director – health sciences, at London-based Swanke Hayden Connell Architects, at the recent Healthcare Estates conference. Jonathan Baillie reports.
Speaking in Harrogate, US-born Keith Millay, whose 25 year-long career has seen him gain extensive academic, research, and healthcare design and planning expertise, made clear just how important he believes the configuration, throughput, and technical functionality of a hospital’s operating department are to its overall success. However, he was equally firm in another belief: that while very significant emphasis, and indeed media attention, has been devoted to good ward design in recent years, there has been substantially less focus, at least publicly, on how much of a difference to the overall patient experience a really high quality operating theatre environment, and indeed associated admission, waiting, anaesthetic preparation, and recovery rooms, could make to those visiting a hospital for surgery. Nor, he argued, had anything like sufficient discussion taken place on how the “flow” and scheduling of operations might be improved by changes to typical operating department layout and configuration. Whether, for instance, equipping each theatre with its own separate anaesthesia preparation room, or, conversely (as his practice recommends), amalgamating this facility within the theatre, thus at one stroke saving considerable space and eliminating one potentially stressful preoperative “step”, represents the optimum approach, had, he suggested, been hotly debated by healthcare professionals in the UK “for at least the past 7-8 years”. However to date there had been little public focus on the issue, nor on how improving the overall ambience and comfort of associated areas, such as the lounge where patients are prepared prior to surgery, might enhance the hospital visit and reduce patient anxiety. As well as contrasting the markedly different approaches to operating department design in different countries, Keith Millay’s presentation outlined a radically different system developed by Swanke Hayden Connell for configuring the various waiting, assessment, operating, and recovery facilities that the architectural practice believes could easily be adopted both in private, and in future, also in NHS hospitals. The firm believes the system would substantially improve both the patient experience, and the efficiency with which operations are carried out. At its heart is the belief that, with ever higher patient expectations, a highly competitive healthcare marketplace, and ever-more sophisticated theatre technology, there has never been a better opportunity to re-appraise both the design of the operating theatre, and of the adjacent waiting and other spaces.
Already successful in the US
Keith Millay explained that a number of the practices and systems advocated are already successfully used elsewhere, especially in North America. For instance with patient outcomes now the key yardstick on which many American hospitals are judged, the “health maintenance organisations” that offer healthcare to many large US businesses have been considerably quicker than their European counterparts to adopt robotic surgery, which they argue is less invasive, and thus carries a lower risk of complications than more “traditional”, “open” procedures. Although the NHS had not yet widely adopted robotic surgery, Keith Millay is convinced its time will come. Much of his presentation’s initial focus, however, was on the “quality” of the patient experience before, and after, surgery, and on how a number of the key elements of Swanke Hayden Connell’s novel approach to operating department design are intended to be implemented at the privately-run London Clinic in London’s Harley Street as part of a multi-million pound scheme currently in its early stages which will see the hospital’s six existing theatres demolished and replaced with 10 new theatres over coming years. A large private hospital, which undertakes a growing range of surgery, it is hoped the hospital could soon be an excellent exemplar of how an operating theatre department re-design and re-build can be successfully undertaken to the benefit of all “stakeholders”, using both the latest technology, and a much more “patient-centric” approach. Referring to the wider UK hospital model as a whole, however, as he began explaining his firm’s thinking on the way UK hospital operating departments are currently designed and “organised”, Keith Millay said a typical patient “processing” approach prior to surgery would often see the newly admitted patient undergo their initial identity checks, have their blood pressure, height and weight checked, and be visited by the anaesthetist, in a “rather poorly designed, curtained off area with little privacy or space”. Undertaking such checks and other pre-operative discussions within a cubicle, cordoned off by a curtain, was hardly, he argued, in keeping with a good 21st Century healthcare system.
Comfortable lounges
Swanke Hayden Connell’s vision advocates instead that arriving patients proceed straight from the admissions unit to a large patient preparation area/lounge equipped with comfortable chairs, sofas and other “homely” furnishing. Here the individual, and their relatives and/or friends, can wait in relaxed surroundings before the patient is assessed and undergoes the usual medical checks in a series of specially designed suites, themselves fitted out with sufficient chairs, tables, and other furnishings, to allow any discussions between clinician, anaesthetist, and patient/relative, to be undertaken in a relaxed, confidential, and calming environment that can be controlled by the patient. As well as preparing patients for their procedure in a more sensitive, appropriate manner, the architects believe such a set-up will streamline the admissions process, and ensure patients are transferred to theatres in an “efficient and comfortable manner”. Keith Millay said: “We have proposed a series of 20 such preparation suites adjacent to the patient lounge for the London Clinic, which will also double up as Stage 2 recovery suites where patients will be taken following the initial Stage 1 recovery closer to the theatre itself. The suites are being designed to be sufficiently flexible to be used either for pre-operative assessment, or as a relaxing Stage 2 recovery space, depending on the clinical schedule on any given day. Each room will also incorporate its own private WC facilities.” One of the most hotly debated operating department issues, at least among surgeons and anaesthetists, Keith Millay said, was the next stage in the patient journey to the theatre – the visit to the anaesthesia preparation room. The traditional UK practice had always been for a patient already administered with “pre-med” medication to be wheeled to the “anaesthesia prep” room or, in more recent times, with changing attitudes on the safety of administering such drugs, for them to walk to the anaesthesia room, where the anaesthetist and his team then administer the required anaesthesia. Although conceding that the issue polarises opinion, Swanke Hayden Connell argues that, rather than having a separate anaesthesia ‘prep’ room, there is no reason not to, and indeed significant advantages in, instead incorporating the facility within a larger theatre space.
