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

As prepared for:

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 Principal, Shepley Bulfinch David Meek, Assoc AIA, LEED AP Associate, Shepley Bulfinch

As prepared for:

I Chart: Agenda

Overview:

• Invasive (Surgical Services)
• Interventional (Card Cath / EP / Interventional Radiology)
• Imaging

Organizational Models The Forecast Thesis

As prepared for:

I Chart: Thesis INVASIVE INTERVENTIONAL IMAGING INFUSION INJECTION INGESTION

DOWNWARD CASCADE: Continuing pressure (i.e., cost, advances in technology and safety, etc.) to push treatments “downward”

As prepared for:

Terminology: It’s Confusing

Invasive

• Operating Rooms (ORs)

Interventional

• Cardiac Catheterization
• Electrophysiology (EP)
• Interventional Radiology (IR)
• Subspecialty
• Department
• Rooms  Labs
• Procedure type
• GI / Endoscopy

Society of Interventional Radiologists: IR is the minimally invasive, image-guided treatment of medical conditions that once required open surgery

As prepared for:

Terminology

Imaging

• MRI and fMRI
• 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

1896 The First X-ray 1842 The First OR

MGH Ether Dome

1927 Angiography 1960 Ceiling Mounted X-ray in OR MROR 1993 2009 Zeego Minimally Invasive Surgery 1980 Robotic Surgery 1987

FDA approved 2000

As prepared for:

Invasive Changes: Environmental

Early surgery under anesthesia with audience ORs with

• bservation

gallery Surgical teams with protective space suits Minimally Invasive Surgery

As prepared for:

Invasive Changes

• 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

• Minimally Invasive ORs, imagine guided for laparoscopic

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

Angiography MROR Flexible arm (Zeego)

As prepared for:

Invasive Changes

OR 500-600 NSF 24 24 SC

(Scrub)

3 650 NSF Footprint General Operating Room Hybrid Operating Room (with fixed imaging) 28 32 Hybrid 750-900 NSF CTL

(Control)

8 EQ

(Scrub)

SC 3 3

Consider using an exchangeable table top system for better room utilization +100 SF for exchange trolley and table tops

1,400 NSF Footprint

As prepared for:

4 4 4

Invasive Changes: Prep and PACU

Changes in Prep/recovery image NSF Pre / Post Private Rooms 150 NSF Pre / Post Bays 100 NSF 11 9

5

(min)

14 3 11

FGI = 120 NSF min FGI required clearance around bed Hand Washing Sink Decentralized Nurse Charting

As prepared for:

R WTG

Invasive Changes: Department

Waiting 75 Chairs

(3C : 1B )

24 P/P Beds

(3-4B : 1 OR)

Pre / Post 8 ORs

(3 Cases : OR x 250 days / yr)

Operating Rooms Pre / Post Clean Core Clean Core

Potential impact of renovating in place for a Hybrid OR

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
• f 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

Cath / EP IR

Radiology

Prep / Recovery

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

• n the suites performing these procedures

Radiology Cardiology

Cath / EP

Prep / Recovery Prep / Recovery

IR

As prepared for:

Interventional Lab : Fixed Equipment

Single Plane : Cath Lab and EP 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

Imaging table and pedestal base C-Arm Monitor array

As prepared for:

Interventional

900 – 1,000 NSF Footprint 28 IR Lab 650-800 NSF 8 3 12 12 SC CTL 24 EQ 325 NSF Footprint 20 16 4

ALC HWS

PR 200-300 NSF

Procedure Room (PR)

For mobile technologies

Alcove for mobile imaging equipment (X-ray, C-arm and Ultrasound)

IR Lab

Fixed imagining systems

(Deep) Hand Washing Sink Control Scrub

EQ

As prepared for:

Interventional

PR

(multi-purpose)

IR Lab CT

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

STOP STOP

As prepared for:

FGI: Interventional + Class 2 Imaging

Procedu

• cedure Room
• om Type

pe Im Imaging aging Room

• om Ty

Type Use

Ex Exam am/ Tr Treatment Room

• om

Cl Class ass 1 Im Imag agin ing Room

• om

A room designated for the performance of patient care that may require high‐level disinfected or sterile 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

• f a procedur
• cedure room.
• om.

Proc

• cedur

edure Room

• om

Cl Class ass 2 Im Imag agin ing Room

• om

(INTER NTERVENTIONAL) VENTIONAL)

A room designated for the performance of patient care that requires high‐level disinfection or sterile instruments and some environmental controls but but is 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

• f an

an oper

• perating

ing room.

• om.

Oper Operating Room

• om

Cl Class ass 3 Im Imag agin ing room

• om

(H (Hyb ybrid OR) OR) A room that meets the requirements of a restricted area, is designated and equipped for performing surgical or other invasive procedures, and has the en envir vironm nmen ental co cont ntrols 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:

Room

• om Ty

Type Use Environmenta ntal Con Controls ls Location Ve Ventilation (excerpte pted from ASH ASHRAE AE 170) 170)

Cl Class ass 2 Im Imagin aging Room

• om

Diagnostic and therapeutic procedures such as coronary, neurological, or peripheral angiography Electrophysiology procedures Accessed from an unr unres estrict tricted

• r a sem

semi‐ re rest stricted area 15 15 to total ACH ACH Positive pressure for catheterization No pressure requirements for other rooms Standard diffuser and return array Pr Procedur edure Room

• om

Patient care that requires high‐level disinfection or sterile instruments and some environmental controls but but does does not not re require re th the enviro ronmenta ntal co controls of

• f an

an oper

• peratin

ing room

• om

15 15 ACH ACH Positive pressure Standard diffuser and return array

FGI: Interventional + Class 2 Imaging

As prepared for:

2018 FGI PROCEDURES – SUMMARY

Type of Sedation Level of Invasiveness Equip & Staff required Infrastructure Rqmnts

St Sterility erility of En Envir vironm nmen ent Low, 4‐6 ACH High, 20 ACH Le Level of Inva vasive veness Non Invasive Invasive (Any) Ri Risk sk of

• f

In Infectio ion Limited 15 ACH Low High

1 2 3

As prepared for:

Interventional: NSF and DGSF

IR NSF:

• IR lab: 650 - 800 NSF → 950 - 1,000 NSF footprint

(includes control, scrub, etc)

• Inventory core model (similar to clean core in ORs)

adds 100 - 200 NSF per lab footprint NSF:DGSF Multiplier

• 1.6 - 1.65

IP DGSF per key room (lab)

• 3,500 - 4,250 DGSF/IR

As prepared for:

Imaging INVASIVE INTERVENTIONAL IMAGING INFUSION INJECTION INGESTION

As prepared for:

Imaging

Dx (Diagnostics)

Magnetic Resonance Imaging (MRI) Computerized Tomography (CT) Nuclear Medicine, including PET X-ray (Gen Rad) Fluoroscopy (Rad Fluoro) Ultrasound

Procedural

Specials Lab MRI CT Fluoroscopy Ultrasound Anesthesia + Prep / Recovery

As prepared for:

Imaging Developments

Equipment: The Ultrasound Evolution

• Increased portability, improved resolution,

drastically reduced to acquire and use

Power-assisted Easily movable Hand-held

As prepared for:

Imaging Developments

Program: EDx (24/7)

• Comprehensive Imaging services and support space for

Emergency and Inpatient needs

` `

MR Dx Dx CT CT

ED Pods Fast Track Trauma Center ED Imaging (EDx)

IP IP

Afterhours Imaging Nerve Center

As prepared for:

Imaging

16 4

ALC HWS

PR 200-300 NSF

Alcove for mobile imaging equipment (X-ray, C-arm and Ultrasound) (Deep) Hand Washing Sink

Multipurpose Procedure Room:

• Who “owns it”?
• How is time scheduled?
• What happens after it?
• What is being done

in this room?

16

As prepared for:

Imaging : Reading

Reading Shift:

• Anatomy driven, not modality specific
• Room Attendant
• Computational 3D Graphics /

Advanced Imaging Lab

As prepared for:

Imaging : Reading

Room Attendant Low-level corridor lighting

• utside

door(s) to minimize disruption when

• pening

Case study wall / area, full length monitors

17.5 32

6.25

(workstation)

As prepared for:

Imaging: NSF and DGSF

MRI 550 - 600 550 - 600 CT 550 400 - 450 PET/CT 550 350 - 450 X-ray (Gen Rad) 300 350 - 450 Fluoroscopy (Rad Fluoro) 320 350 - 450 Ultrasound (Dx) 180 120 - 150 Ultrasound (Procedural) 300 Dx (Diagnostics): IP OP*

NSF does not include control, scrub, etc. *Source: Advisory Board, 2015

NSF: DGSF multiplier 1.55 - 1.60 1.45 - 1.60

As prepared for:

Imaging: DGSF per Key Room

IP DGSF per key room depends on

• Mix of large/small rooms
• Dx vs procedural imaging → prep/recovery
• Extent of reading
• 1,750 DGSF/Imaging room proposed by Scot Latimer

(2008); remarkably accurate OP DGSF per key room depends on

• Mix of large/small rooms
• Corridor width
• ~600 - 750 DGSF/Imaging room

As prepared for:

I Chart

Organizational Models

As prepared for:

Imaging: 1990s

Dartmouth-Hitchcock Medical Center, 1991

• X-ray, R/F with

central work core

• Large film room
• MRI separate
• IR (Specials)

separate MRI IR X-ray; R/F

As prepared for:

ORs: 1990s

Dartmouth-Hitchcock Medical Center, 1991

• 16 ORs with 1

central core, 2 side cores

• PACU
• Same Day P/R
• Cath (w/NIVD)

ORs PACU Same Day P/R Cath

As prepared for:

Invasive + Interventional: 2000s

Cardiovascular Center University of Michigan, 2007 10 OR/labs: 1 Vascular Surgery OR 1 Vascular Hybrid OR 2 IR labs 6 Cardiothoracic ORs

As prepared for:

Invasive + Interventional: 2000s

SURGERY

CARIDAC INTERVENTIONAL PACU INTERVENTIONAL IMAGING SUPPORT PEDS OBSERVATION PRE/POST TREATMENT MED PROC UNIT Ronald Reagan UCLA Medical Center University of California, Los Angeles Perkins + Will

Credit: Perkins + Will

“Super platform” co-locates invasive and interventional services; shared PACU and pre/post

As prepared for:

nbbj | Banner Template

Invasive + Interventional: 2000s

Fast Track Specialty OR with Fixed Imaging Special Procedures Shell Space Operating Rooms Clean Core CSPD/ Support

As prepared for:

Interventional: 2010s

Heart and Vascular Institute Carle Hospital, 2013 10 Cath/EP/IR labs (1 shell):

• Identical labs (arch)
• Shared inventory core
• Shared prep/recovery
• Adjacent to OR suite

As prepared for:

Focus on Prep/Recovery: 2010s

Josie Robertson Surgery Center Memorial Sloan Kettering 2016

Architects: PerkinsEastman + ICRAVE

12 ORs 18 Prep rooms 28 PACU/Recovery

(same day and overnight recovery)

Photography by Karsten Moran

As prepared for:

EMERGENCY DEPT SURGERY RADIOLOGY PREP/RECOVERY RIBBON

72 Flex Prep/Recovery Rooms -- Ribbon

(ED overflow; CDU; P/R for Surgery, IR and Radiology)

Base drawing: UMN Landscape Architecture

Focus on Prep/Recovery: 2010s

Lake Forest Hospital 2017

Architects: Pelli Clarke Pelli, Gensler, HGA

As prepared for:

