The structural features of the surgical suite can influence not only the efficacy of the treatment provided but also the overall patient and staff experience. Modular operating room construction (MOR) is a concept that aims at improving architectural and engineering design as well as ergonomics of the occupied space. Various marketed advantages of MORs include increased functionality, sterility and cleanliness, comfort, safety, flexibility, durability and aesthetics. Aspects such as ease of maintenance and renovation and the possibility of making swift modifications and upgrades to existing utilities are also emphasised.
The substructure is the skeleton of the MOR architecture to which the wall and ceiling elements are installed, connected and sealed. The profiled floor rails, vertical supports and ceiling rails form the framework, creating cavities for the passage of utilities (such as electricity, water and gases). It is because of this substructure that no walls or partitions are required for installing MORs. They may be installed in open-plan areas, alleviating the necessity for duplicated construction (reducing cost and space redundancy).
Wall elements come in different materials and finishes. This article will focus on two categories; powder coated stainless steel attached to plasterboard panels, and more recently, frameless glass elements, made of thermally tempered safety glass. The wall elements can be disassembled and reinstalled if required with minimal operating room downtime. Built-in elements can be integrated, including monitors, cabinets, control panels, central clocks, cameras, etc.
The surfaces of both stainless steel and glass panels are microscopically flat and free of pores, resistant to living organisms, chemical substances and most common hospital detergents and disinfectants. Fire, noise and x-ray protection can be integrated in accordance with project requirements. However, some characteristics can differ from Stainless Steel to glass. In fact, aesthetics and functionality are combined in the glass material, which improves the patient care coefficient. Glass elements can be backlit using high-performance LEDs, which generate friendly and appealing atmospheres in the room and lead to better working environments. Glass is a robust material with a lower number of joints and is fully resistant to acids and bases. On the other hand, stainless steel panels add future-proof flexibility for service, maintenance or modernisation, as individual wall elements can be dismantled without damage and can be designed to incorporate a service panel circulating the room’s perimeter, allowing for utility outlets addition with very minimal disruption.
Other integrated components common to both categories include:
- Operating room ceilings
- Operation room doors
- Laminar airflow systems
- Scrub sinks
- Integrated HIS screens
- Room lights
- Writing boards
- Pressure relief dampers
- Operating room flooring
- Operating room control panel
- Operating room storage systems
- Operating room isolation panels, etc.
Doors can be hinged or sliding, single or double-leaf, manual or motorised, fire and x-ray protected. There is a wide variety of available finishes for the panels (including printing of images and logos), which allows to create spaces that are more pleasant for the users.
Compared with conventional construction, a number of advantages have been claimed to be associated with MORs in medical facilities. The relevance of such advantages should be assessed in an unbiased scientific way, which takes into consideration information made available through evidence-based citations and unbiased institutional reports. While doing so, manufacturer claims ought to be disregarded unless they are backed by scientific and research-based evidence.
Ease and speed of installation of modular operating rooms
This is relative and varies from one project to another, however, depending on how a project is planned, procured and executed, both conventional construction and MOR construction can have bottlenecks and delays. For example, if a prefabricated component breaks during transport or installation, it cannot be replaced by off the shelf items. It would have to undergo the standard manufacturing process, which may be lengthy, especially when a special character is involved such as colour or style. Nevertheless, since MOR concept is a single entity, turn-key construction solution involving all building elements (walls, ceilings, floors, doors, windows and MEP associated services), coordination efforts become much easier and execution time and errors have proven to be reduced considerably in projects involving advanced engineering technologies.
Future modifications and expansion
Although wall panels are prefabricated, removed and re-installed relatively faster and cleaner than conventional works, it remains a fact that any modification to the room layout, shape or size will require serious workflow reconfiguration and ceiling modifications. For instance, the operating room table must remain in the centre of the suite. Ceiling elements must follow. This means that HVAC, room and surgical lights, pendants and associated embedded services like power and medical gases will require extensive work to be relocated. That’s why surgical suites are hardly reconfigured in normal working practices, and when they do, whether the affected room is constructed from conventional material or modular elements, the work site will have to be identified and designated as a “construction site” and sealed off from the rest of the surgical suite until completion of the works. What is marketed very frequently about converting two operating rooms to one in a matter of a few hours is true from a very limited perspective. Nevertheless, there is no doubt that renovations incorporating MOR elements will endure much less noise, dirt, dust and smell when compared with conventional construction (gypsum or other material, plaster, sanding, paint, etc.)
Infection control and prevention
According to the Center for Disease Control (CDC), surgical site infections (SSIs) occur after surgery in the part of the body where the surgery took place. SSIs can sometimes be superficial infections involving the skin only, but they can also be more serious involving tissues under the skin, organs, or implanted material.