Putting patients at ease?
Keith Millay explained: “One of the main arguments for a separate anaesthesia prep facility from the patient standpoint has been that they help to put the individual at ease. However in recent surveys around two-thirds of those questioned said separate anaesthesia “prep” facilities do little to make them feel more relaxed, and less anxious. Instead – and this is the approach we proposed to the London Clinic – why not simply take the patient straight from the patient lounge to the theatre and allow the anaesthetist to carry out their work once they are on the table?” Keith Millay concedes that, for such a change to find widespread UK favour, opponents will need to be convinced that the operating theatre environment will be made significantly more conducive to relaxing the patient than is currently the case. “That is why,” he explains, “we have done a lot of work on aspects such as using softer materials, artwork, and special dimmable LED lighting, so that a patient going straight to a theatre will immediately feel more comfortable and relaxed.” The practice argues that there is also an important additional benefit in undertaking anaesthesia within the theatre. Keith Millay explains: “Traditional practice has seen anaesthesia administered in a room with all the relevant monitoring equipment, but the patient may well then have been taken into the adjacent theatre unmonitored, although, of course, wireless monitoring devices are gaining ground.” Swanke Hayden Connell actually proposed to the London Clinic that its redevelopment scheme see anaesthesia prep rooms incorporated within each new theatre, but when this was put to the vote, the opponents won through. Keith Millay explains: “Many established surgeons feel anaesthesia and surgery should not mix, while the existing practice of having, say, an 18 m2 anaesthesia prep room, is vigorously defended by some anaesthetists.” Another opposing argument has been that, by preparing the patient in a separate room, throughput is improved by allowing the surgical team to prepare for the operation. However, Swanke Hayden Connell argues that it is actually the speed, efficiency, and thoroughness of instrument preparation that most impacts on surgical throughput.
Electronics advances
Alongside arguing for amalgamation of anaesthesia within the operating theatre, the firm advocates having the scrub area adjacent, with a vision window, as well as a well-equipped instrument preparation area close by. Much of its approach is based around the fact that, while in the past, monitoring, medical gas, and much of the other essential theatre equipment, had to be wheeled into the theatre, creating a degree of “clutter”, recent advances in electronics are now increasingly seeing theatre lighting, gases, monitoring, and other essential components, incorporated on hi-tech wall or ceiling-mounted pendants. Keith Millay said: “By eliminating the traditional anaesthetic prep room, which can take up significant space, you can reallocate the space very efficiently to within a larger theatre, enabling it to house the sophisticated imaging systems and indeed robotic surgical equipment increasingly on many hospitals’ wish lists.” He added: “In fact the whole debate about whether or not separate anaesthesia prep rooms are necessary has been raging hard, although seemingly not much in the public arena, since around 2002. Given that eliminating this ‘traditional’ stage will see the patient go straight to the theatre, the environment will often need to be transformed. “One of the other key areas we will address in this particular scheme,” he continues, “will be to use the same consistent lighting and materials, say, in the theatre, and in the Stage 1 recovery area, so that as patients regain consciousness they feel they are in familiar surroundings.” Keith Millay explained to me that, in Swanke Hayden Connell’s model, having spent the required immediate postoperative period in the Stage 1 recovery area, the day-case patient then progresses back to the cubicle area originally used for their pre-operative assessment. Here, within their own private space, they can be joined by family or friends, turn on a TV, read a book, or generally relax. “The next stage”, he said, “would be for them to return to the relaxing lounge they first came into until ready to go home.” Inpatients undergoing surgery at the London Clinic would, conversely, return to their ward or bay following Stage 1 recovery. “The whole emphasis is on smoothing the patient journey, making patents feel they are in as non-clinical a setting as possible, and providing the type of environment you might expect in a good hotel,” Keith Millay explained.
Surgical efficiency enhanced
While the patient experience is central to what the practice is striving to achieve, both at the London Clinic, and, it envisages, in future, similar projects, optimising surgical facilities and procedures is another key goal. Two out of the 10 new theatres to be constructed at the London Clinic will feature surgical robots, with the others designed to be able to incorporate them in future if required. The hospital currently has one operating theatre equipped with robots. Keith Millay explained that his own experience in the US of robotic surgery had been very positive, with many healthcare facilities there convinced that the devices both improve outcomes, and deliver extreme precision, especially in more complex surgical procedures. He says: “Clearly robotic surgery is less invasive – in some instances surgeons can remove diseased organs through a relatively small aperture; there is less opportunity for major blood loss, and the robots’ precision is incredible. I am a strong advocate of robotic surgery, and, although the NHS has not yet pursued it aggressively, I believe this will change in time. SHCA is also keenly following developments in automated robotic surgery.” Two of the London Clinic’s other new theatres will be larger than the remainder, at 70 m2, principally to enable them to incorporate MRI diagnostic imaging equipment. Keith Millay explains: “Incorporating MRI scanners intraoperatively within the theatre gives surgeons, and the patient, several benefits. In particular, when conducting, say, neurosurgery, the surgeon can take an immediate, extremely detailed look within the area of brain being operated on via a 3D image, to ensure, for instance, that all of a tumour has been removed, or that no blood vessels have been damaged. This is surely an advance on wheeling a patient who has had complex brain surgery back to the ward, discovering 24 hours later that they may have complications, and then having to take them back to an MRI suite, re-scan them and, should the suspicions prove correct, return them to the theatre and re-open their skull?”
Evaluating MRI options
Keith Millay went on to explain that, in consultation with the architects, the London Clinic is still considering whether to opt for mobile, or static, MRI units for the two new theatres. He says: “Mobile MRI units, which we know from our research are enjoying considerable US success, can simply be wheeled into the theatre when needed, and then returned to a storage area, usually adjacent. However, as with larger static MRI machines, they do require the adjacent walls to be sufficiently magnetically shielded.” Should the London Clinic, or indeed any other hospital considering equipping a theatre with MRI scanners, prefer to install a static unit, Keith Millay says the latest static scanners can now accommodate patients intra-operatively, mounted on a “track”, enabling the scanners to be moved above the operating table during surgery and then, if necessary, transferred via the tracks to the adjacent theatre for use during another procedure. This does, however, result in a larger RF shield, and there are advantages in provision of a ‘static’ unit where the patient is transferred from the operating table to the MRI scanner. He says: “The advances in diagnostic, lighting, patient monitoring, communication, medical, and overall control system technology in the past five years have been substantial, and it is now the norm for much of such equipment to be incorporated on pendants.” With the pendants’ growing use Swanke Hayden Connell predicts everincreasing use of the touchscreen theatre control systems now increasingly evident in newer UK hospitals, while pan-view LCD monitors, coupled with ceiling cameras for external views, and boom arm cameras for the surgeon’s direct control, will also come more to the fore. Also moving forward apace, Keith Millay explained, was interconnectivity of cameras and other monitoring components with other equipment within a hospital, enabling, for example, images to be transmitted to another clinician, or perhaps a pathologist, remotely, for assessment as surgery is actually taking place. Transmission of patient tissue to other departments via pneumatic tubes, for instance for biopsy, is now, he said, already increasingly commonplace. Swanke Hayden Connell believes increasing use of pendants, wall and ceiling-mounted monitors, and touchscreen control units, as well as new LED lighting and robotics, will benefit surgeons in the first instance, but in the final analysis it will be patients that truly gain – through more efficient, high quality surgery “in a truly state-of-the-art environment”. It feels improving theatre ergonomics and hi-tech design will win over even the most conservative surgeons in the future.
Cost issues
Keith Millay concedes, however, that such equipment’s deployment will often require an adjacent, or nearby theatre control centre, coupled with some form of IT tower adjacent to the operating suite. Of the potential extra costs, he says: “There is little question that some of the sophisticated diagnostic, monitoring, and lighting equipment we are now seeing, and indeed have planned into our scheme for the new London Clinic theatres, will raise costs, but then consider the benefits to patients of having their operation undertaken using the latest robotic equipment under high grade LED lighting that gives surgeons the best possible view of their work. High quality lighting, and components such as boom-mounted surgical cameras, give surgeons a much clearer view of the patient’s anatomy, maximising the chances of them avoiding healthy tissue.” From an estates standpoint, increasing use of MRI equipment within theatres will require walls, ceilings and floors to be covered with copper or mesh, and RF shielding used on the doors. However the architect points out that healthcare architects and designers, and estates and facilities personnel, already have plenty of experience in this area. Incorporating ever-more sophisticated equipment into, in some cases, larger operating theatres, will also have significant building services implications, as Keith Millay acknowledged: “Stripping the structure of the building in the areas where the new theatres will fit back to the bare frame, and virtually re-starting from scratch in creating the 10 new theatres, as we are doing at the London Clinic, requires some extremely complex building services activity. “Alongside the challenge of efficiently connecting up all the equipment, the latest Health Building Note guidance on operating theatre design strongly suggests that each theatre have its own air-handling unit in place of the previous common configuration of two theatres sharing one AHU. The recently published Health Technical Memorandum, HTM 03, also takes into account, in a change to previous policy, the operating theatre’s size, in terms of how many air changes per hour should be needed. At the London Clinic each theatre will need to have 25 changes /hour and this factor, combined with the need to provide each with its own AHU, will necessitate a very substantial investment in new plant.” So significant, in fact, is the change required at the Harley Street facility, that a new multi-level plant building for the new theatre complex will be constructed as part of the project.
