Integration, hybrid

technology steal the

show

Surgical tables and lights may

still be the star attractions in the
operating
theatre, but in today’s fast-paced,
state-of-the-art surgical suites,
high-tech digital integration and
hybrid functionality gets top
billing.

"OR Suites have evolved

dramatically from those of a
decade ago, owing largely to the
dramatic growth of MIS
[minimally invasive surgery] SKYTRON-Philips Hybrid Room Suite featuring Philips interventional X-ray imaging.
procedures across surgical fields,"
commented Randy Tomaszewski, vice president of marketing, SKYTRON. "In addition, the advancement of video,
data and telecommunications within the OR to providing critical patient data at the fingertips of the surgical team
(PACS, EMR, video images and more) has been a tremendous advantage in improving clinical workflows, staff and
operational efficiencies, as well as the quality of patient care."

Accompanying the trend towards minimally invasive, natural orifice, as well as robotic procedures, "integrated
operating rooms are becoming the standard for quality patient care," remarked Lauren Ashley, marketing associate
for Stryker Communications. "With advances in surgical technology, hospitals are utilizing this integrated platform
to maximize efficiencies, increase the level of patient care, and minimize cost of ownership."

"Hybrid" suites are also becoming the norm, observed Jim Norris, senior manager, market development, STERIS
Corporation. "We see basic OR suites evolving into a combination of advanced ORs and general surgical rooms. As
more procedures become minimally invasive (whether via an endoscope, a robot or trans-catheters), OR designers
need to accommodate these new technologies by developing flexible room designs. High definition (HD) cameras,
HD monitors, intra-operative imaging, 3D image capabilities and robotics are transforming patient care. Surgical
room design must take all these advancements into consideration, and facilities must look into the future in order to
make the most of scarce capital funds."

Through its OR SuperSuite expert design services, BERCHTOLD Corporation has completed hundreds of designs
for hybrid suites that combine a typical surgical environment with diagnostic imaging/interventional capabilities
ranging from ceiling mounted C-arms, to CTs and MRIs, described Matthew Weismiller, president. "What we’re
seeing today on larger projects is that the hospital will build two hybrid suites for every 12-15 standard suites. And
we believe that ratio will continue to grow as surgeons perfect the use of imaging technologies in the surgical
arena."

According to Steve Palmer, director of marketing, TRUMPF, "the definition [of a hybrid room] can range
dramatically, but it’s basically bringing high-end imaging and surgery together in the same room. Now everything
can be done in sequence without having to wait."

Generally speaking, operating suites that are flexible or "universal" are becoming increasingly popular, indicated
Palmer. "Because technology and surgical procedures continue to evolve fairly rapidly these days, they don’t want a
room that’s dedicated to one specific discipline, e.g., orthopedics or neurosurgery. They want to be able to use these
rooms with as many disciplines as possible."
Eric Berger, marketing coordinator for ConMed Integrated Systems, noted several trends in surgical suites,
including: "Larger suites to accommodate multi-specialty procedures and auxiliary equipment; most new suites will
implement boom solutions; most new suites will be HD-ready for digital integration and documentation; hybrid
(interventional) ORs that can address surgical procedures as well as angiography; navigation and robotics are part of
the integrated OR with greater frequency; open systems and interoperability of devices; and more integration with
EMR, data management and archiving."

A Philips-STERIS hybrid suite

Commenting on the growing size of ORs, Tomaszewski, SKYTRON, noted, "A decade ago, ORs were typically 400
square feet. Older operating rooms commonly have even less space. Today, the minimum requirement for new
construction is 600-800 square feet. For specialty ORs, such as cardiovascular and orthopedic suites, even larger
foot prints are the norm. Why? Because with the growth and advancements of surgical technology and equipment
commonly used today, smaller rooms would leave no room for the patient and clinical staff. Robotics, C-arms, video
carts, microscopes and more that make surgeons so proficient also require far more space. The general OR rule of
thumb is, ‘the smaller the wound, the larger the room,’" he said.

A desire to increase square footage is one of the key reasons that facilities choose to renovate their existing surgical
suites. Weismiller, BERCHTOLD, explained, "As technology has advanced in the surgical arena, the space required
for a fully capable and flexible suite is larger than in the past."

In addition, "the organization and workflow required to deploy the myriad technology while maintaining the sterile
field, that has changed over the years as well," he said. "Creating a workflow in the rooms that approaches
maximum efficiency as well as maintaining all of the appropriate infection prevention criteria, that’s demanding
larger rooms and creative new room designs."