According to a study published in Infection Control and Hospital Epidemiology Journal, Vol. 35, No. 6 (June 2014), pp. 605-627, and endorsed by the CDC, SSIs are common complications in acute care facilities. They occur in 2 – 5 per cent of patients undergoing inpatient surgery and are considered to be the most common (20 per cent) and most costly hospital-acquired infections (each SSI is associated with 7–11 additional postoperative hospital-days). SSIs are associated with substantial morbidity and mortality; patients with SSIs have a 2 –11 times higher risk of death compared with operative patients without an SSI (77 per cent of deaths in patients with SSI are directly attributable to SSI). Such factors place a considerable burden on healthcare systems and must be treated very seriously.
Up to 60 per cent of SSIs have been estimated to be preventable by using evidence-based guidelines. Several infrastructure elements have been proven to contribute positively in reducing SSIs. They include training and education of staff, patients and patients’ families on the proper implementation of processes, methods and tools related to the reduction of SSI risks.
Proper ventilation was listed among the most important factors affecting infection prevention and reduction in the operating room. Patient cleanliness, surgical site shaving, surgeon’s attire and scrubbing, antibiotics administration, etc. have all been proven to affect SSIs in one way or another. However, no evidence-based citations were found to link material performance and the ease of cleaning and disinfection of vertical surfaces (walls and doors) with reduced post-surgical infections.
Reduced downtime
The total cost of operations in hospitals can be separated into fixed and variable components. Fixed costs are ones that don’t change in proportion to the volume of operations or occupancy. They include overhead, facility and equipment upkeeping, maintenance and depreciation, services and indirect staff. Variable costs are ones that are linked directly to the work volume and they change in direct proportion to volume and occupancy. They include staff in direct connection with patients, the activity functional rooms, sterile supplies, disposables, medication, medical waste disposal, etc.
Operational costs of surgical suites vary from one place to another, but they generally range from US$16 to US$150 per minute depending on surgical speciality (staff, equipment, etc.) and type of facility, among many other factors. Downtime of the activity spaces is directly proportional to operational loss, which is made up of the full fixed cost and part of the variable cost. In surgical suites, where resources are limited (space, materials and equipment), any downtime due to maintenance, disinfection or other reasons will create a significant impact on the return on investment and overall cash flow. For instance, one day of inoperability of one operating room incurs losses in the range of US$30,000 or more (assuming a median of US$50 per minute for a combination of fixed and partial variable costs).
Maintenance-related incidents leading to operating room closure and consequently downtime may be divided into two general categories; namely, emergency corrective maintenance (unscheduled) and planned preventive maintenance (scheduled).
Emergency corrective maintenance is the response to sudden failures, which cannot be controlled or prevented, irrespective of construction method and materials. Such failures include fixed equipment (lights, pendants, fire elements, HVAC elements, etc.), wall outlets (PMG, power and network), as well as architectural elements (doors, motors, fixed cabinets, etc.).
Planned preventive maintenance is the scheduled type of maintenance where the facility engineering team of the hospital has the luxury of planning and scheduling the works ahead of time, with the surgical suite coordinator, and preparing the required parts to be replaced, as well as any tools, accessories or other materials necessary for job completion. When the facility maintenance team conducts the required scheduled preventive maintenance works, it should seldom affect the schedule of surgeries. Such works may be done on weekends or nights.
While corrective and preventive maintenance of engineering elements are somewhat the same for MOR and conventional methods, the MOR panels, whether made of glass or stainless steel, require no paint or maintenance and are easier to clean and disinfect when compared with conventional walls. Re-paint is totally alleviated throughout the life cycle of the glass or stainless-steel wall elements.
In summary, the advantages of the MOR concept may be divided into two categories:
General and long term
This is related to enhancing the working environment and staff comfort, through ambient aesthetics such as convivial lighting and colour attributes, resulting in a modern and lively working environment.
Additionally, ease of cleaning and disinfection, as well as reduction of downtime and disturbances related to scheduled preventive maintenance and renovation works.
Immediate and project-specific
This is related to streamlining the project coordination and execution process which, to a certain extent, can reduce the otherwise encountered errors and delays.
Other issues related to project-specific considerations such as budget and schedule attributes should be examined carefully to properly and adequately assess the suitability of the MOR concept.
Ahmad Jawhar
This article appears in the March/April edition of Omnia Health Magazine. Other topics include AI in healthcare, patient safety, mobile healthcare and further updates around on COVID-19 from the healthcare industry.