Impact on building services
Keith Millay said: “These facilities are needed to ensure that the common instrument ‘prep’ room air change rate, and the room pressure, are maintained irrespective of the theatre plant status.” Among the many other considerations for the building services team at Arup, with whom Swanke Hayden Connell is working closely on the project, are the need to change extract grille locations to low level within scrub bays, anaesthetic and recovery rooms; the addition of positive extract from within the large theatres, necessitating detailed guidance on the location of extract and exhaust relief paths, and guidance on suitable theatre supply diffusers and their location. The reduction in the theatre corridor pressure in the configuration proposed for the new operating suite will also result in the theatre department no longer operating at positive pressure to adjacent departments. “Interestingly, “adds Keith Millay, “previous Department of Health guidance based services design on predicted air leakage, with no specific consideration of the size of the theatre, but HTM 03 has changed this.” Another significant building services issue on the London Clinic project, and one that the firm argues will be equally pertinent to the design of other future UK operating theatres, is whether to incorporate full-scale HEPA filtration and laminar air flow. Keith Millay explained that many UK surgeons argue vociferously for such features, but the practice’s view is that, given that 100% of the air circulated within UK hospitals is generally drawn from outside, and that temperature extremes are uncommon, there is little need for either sizeable HEPA filtration units or laminar flow canopies in many theatres. He explains: “In, say, a hot country like Australia, where about 50% of the hospital air may be being recirculated, I can see the arguments, but here in the UK we believe large-scale units may be an expensive luxury. In HEPA filtration’s case, provided the number of air changes is sufficient, you may well get away with much smaller units, or indeed no HEPA filtration at all, while, with the number of pendants now present in many theatres, much of the air from large laminar flow canopies may well end up being compromised.” Keith Millay explained that Swanke Hayden Connell is now keener to recommend, including to the London Clinic (no firm decision has yet been taken on this), the use of smaller, locationspecific wall or floor-mounted HEPA filters and laminar flow units, which can be quickly and easily positioned wherever they are needed (for instance close to a sterile instrument tray) used, and then either deployed for use elsewhere, or put away. He adds: “Some recent study evidence suggests that, not only are such units cheaper, but that they are also more effective in combating infection, particularly in orthopaedic cases. “A significant advantage for estates and facilities personnel is that, unlike a large HEPA filtration unit built into the operating theatre wall, mobile units will not require the theatre’s closure for cleaning or changing of filters etc.” Keith Millay says the benefits of such mobile units have been especially well documented in Scandinavian hospitals, and expects increasing UK take-up over time.
NHS expectations peak
In conclusion he admitted that, while use of hi-tech robotic surgery, and the strategy of combining surgical and anaesthesia prep activities within one operating theatre, to take just two examples of the novel approach to operating theatre design Swanke Hayden Connell recommends, are still a novelty in the UK, the advantages of such practices both to clinicians and patients, in terms of a faster, more efficient treatment process and overall patient perceptions, would convince more and more healthcare personnel of their value in the future. Although acknowledging that, with public funding currently extremely tight, it was private sector hospitals that were most likely to be among the early adopters, he believed the NHS would gradually follow suit. He added: “As, in one sense, an outsider, having been brought up and spent many years in the US, I am always amazed at how fantastic many aspects of the NHS are, but simultaneously at how often its qualities are under-estimated and its achievements talked down. “NHS patients have arguably never had higher expectations of the care and treatment they will receive, and the changes to operating theatre and ancillary accommodation design we are proposing merely reflect this. You would also have to agree, I am sure, that to, for instance, have patients awaiting, say, cancer surgery, separated from other patients and their families just a few metres away by nothing more than a traditional curtain does not really accord with a modern healthcare system. “At Swanke Hayden Connell we are fortunate to be able to draw both on traditional architectural skills and extensive interior design expertise to propose a more forward-thinking, creative approach to operating department design which we hope could soon become the rule, rather than the exception, in many UK hospitals.”