Examples

Banner University Medical Center Tucson, 2019 100,000 SF for Interventional, Imaging (and future GI Endoscopy) Shared prep/recovery (adult and separate pediatric pod)

As prepared for:

Examples

Nuc Med U/S Dx CT MRI

Non- Invasive Cardiology Shared Patient Prep / Recovery Endoscopy / Bronchoscopy

TAVR

Interventional Cardiology (Cath / EP)

IR EP CL

Labs Imaging

As prepared for:

A Hybrid of a Hybrid

Prep / Resuscitation, also used for induction (10’ dia) Surgical Cart Storage Surgical Equipment Storage Sliding doors for anesthesia separation MRI equipped with anesthesia support and OR quality HVAC for intraoperative surgery and pediatric scans Surgery access Z3 Z4 MRI 2 MRI 3 CTL Z3

As prepared for:

Invasive (ORs) Imaging

Special Proc

Organizational Models: I

As prepared for:

Organizational Models: II

Card Cath EP

Invasive (ORs) Imaging

Special Proc Hybrid OR

As prepared for:

Organizational Models: II

Invasive (ORs) Imaging

Special Proc Hybrid OR Card Cath EP Special Proc

As prepared for:

Organizational Models: III

Invasive (ORs) Imaging

Hybrid OR Card Cath EP Special Proc

Imaging Dx Imaging Proc

As prepared for:

Organizational Models: IV

Invasive (ORs)

Hybrid OR

Imaging Dx Interventional Imaging Proc

Card Cath EP Special Proc

As prepared for:

Imaging Proc

Organizational Models: V

Invasive (ORs)

Hybrid OR

Imaging Dx

MR OR TAVR

Interventional

Card Cath EP Special Proc

As prepared for:

Organizational Models: VI

Invasive (ORs) Imaging Dx Interventional

TAVR MR OR TAVR MR OR Hybrid OR

Imaging Proc

Card Cath EP Special Proc

As prepared for:

Organizational Models: VI

Imaging Dx

Card Cath EP Special Proc TAVR MR OR

Interventional Invasive (ORs)

Hybrid OR

Imaging Proc

As prepared for:

Imaging Proc

Organizational Models: VI

Imaging Dx OP Imaging OP Interventional OP ORs

Card Cath EP Special Proc TAVR MR OR

Interventional

Hybrid OR

Invasive (ORs)

As prepared for:

Organizational Models: VI

Imaging Dx OP Imaging OP ORs

Imaging Proc

Card Cath EP Special Proc TAVR

Interventional Invasive (ORs)

Hybrid OR MR OR

OP Interventional

As prepared for:

Organizational Models Department vs Functional Model?

As prepared for:

Forecast “The future is unknown; plan for it”

• Dr. Joel Barkmeier

Interventional Radiologist

As prepared for:

INVASIVE INTERVENTIONAL IMAGING INFUSION INJECTION INGESTION

Expect the downward cascade to continue

I Chart Forecast

As prepared for:

I Chart Forecast

Future of Hospital Imaging… Smaller departments…?

• MRI and CT moving to EDx
• Gen Rad and US (and some CT) moving to beds
• Push to smart phone technologies and OP

imaging sites

As prepared for:

IR Procedures

OP IR growth has been slowed by radiology group concerns With the exception of

• ncology

programs, limited anesthesia in OP settings

Advisory Board

As prepared for:

I Chart Forecast

Expect that Interventional will follow the Invasive model to OP settings Will require increased anesthesia coverage in OP environments

As prepared for:

I Chart Forecast

The two midnight post-op stay

As prepared for:

I Chart Forecast

Invasive “super hybrids” image guided systems robotics

+

As prepared for:

I Chart

Questions?

As prepared for:

I Chart Presenters

Jennifer Aliber, FAIA, FACHA, LEED AP Principal, Shepley Bulfinch

jaliber@shepleybulfinch.com

David Meek, Assoc AIA, LEED AP Associate, Shepley Bulfinch

dmeek@shepleybulfinch.com