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A Guide to Designing Hybrid ORs

Hybrid ORs are becoming more and more common, but what is a Hybrid OR? What makes it different from a regular OR? What does it take to establish one?  This article will try to address those questions.  It will not help determine if you should establish one nor will provide a definitive program for one.  It will however provide a list of issues, concerns and distinguishing features that can be employed to answer those questions.

Meritus RICUnit floorplan

The devil will be in the details – Flow, Finishes, Engineering, Coordination. More than any other room in a hospital, Hybrid ORs are more complex at every level, from internal politics to equipment locations and infrastructure.

If you get only one useful takeaway, understand this: When designing or using a cath/angio lab, after the patient, the equipment is the reason for the facility to be in existence.  Its function is first and foremost one of imaging and image guided procedures.  The imaging equipment is where the design and planning start.  In a Hybrid OR, on the other hand, we may be dealing with the same equipment, but the function of the equipment is to be one of many other tools.  This imaging equipment’s function is to inform a procedure that once underway may have little to do with the imaging equipment.  Indeed once the meat of the procedure starts, we may want the imaging equipment to be entirely out of the way.

A traditional OR is 450 to 650sf.  Not much has changed in the design of a traditional OR except the size and complexity of some of the equipment that get used therein.  An OR built today will look very much like one built 20 years ago except with LED lights.

Hybrid ORs come in all shapes and sizes.  Depending on the specialty served and the imaging equipment, the layout will vary greatly. The size of the procedure room itself, is anywhere between 650sf and 1000sf then add to that control rooms and electronics rooms.  

This paper will describe 4 ORs that were built within a couple of years of each other for the same healthcare system.  They are all 4 renovations within existing surgery suites in two separate hospitals. 

Each supported a different specialty and had different pressures imposed.

Some common elements include

  • A built in circulating nurse station to support all of the digital integration, communications and charting computer
  • Two have IT server and electronics cabinets that are accessed from the corridor.
  • Equipment booms
  • LED procedure lights
  • Separate anesthesia support boom
  • Two were organized to support open heart procedures

The design for these Hybrid ORs started with the client’s standards and took some different directions to meet their specific needs.  Below are listed some of the biggest concerns that need to be in mind during the entire planning process.  Each will inform the solution.

Entrance from the corridor is on the left.  Access to the sterile core in at the left rear.  The sterile field is offset to the right.  Circulating nurse station and materials are room left.

  • Procedures – Vascular? Neuro? Cardiac? All? Other? One of the rooms was designed to function as a vascular Hybrid OR, but can be used for traditional general surgery also.
  • Primary Equipment – Imaging, Lights, Booms, OR Table All of this equipment has huge infrastructure needs, power, plumbing structural supports – difficult to accommodate in new construction more challenging in renovation.
  • Number of People Perhaps the most interesting is how many people will be involved in a given procedure.
  • Visualization from Control and Circulating Nurse Station Who and what does the team in the control room need to see and who in the procedure needs to communicate with the control room
  • Room Layout to accommodate a variety of procedures Does the room need to meet the needs of a variety of procedures or specialties? Or will it be dedicated to one specialty?
  • Access to support – Supplies, Equipment. Etc. What will be stored in the room?  Where will it be and how will it be accessed?

OR1
1,000 SF net
1,500 SF gross
Primary Use:
Pediatric Open Heart Surgery

This room is used primarily for pediatric open heart surgery.   It has a biplane imaging system.  There are multiple video displays that can display a variety of information from several platforms simultaneously and separately.  At the peak of a complicated procedure there can be more than a dozen people within the OR itself.  Note that the entrance is on the right and access to the substerile area is to the left of the room entry.  These variations from the planning standard come from two issues.  1. View from the control area and patient transfer coordinating with the other equipment argued for the right entry.  2.  This room and another hybrid room are not on the typical center shared core.

The room organizes thus.  Visualization from the control room coupled with the Circulating Nurse Station flank the patient access.  Perfusion and anesthesia are in the rear of the room away from supplies and movement areas.  Supplies and access to the substerile room for backup are located on the left of the room, in ready position, but out of the way.

In most cases there will be two surgeons and two scrub nurses one each on each side of the table.

Anesthesia is at the head, but unlike most ORs the circuits are very long to allow the anesthesia machines to be moved allowing the imaging equipment to move in and out and spin.

Perfusion is to the side and out of the way and will probably never move during a procedure. 

VIEW TO CONTROL ROOM

VIEW FROM CONTROL ROOM

Note the size of the video displays now.  They preclude direct line of sight between people in the sterile field and control, so properly engineered cameras and communication systems are much more important.  Note perfusion and anesthesia both have ceiling mounted video.  The room is too large and the main displays too far away for them much of the time.

This OR also has a prefabricated ceiling system that includes lighting, laminar flow diffusers and equipment mounting.  To the users, the best part of these systems is the even shadow free lighting provided within the sterile field, which is unavailable in traditional stick built individual component based ceilings.

