The I Chart: Rethinking Invasive, Interventional and Imaging - PowerPoint PPT Presentation

The “I” Chart: Rethinking Invasive, Interventional and Imaging Services Jennifer Aliber, FAIA, FACHA David Meek, Assoc. AIA As prepared for:

I Chart Introductions Jennifer Aliber, FAIA, FACHA, LEED AP David Meek, Assoc AIA, LEED AP Principal, Shepley Bulfinch Associate, Shepley Bulfinch As prepared for:

I Chart: Agenda Thesis Overview:  Invasive (Surgical Services)  Interventional (Card Cath / EP / Interventional Radiology)  Imaging Organizational Models The Forecast As prepared for:

I Chart: Thesis DOWNWARD CASCADE: INVASIVE INTERVENTIONAL Continuing pressure (i.e., cost, advances in IMAGING technology and safety, etc.) INFUSION to push treatments “downward” INJECTION INGESTION As prepared for:

Terminology: It’s Confusing Invasive  Operating Rooms (ORs) Interventional Society of  Cardiac Catheterization Interventional  Electrophysiology (EP) Radiologists:  Interventional Radiology (IR)  Subspecialty IR is the minimally invasive, image-guided  Department treatment of medical  Rooms  Labs conditions that once  Procedure type required open surgery  GI / Endoscopy As prepared for:

Terminology Imaging  MRI and f MRI  CT and PET/CT  Gen Rad  Rad Fluoro  Ultrasound  Mammography  Dexascan  Nuclear Medicine As prepared for:

Invasive: ORs INVASIVE INTERVENTIONAL IMAGING INFUSION INJECTION INGESTION As prepared for:

Timeline Ceiling The The Minimally Mounted First First Angiography X-ray in Invasive Robotic X-ray OR Surgery OR Surgery MROR Zeego 1927 1960 1980 1987 1993 1842 1896 2009 MGH FDA approved Ether 2000 Dome As prepared for:

Invasive Changes: Environmental Early surgery ORs with Surgical teams Minimally under anesthesia observation with protective Invasive with audience gallery space suits Surgery As prepared for:

Invasive Changes  Minimally Invasive ORs, imagine guided for laparoscopic  NOTES (Natural Orifice Transluminal Endoscopic Surgery) reducing invasiveness and going scarless  Specialized OR equipment, such as booms, robotics, navigation, and fixed and mobile imaging (Bodytoms, C and O-Arms, Scopes, Ultrasound)  Dedicated specialty and Hybrid ORs with fixed equipment  Additional support (OR rad techs, biomed engineering, etc) for preventive maintenance and repair, storage for special surgical equipment, specialized on-floor sterile processing As prepared for:

Minimally Invasive Smaller incisions through minimally-invasive laparoscopic surgery result in reduced infection rates, shorter stays and faster recoveries (but longer OR time). Facility consequence: - “The smaller the incision, the larger the room…” - Piping CO2 to ORs for insufflation - Boom-mounted monitors bringing the images up-close into the surgical field - Equipment booms to support surgical and endoscopic imaging equipment As prepared for:

Invasive Changes: Fixed Imaging in ORs Development of Hybrid ORs  Fixed imaging systems requiring Control Rooms and high-energy equipment rooms  Large video arrays in multiple areas of the OR and a control point to manage / direct image projection  Table-top swapping to increase room functionality and overall utilization Flexible arm (Zeego) Angiography MROR As prepared for:

Invasive Changes Hybrid Operating Room General Operating Room ( with fixed imaging) Consider using an exchangeable table 28 top system for better 8 room utilization 3 EQ 24 +100 SF for exchange trolley and table tops CTL (Control) 24 32 OR 500-600 NSF Hybrid (Scrub) 750-900 NSF SC 3 SC 3 (Scrub) 650 NSF Footprint 1,400 NSF Footprint As prepared for:

Invasive Changes: Prep and PACU Changes in Prep/recovery image NSF 9 11 FGI = 120 NSF min 4 4 11 14 4 5 Hand Washing (min) 3 Sink Decentralized FGI required Nurse Charting clearance around bed Pre / Post Bays Pre / Post Private Rooms 100 NSF 150 NSF As prepared for:

Invasive Changes: Department Potential impact of Waiting Pre / Post Operating Rooms renovating in place for a Hybrid OR Pre / Post WTG Clean Core Clean Core R 75 Chairs 24 P/P Beds 8 ORs (3C : 1B ) (3-4B : 1 OR) (3 Cases : OR x 250 days / yr) As prepared for:

Invasive Changes: Prep and PACU  Improved anesthesia and pharmacology → changed prep/recovery ratios  Privacy: visual and acoustical → larger rooms with doors Facility consequence: - Prep / recovery / PACU a much larger percentage of department - Impacts NSF : DGSF multiplier ( ↑ ) As prepared for:

Invasive: NSF OR IP NSF:  General OR: 500 - 600 NSF  Specialty OR: 700 - 800 NSF  Hybrid OR: 750 - 900 NSF + Control, equip OR OP NSF:  General OR: 400 - 650 NSF  Specialty OR: 700 NSF (future ortho?) Note: system OP OR sizes may be driven by IP OR standards As prepared for:

Invasive : DGSF NSF:DGSF Multiplier (IP and OP)  1.6 – 1.65  Note: the OR component is lower; the PACU/P/R may be closer to 1.75 Example: PACU  20 bays @ 100 NSF = 2,000 NSF 2,000 NSF x 1.7 = 3,400 DGSF  20 rooms @ 150 NSF = 3,000 NSF 3,000 NSF x 1.7 = 5,100 DGSF As prepared for:

Invasive: DGSF per Key Room IP DGSF per key room (OR)  3,500 – 4,250 DGSF/OR  Note: DGSF/OR will be affected by increase in hybrid ORs and larger PACU/P/R rooms OP DGSF per key room (OR)  2,500 – 3,000 DGSF/OR  Note: DGSF/OR will be affected by increase in OR sizes and larger PACU/P/R rooms (OBSV status) *Scale (# of key rooms) will impact DGSF/key room **DGSF per key room does not include CSS/SPD As prepared for:

Interventional INVASIVE INTERVENTIONAL IMAGING INFUSION INJECTION INGESTION As prepared for:

Interventional One Word: PLASTICS As prepared for:

Interventional Aggregation Aggregation: Cardiac Cath / EP / IR  Interventional “department” often includes specialties that appear similar (control rooms, large labs, etc.) and share resources (prep/recovery) rather than function as a unit Radiology Prep / Recovery Cath / IR EP As prepared for:

Interventional Diversification Diversification:  Vascular and Neuro are typically part of Radiology, whereas Cath and EP may become part of an integrated Cardiology Center elsewhere and the functional demand on the suites performing these procedures Prep / Prep / Radiology Cardiology Recovery Recovery Cath / IR EP As prepared for:

Interventional Lab : Fixed Equipment Monitor array Single Plane : Cath Lab and EP C-Arm Imaging table and pedestal base Bi-Plane : Cardiac, EP, Neuro, Vascular (allows 3D reconstruction) Word to the wise: resist the temptation, keep the bi-plane in IR and out of the OR As prepared for:

Interventional IR Lab Procedure Room (PR) Fixed imagining systems For mobile technologies 24 EQ 3 EQ 16 28 IR Lab 650-800 NSF Alcove for mobile imaging equipment 20 (X-ray, C-arm and PR Ultrasound) 200-300 NSF (Deep) Hand 8 Washing Sink CTL SC 4 ALC Control Scrub 12 12 HWS 900 – 1,000 NSF Footprint 325 NSF Footprint As prepared for:

Interventional OR quality air, low air returns CT PR IR Lab and OR finishes (multi-purpose) EQ EQ Shared Meds / Supply Room PPE Alcove IR IR CT CTL PR CTL CTL SC SC ALC Alcove for mobile imaging Semi-restricted corridor, STOP STOP equipment (X-ray, C-arm appropriate attire required and Ultrasound) As prepared for:

FGI: Interventional + Class 2 Imaging Procedu ocedure Room oom Type pe Im Imaging aging Room oom Ty Type Use A room designated for the performance of patient care Ex Exam am/ Tr Treatment that may require high ‐ level disinfected or sterile Cl Class ass 1 Im Imag agin ing Room oom Room oom instruments but is not not re required to to be be perf performed wi with th th the en envir vironm nmen ental co cont ntrols of of a procedur ocedure room. oom. A room designated for the performance of patient care that requires high ‐ level disinfection or sterile instruments Cl Class ass 2 Im Imag agin ing Room oom Proc ocedur edure Room oom and some environmental controls but but is is not not re required to to be be (INTER NTERVENTIONAL) VENTIONAL) performed wi perf with th th the en envir vironm nmen ental co cont ntrols of of an an oper operating ing room. oom. A room that meets the requirements of a restricted area, is designated and equipped for performing surgical or other Cl Class ass 3 Im Imag agin ing room oom Operating Room Oper oom invasive procedures, and has the en envir vironm nmen ental co cont ntrols (Hyb (H ybrid OR) OR) fo for an an OR OR as as indi ndicated in in ASHRAE ASHRAE 170. 170. An aseptic field is required for all procedures performed in an OR. As prepared for: