a limited number of patients are waiting in the admit-
must be considered, including obtaining an adequate ting area at one time. Preoperative and postoperative
MRI scan, medical imaging in a high magnetic areas also need to be planned to balance the need for
field, and isolation from radiofrequency artifact. privacy with smooth, safe, and efficient patient flow.
Radiofrequency isolation is one of the more diffi- For an ASC project, it is advisable to have an
cult tasks and should receive priority from physicists architect who specializes in the design of outpatient
involved within the project [26]. facilities, specifically surgical centers. The design
The minimum clear floor area of 650 sq ft (60.39 team needs to include members who understand the
m2) is recommended for a hybrid OR. However, the importance of efficient patient flow.
size of a hybrid OR is highly dependent on the func- The detailed size and facility requirements for an
tional requirements of the room as an operating envir- ASC can be found in the FGI guidelines [1]. In general
onment as well as the requirements of the imaging in ASCs, the OR size is smaller than in a hospital, and
equipment. This generally increases the room area hallway dimensions vary by location. The former class
requirements. The project team is strongly encouraged A OR is now termed a “procedure room,” which is
to develop a full-​scale mockup of the room during designated for procedures that are not defined as inva-
design to ensure it will function properly. sive and that may be performed outside the restricted
Many imaging systems are sensitive to vibra- area of the surgical suite but that may require sterile
tion, electromagnetic interference, and other forces. instruments and supplies. Outpatient ORs, formerly
The project team should consult with equipment class B and C, are required to have a minimum clear
manufacturers to determine if site readiness testing floor area of 250 sq ft (23.25 m2) and a clear dimension
is required. Also, these imaging systems often use of 15 ft (4.58 m) between fixed cabinets and built-​in
liquid-​based cooling, which may cross into the sur- shelves. Where complex orthopedic and neurosur-
gical environment, requiring additional protection gical procedures are performed in the outpatient
from dripping. setting, the rooms should have a minimum clear floor

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Section 2: Economic Considerations, Efficiency, Design

area of 600 sq ft (55.74 m2) with a clear dimension of regularly. The Joint Commission’s Planning, Design,
20 sq ft (6.10 m2). Outpatient surgery also follows the and Construction of Health Care Facilities is updated
surgical suite guidelines for two areas, semirestricted every one to two years.
and restricted [1]. With these resources as well as a team of quali-
The NFPA Life Safety Code and infection preven- fied professionals and the close involvement of end
tion and control requirements apply to the design and users, OR leaders can participate in designing and
construction of an ASC just as they do to a hospital. building a project that will meet the quality and safety
The facility’s entrance forms the patient’s and expectations of patients and clinicians as well as help
family’s first impression of the ASC’s services. The to fulfill the organization’s vision and mission.
facility needs to be designed so patients can easily
enter the building whether they are ambulatory or
have assistive devices (such as crutches, a walker, References
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protected from the elements. A separate exit and Care Facilities. Chicago, IL. Facility Guidelines
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passageways and/​or elevators. The pick-​up area needs of Health Care Facilities, 3rd edn. Oakbrook Terrace,
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Chapter 11: OR Design and Construction

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