AIA, NCARB, CSI, ICC
Constructive Criticism columnist Paul Gladysz, AIA, NCARB, CSI, ICC, is the principal architect at BDA Architecture. The Albuquerque, New Mexico, firm specializes in the planning, design and construction of animal care facilities. Gladysz has over 35 years experience in design and managing animal care facility projects. He has been involved in more than 300 veterinary designs, including 20 award-winning projects. His areas of special interest include project delivery methods, including design/build and construction management; lighting; acoustical control and new construction materials and methods.Read Articles Written by Paul Gladysz
Just about every veterinary hospital does surgery, yet there is no-one-size-fits-all surgery suite design. This article will assume you are constructing a new surgery suite, though most of my advice will apply to a renovation or expansion.
As with any construction project, the first step is defining the what, where, how much and how long. This programming is essential for many reasons and is a mechanism for controlling the scope and costs, organizing your thinking and making sure nothing is missed. How your practice operates is somewhat unique, so your surgery needs and design solution need to be individualized, too.
Answer these questions:
- Do you practice general or specialty medicine?
- Will your hospital seek accreditation from the American Animal Hospital Association?
- What is the surgical caseload now, and what do you project it to be in five and 10 years?
- How many surgeons do you employ now and how many will you have in the future?
- Will you expand the procedure types performed?
- Do you need to accommodate visiting specialists?
- What new or additional equipment will be needed, and is the budget sufficient?
- How large is the equipment, and where will it be placed when in use and stored?
- What power, data, gas or vacuum connections are needed?
- What are the desired scrub and gown protocols?
- What will be the hours of operation and the surgery patient capacity?
All your answers need to be documented. Talk with experienced designers for assistance.
The Lay of the Land
Once your surgery needs are known, think about space, meaning room sizes and adjacent areas. As an example, you might say you need two surgery rooms: one soft tissue and one dedicated to orthopedic work. Perhaps the soft-tissue caseload justifies multiple tables. You decide whether the tables can be in the same room, in separate places or in semiseparate spaces. You also need to consider support spaces for pack preparation and sterilization, scrubbing and gowning, patient preparation and induction, and post-op recovery. Once all these areas are defined, you can determine the necessary size of that portion of the building.
Along with the project scope, you need to keep expenses in mind, if course. Cost control is most effective when it’s part of the early planning. An important check is to generate an estimated cost based on what similar hospitals have paid on a square-footage basis. You need to confirm that you are not chasing something outside of a reasonable budget.
Since the rooms are equipment-intensive, you must budget not only for space but for the things you’ll put inside. Almost always, your initial plan will exceed the initial budget. You might have to reduce the size of some areas and combine certain functions into a single space. You might decide to leave some of the work until later, or you have to find a way to increase the budget. In any case, starting a project before the plans and budget are resolved is a waste of time and resources.
Who Goes Where
Now let’s talk about basic flow. In general, the best practice is to establish a one-way traffic scheme that minimizes the crossing of pre- and post-op patients. Ideally, if space permits, a dedicated pre-op area should be adjacent to the main treatment room. This is where patients are induced, shaved and prepped for surgery. Having at least one mobile table positioned here is important so that large breeds can be wheeled into the OR with minimal table transfers.
Each of the prep stations is equipped with oxygen and anesthesia gas scavenging, an exam light and power outlets. Consider some form of fur management: a local vacuum or a central housekeeping system. A busy practice will produce a lot of loose hair, so capturing it quickly at the source helps with overall hospital cleanliness.
Once prepped, the patient is brought into the OR, ideally through a sterile hallway that segregates surgery traffic from general hospital traffic. Likewise, the post-op patient should be transferred to a recovery area through sterile space.
Recovery areas vary in size and configuration depending on the caseload and types of procedures. They all should have space for feline patients and different sizes of dogs. Smaller dog breeds and cats typically recover in upper-tier cages where they can be easily monitored. Larger breeds are placed in bigger, lower-tier cages or an ICU-type run.