OR2
1,000 SF net
1,500 SF gross
Primary Use:
Vascular Surgery

This room is used primarily for vascular surgery.   It has a retracting single plane imaging system.  There are multiple video displays that can display a variety of information from several platforms simultaneously and separately.  Normally there are no more than 5 people within the OR itself.  Note that the entrance is on the right and access to the substerile area is to the right of the room entry. 1. View from the control area and circulating nurse station is the same.  2. This was designed with the supplies massed behind the anesthesia station, and to the right.

VIEW TO CONTROL ROOM

VIEW FROM CONTROL ROOM

OR2 organizes thus.  Visualization from the control room and the Circulating nurse have clear view of the OR table and procedure, even when the video screens are drawn into place.  Anesthesia is in the rear of the room away from supplies and movement areas.  Supplies and access to the substerile room for backup are located on the right and rear of the room. 

In most cases there will be one surgeon with an assisting surgeon and one scrub nurse.

Anesthesia is at the head, but again the circuits are very long to allow the anesthesia machines to be moved during the procedure allowing the imaging equipment to move in and out and spin. 

The retracting imaging equipment withdraws completely out of the sterile field with no cables or ceiling hung elements allowing unimpeded access all around the table.

OR3
1,000 SF net
1,500 SF gross
Primary Use:
Neurosurgery

OR3  This room is designed specifically for Neurosurgery.   It is really just an OR with a mobile CT configured for Neuro scans.  We include it as a Hybrid OR, because the planning issues are the same and the equipment is dedicated to this OR. Typically 3 to 5 people in the room.  There is no control room or electronics room since the mobile CT is fully self contained.  Note that the entrance is on the right and access to the substerile area is on the right opposite the room entry.  Because of the existing structure and substerile access points the room is opposite the Standard.  Other than being opposite hand, this room most clearly resembles the system standard.

VIEW TO CIRCULATING NURSE

VIEW FROM CIRCULATING NURSE

Head of the patient is to the corridor.  O Arm CT system parks here and can roll in and out of the sterile field efficiently.  Once the patient on the table the anesthesia equipment is setup at the patient’s right.  Supporting equipment is at the right side of the room, readily available.  Circulating nurse station is back right adjacent to access to the core.  Supplies and small equipment is arrayed at the patient’s foot with easy access to the circulating nurse.

View from the core door.  Note the profusion of video displays, boom mounted and wall mounted.  The wall displays will be used as the patient is being prepped and after the first set of images is up.  The surgeons can access the latest information while not disrupting the work being done within the sterile field. 

OR4
1,000 SF net
1,500 SF gross
Primary Use:
Adult Vascular Surgery

OR4  This room is used primarily for adult vascular surgery.   It has a single plane ceiling mount imaging system with extended rails, so it can be stored completely out of the sterile field.  It is also designed to function as a back up open heart room.  Note that the entrance is on the left and access to the core is on the left opposite the room entry.  Due to space limitations imposed by the existing structure and the need for visual connection with the control room, supplies are opposite the circulating nurse desk.  This room is a camel, trying to do many things at once.  Vascular surgery, back up open heart room, and the Owner wanted to hedge their bets so we ran several simulations wherein the imaging/surgery table is turned 90 degrees for use as a back table for general surgery.  In real life this option is not used.  There is too much equipment and work flow relocation required, to make it effective. 

VIEW TO CONTROL ROOM

VIEW FROM CONTROL ROOM

Not the ideal situation, but the imaging generator and controls cabinets are in this closet at the room right.  This allowed more floor space to be dedicated to the OR itself, but maintenance and repair work is more difficult.

Head of the patient is at the corridor end.  When not in use the imaging system parks in front of the control window out of the sterile field efficiently.  The anesthesia setup is at the typical patients right location.  Supporting equipment is at the left side of the room, readily available.  Supplies stored in the room are at the right side. Circulating nurse station is back left, adjacent to access to the core.  There is more case specific equipment stored in the room accessed through the control room.  Because this control room has no door, the staff is considered part of the surgical team and must wear masks, booties, hair nets, etc.  This decision was discussed at great length, because it is part of the OR Room and is subject to the higher air exchanges required of surgery. The communication and access value of having no door was deemed of greater value. 

View from the control room, with all of the major equipment including perfusion in the room.  Lots and lots of wall and boom mounted video display.  All of it can be managed to display from multiple feeds.  

Since 1974, Matthei & Colin Associates, LLC (M&CA) has specialized in the planning and design of health care environments. Through the passion of our creative effort, we have emerged today as one of the nation’s few firms exclusively dedicated to health care architecture. We are committed to collaborating with our clients by understanding the challenges and recognizing the opportunities.  Our singular focus on designing and creating health care environments and our productive client partnerships result in highly individualized planning recommendations to address the unique requirements of each project. Though a proven process of listening, asking, and creating, we translate dialogue into design.

For more information contact:
William W. Heun, AIA, Principal
Matthei & Colin Associates, LLC
1.312.939.4002
williamh@mca-architecture.com