"Today’s healthcare structure increasingly focuses on quality, safety and prevention," said Donna Ungvarsky,
business development specialist, Olympus EndoSite Consulting. "Keeping this in mind, few aspects are as critical in
affecting the success of a healthcare facility as its workspace structure and flow patterns. Very often, unit design and
support services no longer adequately keep pace with the current and projected growth in volume, change in
procedure mix and/or other current trends in the healthcare arena."
 MacBethPhoto.com

BERCHTOLD SUPERSUITE

Integration and the digital OR

With the growing number of collaborations between interventional radiology and diagnostic imaging technology
providers and surgical suite vendors, integration is becoming a seamless operation.

"ORs of today demand integration technology within the OR that delivers speed of access, accuracy, reliability, ease
of use, flexibility, OR up time, future proof expansion and more," said Tomaszewski. "Advanced integration
technology improves clinical support processes and workflow solutions both within and outside the operating room
via video and data display in and around the surgical field, linking the operating room with pathology, radiology,
cath lab, ICU, interventional radiology, with C-arms, robotics, teleconferencing and more. Booms and surgical
lighting play a key role forming the backbone of the integration framework required for key delivery of locations in
and around the surgical field, to the main communications hub for access and routing of critical video and data
images within and outside the surgical suite."

Noted Ungvarsky, "When thinking of integrating your operating/procedure rooms, you must first thoroughly
examine your needs and determine what you want integration to do for you. You will need to look at the people,
processes and technology that will create the system that will best accomplish your goals. The best possible
outcomes with integration are a combination of process change (the elimination of waste in the process), training
and technology. The best technology in the world can only have real impact if the people who use it buy into it and
the processes applied are utilized to their fullest capacities."

For successful integration projects, "buyers and planners should understand the goals of the end users; know the
hospital’s five year plan for the operating rooms; focus on purchasing equipment that complies with current video
standards; and select regulated medical devices for the OR, not simply audio/video equipment," advised Ashley,
Stryker.

"An OR integration system should be vendor-neutral in order to ensure the best images and data exchange possible,"
recommended Rich Schafer, director of project design and planning, STERIS. "Also, it’s important that OR
integration systems are able to link to other rooms with integration as well as to other departments and software
within a hospital."
With integration capabilities ranging from "simple cabling through connection plates on the booms to a very
sophisticated HD integration system which can include on-site and off-site conferencing," described Berger,
ConMed, he stressed that "the facility needs to be ‘prepped’ and ready to embrace future technology."

ConMed Smart OR

Surgical suite planners should understand the various levels of integration options available, said Tomaszewski. "A
basic integration system enables clinical staff the ability to route video images within the operating room to LCD
flat panel and wall-mounted displays. Most of these are considered entry level systems and often times are not
upgradeable or expandable in functionality," he cautioned. "Buyers should be aware of this as these systems may be
priced within a desired budget they may not meet the functional requirement and goals of the facility.

"The next level above these entry level systems is an advanced integration system which offers the equivalent
functionality of the entry level system, but these systems provide a platform for growth both in the number of video
and imaging devices which can be managed as well as adding optional features such as image capture, recording,
streaming, music accessories, hands-free phone, video conferencing and more."

Digital technology, such as with Skytron’s SkyVision Hybrid II digital integration system, provides additional
advantages, described Tomaszewski. "There are several integrated OR’s today and many of them are based on older
analog technology. Some are a mix of analog and digital technology and recently, the all digital integration systems
have been implemented.

"Digital OR communications takes OR communications to the next level of flexibility with greater speed of access,
accuracy, reliability, OR up time, future proof expansion, HD digital image quality up to 1080p over IP, optimizing
clinical use, workflows and efficiencies," he explained. "Digital Capture Streaming, for example, simplifies audio
and video communication over IP from the OR to any remote destination such as conference rooms, another
operating room, physician’s office or other healthcare facility."
According to Ashley, "There are many key attributes critical to a successful hybrid suite including: Room layout—
The hybrid suite should accommodate imaging, surgery, or imaging during surgery; Multiple displays—Due to the
vast number of video sources, consideration should be taken to accommodate more than one simultaneously; Video
routing device—The suite should have the ability to route any source to any display without distorting (upscaling)
the image."