For a long time, my firm has designed open floor spaces where big breeds can be placed on blankets and near warmers. While this approach provided excellent access, there was a tendency for patients to spill out into circulation spaces, impeding traffic and creating less-than-sterile conditions. Now, we design dedicated recovery runs of about 5 by 3 feet that open with double gates on the long side. This strategy contains the patient and associated IVs, warmers, monitors and fluid pumps while preserving a higher degree of separation and pathogen control.
Once recovered, patients are moved to the intensive care unit or a species-specific holding ward.
Just as important as efficient and safe patient traffic is logical staff flow. First, you need to work out how and where scrubbing occurs. A growing trend is waterless scrub protocols. While this does not eliminate a sink, it does raise the possibility of using a smaller, less expensive hand wash rather than a traditional scrub sink. My firm does not advocate one over the other.
Along with scrubbing comes gowning. Some surgeons prefer to put on gloves in the OR while others do it adjacent to the scrub station. Placing a cabinet and countertop in the appropriate spot provides space for supplies and to lay out gowns and gloves. I try to minimize inside-the-OR storage cabinets to facilitate cleaning, so gowning in a sterile hallway would be my first choice.
Proper room cleaning requires surgery-specific janitorial supplies. In a multiroom surgery suite, I prefer building a closet off the sterile hallway to hold the mop, bucket and sanitizing products. These supplies should be used only in the OR suite and marked or color-coded to identify them as such.
Watch Where You Step
To promote ease of cleaning, selecting the right room finishes is critical. My firm recommends impervious and either sealed-seam or seamless flooring. Hospital-grade sheet products or a seamless resin floor are preferred.
An important consideration is skilled installers. Resin (epoxy/polyurethane) floor systems are excellent choices when installed properly, but they can be highly problematic if not. The specialized finish requires skilled craftspeople. There’s nothing worse (or as expensive) than a finish that cracks, bubbles or delaminates from the substrate, or one that is installed too rough (hard to clean) or too smooth (slippery).
Walls should be covered with scrubbable finishes. Paint can be used if it’s the right kind, so consult with a professional. Tile and vinyl wall cladding are other options if the budget supports them.
Veterinary facilities often do best with high-acoustical-performance ceiling tiles. Surgery is an exception since those sound-absorbing tiles also absorb moisture. In the OR, I specify film-faced scrubbable tiles or painted gypsum ceilings. Normally, the acoustics are not an issue unless nobody likes the surgeon’s music selection.
The Center of Attention
Sizing an OR starts with equipment. The center of gravity is the patient table. I like to see at least five feet of clear space around three sides of the table. The wall end can be placed closer to the headwall, where a shelf is often installed to hold monitors and other equipment. Other than an anesthesia machine, warmers, radiograph viewers and mayo stands, any other equipment is highly dependent on the procedures being done. Will you need an operating scope? A C-arm fluoroscope? The room expands with the equipment list.
A double-arm surgery light is centered above the table. Flanking both long sides are ceiling light fixtures, normally 2-by-4-foot LED lamps with a 4,000K color temp. We are looking for 100 foot-candles on the table surface with the surgery lights off.
Also above the table is the HVAC air diffuser and grill pushing low-velocity, HEPA-filtered air into the sterile field. Medical gases and vacuum outlets can be wall-mounted, but more commonly, ceiling drops are used at the head end of the table where the anesthesia machine is located.
Consider what types of connections are needed. Today, those are typically oxygen and waste anesthesia gas disposal. You also might need nitrogen if you use air tools, but a standalone tank might be the more economical choice.
Keep It Cool
Because the OR team frequently desires a lower temperature than in surrounding rooms, consider adding supplemental room cooling. This is hard to achieve with a building HVAC system that serves groups of rooms with a single thermostat. My solution is to add a minisplit air cooler and thermostat to the OR. These units do not introduce new air; they recycle the room air through a cooling coil. Ventilated fresh air comes from the building’s HVAC though the HEPA filter. The split unit lowers the temperature to a comfortable level.
Instrument flow is the next consideration. Pack prep and sterilization ideally is done in a two-room configuration featuring a dirty side and a clean side. These might be distinct rooms or subdivided space.
Surgery involves one of the most technical spaces and can be one of the highest income generators. It pays to put in the work to get everything right.