Healthcare Facility Planning Tools and Guidelines

Winter 2017

Volume 10, Number 1

IN THIS ISSUE

FEATURE

How Many Operating Rooms? It's Complicated

By Cynthia Hayward

Procedure Room

Planning a surgery suite used to be fairly simple. General operating rooms were used for a wide range of procedures with dedicated operating rooms limited to cardiac surgery and orthopedics. Today, the question “How many operating rooms are needed?” is complicated by more stringent distinctions between operating rooms and procedure rooms, changing technology and increasing specialization, and the convergence of diagnostic imaging and surgical procedures. From a facility planning perspective, the number, size, and specialization of the operating rooms (ORs) is the single biggest factor contributing to the overall footprint of the surgery suite (and project cost). Moreover, the numbers and sizes of related patient care and support spaces are planned based on the number and types of ORs. And, from an operational standpoint, the number of ORs drives ongoing staffing and related operational costs.

To read about issues associated with planning operating rooms, interventional radiology rooms, and other procedure rooms, and review a typical planning approach >>

OPERATING ROOMS VERSUS PROCEDURE ROOMS

In the surgery suite, a distinction is made between operating rooms and procedure rooms. ORs are designed to provide a safe environment for procedures that carry a high risk of infection. Any form of anesthetic may be administered in an OR as long as the appropriate anesthesia gas administration devices and exhaust systems are provided. On the other hand, procedure rooms are used for procedures that do not require an aseptic field although they may use sterile instruments and supplies. Local anesthesia or minimal or moderate sedation may be administered in a procedure room, but anesthetic agents used in procedure rooms should not require special ventilation. Procedure rooms are considered unrestricted areas and may be used for endoscopy, pain management, laser, or other procedures in which there is no cutting of the mucous membranes.

CHANGING TECHNOLOGY AND INCREASING SPECIALIZATION

Mobile ultrasound, endoscopy units, or c-arms (their name derived from their shape) have been a standard part of surgical operating rooms for many years. However, today, hybrid operating rooms have permanently installed equipment, such as intraoperative CT, MRI, and fixed c-arms, which are typically used in conjunction with cardiovascular, thoracic, neurosurgery, spinal, and orthopedic procedures to enable diagnostic imaging before, during, and after surgery. This arrangement enables the surgeon to assess the effectiveness of the surgery and perform further resections or additional interventions in a single encounter. Many equipment vendors offer highly specialized, proprietary imaging systems that are permanently integrated with operating rooms while others offer designs that position the CT or MRI unit so it can be used independently for diagnostic procedures when surgery is not in progress.

CONVERGENCE OF IMAGING WITH SURGERY

As imaging procedures are becoming more interventional and no longer limited to diagnostic uses, surgery is becoming less invasive. With the melding of interventional radiology and minimally-invasive, image-guided, and traditional open surgical techniques, the co-location of the interventional suite with the surgical suite, when feasible, provides additional long-term flexibility.

TYPICAL PLANNING APPROACH

Whether planning a traditional surgery suite or an integrated surgical and interventional radiology area, the process begins with determining the number of procedure rooms — surgical operating rooms (ORs), interventional rooms (IRs), minor procedure rooms (MPRs), and hybrid rooms. Some healthcare organizations may have already settled on the number and type of procedure rooms based on a detailed business plan (What can we afford?). Also, partnerships with equipment vendors or the existence of an enthusiastic donor may result in early agreement on one or more hybrid or specialty procedure rooms regardless of the current workload.

Current and historical workload. When a detailed analysis is required, a look at the existing workload is a good starting point. Historical data — such as the past three years — is also used to identify trends in conjunction with projecting future workload. The current annual number and minutes of surgery cases and interventional procedures (as applicable) should be tabulated by specialty and patient type (inpatient, same-day admit, and outpatient) and sorted by the type of procedure room used. For example, surgical specialties that may use a dedicated procedure room include cardiovascular surgery, neurosurgery, orthopedics, gastrointestinal/genitourinary (GI/GU), gynecology, and ophthalmology. Many other procedures can be accommodated in the same flexible OR or procedure room. Ideally, the number of dedicated rooms should be kept to a minimum.

If an institution has a busy trauma center, the total annual minutes should be adjusted to reflect emergency procedures that occur outside the normal hours when elective procedures are scheduled. Procedures that occur outside the primary weekday shift should not be used to calculate procedure room demand.

The average minutes per procedure, or room time, can be calculated for various specialties by dividing the annual minutes by the annual number of procedures. Hospitals also typically record the average room turnaround time which is the time between when one patient leaves the procedure room and the room is ready for the next patient. Throughput is the rate of patient flow through the OR or procedure room — such as or 2.5 cases per OR per day or 900 annual cases per OR.

