Dirt and aspergillus in surgical suite renovation

04/01/2001

Surgical Suites

by Bruce Knepper, AIA, ACHA

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Burt Hill Kosar Rittelmann Associates (Burt Hill) recently designed and supervised the construction of two state-of-the-art operating rooms for the Minimally Invasive Surgery group for UPMC Health System's Presbyterian Hospital in Oakland, PA. Keeping dirt out of the OR requires constant vigilance, but is especially challenging during renovation and construction in a functioning surgical department. With advance planning and teamwork, however, it is possible to maintain an active OR schedule and provide a safe environment for patients and staff.

The renovation or expansion of an existing surgical suite is not a project to be undertaken lightly. In general, facilities put this off until the need to expand or update can be financially justified. But whatever the reasons or rationale, the journey from beginning to end can be difficult. The key to any successful program is a clear and concise plan.

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 life span. Suites that are 30 years old can seldom support today's procedures.

Implementing the plan: a problem/solution approach
After completing a balanced strategic plan, it's time to map out the implementation. Step number 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 throughput, 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: Will there be dedicated rooms for orthopedics, cardiovascular? 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, even if it has to be developed over time, is the best approach.

The following are keys to implementation:

• 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—pre-op, operating rooms and recovery.
• Manage 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.

The ideal plan must be buildable. 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 workmen without entering the surgically clean areas. Work hard to achieve as much 'daylight' shift work as possible—this will reduce both the costs and the total time. Night shift work is only 80 percent efficient as the eight hour shift is often reduced to seven or seven-and-one-half hours. Make the "time blocks" as large as possible—this will increase the productivity of the workmen, reducing construction time and costs.

Don't ignore 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.

Phasing adds significantly to the costs of renovation, and in some cases adding between five and 30 percent to the cost of actual improvements. 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, therefore, 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 contractors 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. Aspergillus 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 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 through numerous methods. The easiest is to install a fan and exhaust it directly to the outside, but 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 workmen about the dangers of spreading aspergillus. If they understand the danger, they are more apt to exercise the extra care necessary. Some institutions have required workmen to attend classes to fully understand the importance of containment as well as the exposure risk to themselves.

Clean finishes
Select finish materials that comply with the Volatile Organic Compounds (VOC) regulations. If products do not meet the standards (indicated by the manufacturer), do not allow their use. With current specifications and product labeling requirements, this is relatively easy to achieve.

In a renovation where dust is difficult to control, facilities may choose to construct the walls with gypsum lath and plaster in lieu of drywall. In general there is little dust created with plaster, while drywall requires sanding of the seams. The cost of plaster is higher, but may be offset by a reduced need for dust control. Each facility must evaluate the conditions and make an informed choice.

Flooring is one of the most hotly debated finishes in a surgical suite project, as it has to perform in many contradictory ways.

It must be seamless for infection control and aid in maintaining the sterile environment. It must resist the absorption of a wide variety of fluids, the worst being betadine, known for its insidious staining quality, and it must resist static build-up. While not to the level necessary when flammable anesthetics were used, it must be adapted to the OR's increasingly electronic environment.

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. There are problems with this material in that it can 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, and are only as good the craftsmen who assemble them.

Thin-set terrazzo is a highly durable flooring choice with good stain resistant properties and extremely long wear. This does have the drawback of being one of the most costly of choices. Terrazzo is seamless and can be flashed coved for ease in maintaining a sterile environment.

There are also epoxy/quartz flooring solutions, but they are less common. These provide a durable finish, but they will require recoating after some period of time depending on use. The solvent odors are generally not well tolerated, so if this product is chosen a careful plan must be made to control odors.

A new-comer to the flooring market is a rubber sheet flooring that is weldable and similar in cost and installation to welded PVC. It has been reported to be more slip resistant if finished properly.

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
Up to this point, tangible factors that one can hear, feel or see have been discussed. 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.

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. Providing cylinders for all of the gasses is an inexpensive safety precaution—these can be stationed in the ORs themselves. Consideration for emergency battery lighting is also a relatively inexpensive safety precaution.

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 systems or modifications to the sprinkler systems. The rules for this plan are defined in the JCAHO requirements as well as the Life Safety Code.

Sewing it up
If a facility cannot afford to completely replace its surgical suite, in a new location, it is possible to renovate, update and keep existing ORs functional through proper planning. Identify needs and goals, develop a plan to achieve them, work to find a phased approach to the renovation, and follow precautions to minimize dirt and accidents during construction. As with many activities, communication is the key to success.

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. A graduate of The Ohio State University, Knepper's career has kept him on the cutting edge of healthcare technology. He has specialized in the design and planning of healthcare facilities for 23 years, and is a founding member of the American Academy of Healthcare Architects. He can be reached at [email protected].