Future-proof suites

While it’s impossible to predict exactly where surgical technology is headed, there are several ways that facilities
can build their OR suites to be "future-ready."

"Technology advances very rapidly, so flexibility is key," reinforced Weismiller. For example, he described how a
modular ceiling grid system can allow for easy repositioning of equipment mounts compared to traditional
equipment mounts that are welded into the structure above the ceiling. "If four years after you build your suite you
decide you want to convert it from an endoscopy room to an orthopedics room and you want to move your
equipment, we can do it. And we don’t have to come in with a torch and cut all your welded frames out of the
ceiling. We can go in after the last surgery on a Friday, and in a couple of days, we can move the lights and booms."

Also, he noted, "every equipment boom that we ship has two empty conduits in it so that, if in the future the
customer says, ‘I need to upgrade my video cable and add ethernet,’ we already have the conduits in place, so
literally in a day, we can pull a new circuit and give them new capability."

In addition to "ceiling grids" that allow equipment to be easily moved without extensive construction downtime,
Palmer explained how the TRUMPF Clean Operating System – featuring pre-fabricated wall and ceiling panels –
not only provides unique infection prevention benefits, but can also make it easier and less expensive to reconfigure
suites down the road. With the TRUMPF Clean Operating System, panels are cut to the exact size, screwed into the
wall studs, and the seams filled with a water-proof gasket. Windows, wall controls, flat panel monitors, etc., are all
recessed into the panels to provide a durable, flush surface that’s easy to clean.

"With these wall panel systems, because they’re modular in design and pre-fabricated...it simplifies the long term
upgrade capability, in terms of down time and cost involved," said Palmer. For example, if a facility wanted to add a
50-inch LCD screen, or additional electric outlets, instead of shutting down the room to knock out a wall, a new
panel can simply be screwed into place. The Clean Operating System has been in use outside the U.S. for many
years, and TRUMPF’s first U.S. installation is scheduled to be completed by late summer at Roper St. Francis
hospital in Charleston, SC.

MAQUET’s VARIOP system is a prefabricated Modular Wall & Ceiling System that has been used in Europe for
over 25 years, and was launched in the U.S. over a year ago with an installation at Spartanburg (SC) Regional
Medical Center. The rooms are built in MAQUET’s factory in Germany, shipped to the U.S., and assembled onsite.
When modifications need to be made, panels can be removed from the walls and replaced with minimal construction
downtime. In addition, the rooms can be reconfigured to accommodate renovation and expansion needs.
 An OR suite inside the Clean Operating Room System at TRUMPF’s Design & Innovation Center.

According to Schafer, STERIS, "Selecting technologies that are modular and upgradable will provide the best ability
to adapt to future requirements. The ability to add modular devices such as HD cameras, surgical-grade monitors
and additional lighting to existing support systems allows the hospital to make modifications less expensively and
more quickly."

Ashley, Stryker, advised, "Request additional conduit runs, request additional ceiling structure, and purchase an OR
control system that is easily upgradeable (the easiest systems to upgrade are those that are board integrated, not rack
mounted)."

Berger, ConMed, noted that future-proofing an OR suite includes "correct planning of boom placements; wiring for
total HD imaging, EMR, PACS and other hardware/software solutions; and staying current with emerging
technologies and the regulations that may affect them."

Skytron’s SkyVision Hybrid II fully fiber optic digital integration system with its "plug-and-play" capabilities,
allows for today’s HD digital sources as well as older, previous technologies to be connected to the integration
system via a single strand fiber cable. Future adaptability is seamless with swap-out expansion ports for simple
upgrades.

Mission-critical planning

As Weismiller described, "There is no area that is more dynamic and ever-changing" than the operating suite. "It’s
very chaotic, and when you design that environment, you have to create an environment that’s going to work from
the 6am start to 7 at night, and just go all day and do everything you want it to do – and that’s a tough thing to do.
It’s without a doubt the most challenging area of the hospital," he stated, adding, "The technology in a room is so
complex, if you don’t do the early design process properly you can easily end up with a room that you’re very
dissatisfied with."

Vendors all agreed that the best approach is a team effort guided by key hospital staff who have a good
understanding of the hospital’s mission and care objectives. "You have to assemble all the right user community
from the hospital to identify all of the current needs, and whatever can be anticipated for the future," said
Weismiller.

Schafer advised, "It’s important to establish clearly defined functional and budgetary goals, since this will reduce the
number of iterative design steps and will assure that the space that’s created works for everyone."