Projected workload. Once the projected workload is confirmed, the annual minutes of room time can be calculated based on a review of existing data with adjustments to reflect anticipated future changes in case length. A target room turnaround time also needs to be established (usually 15 to 20 minutes). This again should be based on an analysis of the existing room turnaround time and adjusted to reflect potential operational improvement initiatives. The target room turnaround time is multiplied by the projected procedures and added to the annual minutes of room time. This results in the total annual minutes required which is used to determine the number of procedure rooms.

Procedure room availability. Most procedure rooms are available eight hours per day for a total of 480 minutes per day. However, many institutions are extending hours of operation into the early evening to optimize the utilization of these expensive facilities. The number of days per year the suite will be in operation must then be determined. If the suite operates five days per week, 50 weeks per year (assuming 10 holidays), 250 annual days of operation will be calculated. Multiplying the annual days of operation by the minutes per day will provide the annual minutes available per procedure room at 100 percent utilization (typically 120,000 annual minutes).

Scheduling efficiency. A scheduling efficiency factor is multiplied by the annual minutes available per procedure room to account for periods of time that a case cannot be scheduled. This factor may range from 70 percent for ORs or procedure rooms used for complex (and sometimes unscheduled) procedures — such as cardiothoracic, neurosurgery, and trauma/orthopedics — to 90 percent for an outpatient suite where all procedures are scheduled.

Estimating the number of procedure rooms needed.The total annual minutes required are then divided by the annual minutes available per room (adjusted for scheduling efficiency). It must be noted that if the hospital is designated as a trauma center, an OR may need to be available at all times for emergencies. This must be considered in calculating the number of ORs for the surgical suite.

OTHER COMPLICATIONS

In an integrated surgical and interventional radiology suite, optimal flexibility could be achieved if all the procedure rooms were interchangeable. However, the physical configuration and patient and staff flow of an OR and an IR are different. ORs are typically designed with dual access to the procedure room — one from a perimeter corridor for the patient and staff and the other from a central clean “core” area from which case carts and other sterile supplies and equipment are placed in the procedure room. An IR is configured with both a contiguous control room with staff workstations, and a contiguous equipment component room, rather than a clean core area. IRs also require radiation protection.

The difficulty in projecting future workload comes when procedures performed in an OR or IR today are expected to migrate to a hybrid room. Also, new, and often experimental technology, may involve longer procedure times thus reducing the number of procedures to be accommodated in a specific room initially.

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IN THE NEWS

Community Clinics, ACA Beneficiaries, Worry About Their Future

Patient in Clinic

Community clinics are key providers of primary care services for the poor. Treating people for free or for very little money has been the role of community health centers — a type of community clinic — across the U.S. for decades. In 2015, 1 in 12 Americans sought care at one of these clinics; nearly 6 in 10 were women, and hundreds of thousands were veterans. With roughly 1,400 community clinics nationwide, they have also expanded in recent years to serve people who gained insurance under the Affordable Care Act (ACA) and these clinics have been the poster child of the positive impact of the landmark ACA.

To read about the impact of ACA repeal on community clinics >>

In 2015, community health centers served 24.3 million people — up from 19.5 million in 2010. Most of the centers are nonprofits with deep roots in their communities. By meeting the criteria to be a federally-qualified health center, they can qualify for federal grants and a higher payment rate from Medicaid and Medicare. Revenue at many clinics went up overall, and many of the health centers used federal grants to expand their physical facilities and add services, such as dentistry, urgent care, or mental health care.

A November 2016 study in the American Journal of Public Health showed that Medicaid spending was 24 percent lower for patients who received a majority of their primary care from federally-qualified community health centers than for patients who got care in other settings. The savings extended across all services, the study’s authors reported.

Republicans, newly empowered by Donald Trump’s ascendance to the White House, have made clear they plan to repeal large parts of the ACA in short order although the timing of any replacement is still uncertain. Community clinic leaders say they’re focusing on several funding challenges. First is a potential rollback of the ACA’s Medicaid expansion program, which extended new coverage to about 20 million people in the U.S. Some also worry that shifting Medicaid to a block grant system, an idea President Trump has endorsed, would result in cuts to services; or that Congress could decline to reauthorize “330 funding” — an additional $5 billion community clinics receive each year from the federal government. That stream of federal dollars is set to expire in September 2017. However, without clarity about where funding will come from in the future, or how much of it there will be, it’s possible that clinics will “go into hunker-down mode” which could mean limiting hours, reinstating waiting lists for new patients, and cutting promising new programs.

Sources: Becker's Hospital CFO, American Hospital Association, and Federation of American Hospitals.

TRENDLINE

MIcro-Hospitals: A New Healthcare Model

By Cynthia Hayward

Thinking small allows a healthcare system to test demand or grow its presence in a specific market without the expense of a traditional greenfield full-service campus. However, unlike community hospitals and small, rural hospitals, healthcare systems are developing micro-hospitals in larger metropolitan areas to treat low-acuity patients and provide ambulatory and emergency services along with a small amount of inpatient beds.

To read about this new healthcare model and the facility impact >>

WHAT IS A MICRO-HOSPITAL

Although not all alike, most micro-hospitals focus on treating low-acuity patients and provide ambulatory and emergency services — leaving more complex clinical services and surgeries to the larger, full-service hospitals within their broader healthcare network. They also have a lot fewer beds, often only 8 to 12.

LOCATION IS KEY

Unlike community hospitals and small, rural hospitals, healthcare systems are placing micro-hospitals in larger metropolitan areas. The focus is to provide care at the right time in the appropriate setting allowing care to be delivered closer to home with easier access than can be provided at larger, more complex facilities. They can also be seen as an extension of a bedless emergency department which needs to be affiliated with a fully-licensed hospital anyway. This allows patients to be stabilized and transferred to a more appropriate healthcare setting as necessary.

The San Francisco-based Dignity Health opened one micro-hospital in Phoenix and plans to open one more in Phoenix and four in the Las Vegas area. The Colorado-based SCL Health has two micro-hospitals in the Denver area, and the Dallas-based Baylor Scott & White Health has micro-hospitals sprinkled throughout Texas, according to Kaiser Health News.

FACILITY IMPACT

Compared to a traditional hospital, micro-hospitals are less of a financial burden for a healthcare system. They typically require only about 15,000 to 50,000 square feet. The Advisory Board estimates that a micro-hospital project can cost anywhere from $7 million to $30 million. With a shorter construction timeline, micro-hospitals expedite bringing healthcare services to patients in the community. A micro-hospital is also an ideal candidate for developing a prototype facility that can further reduce the planning, design, and construction time. Compared to robust outpatient facilities, micro-hospitals must comply with the same stringent design and construction regulations of an inpatient hospital and may not be an option in heavily-regulated states.

Source: “The Rise of the Micro-Hospital” by Heather Punke, Becker’s Hospital Review, July 21, 2016.

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TECHNOLOGY

Robotic Nurse Being Developed To Assist Infectious Patients

Nurse Robot

Trina — which stands for Tele-Robotic Intelligent Nursing Assistant — is a first-generation nursing robot that is being built by a collaboration of Duke University’s engineering and nursing students and staff. Since the Ebola outbreak in 2014, new technologies, including robots, are being tested as alternatives to human contact to diminish risks for providers as they care for patients with infectious diseases. Funded by a National Science Foundation grant, Duke officials started working on the $85,000 robot about a year-and-a-half ago.

Trina looks like a science-fiction cyborg with a dash of Rosie the housecleaning robot from “The Jetsons.” Its face is a tablet, which shows its human operator, like on Skype. On its head sits a gray wig, topped with a surgical cap. In a simulation lab in Duke University’s School of Nursing, Trina’s tasks included delivering a red cup, a bowl, pills, and a stethoscope to a pretend patient. Although robots are commonly used in surgery to help doctors perform tasks with precision and flexibility, the machines don’t move about the room and perform tasks like preparing drinks or adjusting an oxygen mask.

“We are not trying to replace nurses,” said Margie Molloy, an assistant nursing professor, but trying to create a safer environment for healthcare providers. When healthcare providers work with patients infected with diseases like Ebola, they dress in multiple layers of protective clothing, wipe everything down with bleach, and utilize multiple rooms. Duke officials are hoping to improve the process with the remote-controlled Trina robot that nurses and doctors can navigate — in another room — and direct to move linens, take vital signs, and pass food and medications to an infectious patient.

Source: "Duke Officials Test, Refine Robotic Nurse" by Virginia Bridges, Durham News, November 16, 2016.

RULE-OF-THUMB

Cardiovascular Services Capacity and Preliminary Space Need

Cardiovascular procedures include routine noninvasive diagnostic tests as well as more complicated diagnostic and therapeutic interventions. Noninvasive cardiovascular procedures are generally simple, quick, and routine while interventional procedures involve longer procedure times and recovery periods.

See rules-of-thumb for cardiovascular services >>

COMMENTS

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I appreciate any comments that you have about the SpaceMed Newsletter.
— Cynthia Hayward

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