The Blue Cottage Blog

Evidential Operating Rooms: High-Intensity Environments Beg to be Studied

by on November 23, 2015

Another great Healthcare Design Conference has come and gone, and one of my favorite moments was watching the keynote conversation between Dr. Roger Ulrich and Kirk Hamilton. Both Roger and Kirk have made lasting impacts on the world of healthcare architecture design and research. Listening to them recount the evolution of the healthcare architecture industry over the last three decades was fascinating and also made me smile at the memory and privilege of sitting in their respective classrooms at Texas A&M University. These two guys are definitely changemakers – and they once again underscored their future-focused, changemaking vision by discussing a rather obvious point once you think about it. Roger, healthcare design’s most notable and influential researcher, relayed this important message (which I’ve summarized as such):

We have greatly studied the patient room and inpatient unit, yet the operating room (OR) has been severely understudied from an evidence-based perspective and it is our next important healthcare research subject area. These are small environments with intense functionality, occurring in a small amount of square footage. There is much to study and empirically understand about these environments.

As soon as he said that I thought, “wow, so true.” What made me agree so much with him in that moment was the fact that I’ve spent the last several months with a client in Canada who is redesigning their surgical suite and ORs. And there is, indeed, a great deal to think about in designing those intense and variable environments. With this particular client we have worked thoroughly to understand the operations of their current department and specifically their various ORs functionality and spatial configuration’s strengths and weaknesses. We have met with each service-line’s lead surgeon to discuss how their specialty uses their current ORs. What we have found through operational planning discussions and scaled mock-ups exercises is that their current operating rooms have to be incredibly flexible and customizable for so many different procedure types. Currently, they have several room setup configurations per OR depending on what procedures are typically conducted in each room and the layout of the room.

The variability and flexibility required was especially demonstrated during our mock-up session with the lead neurosurgeon. He discussed the varying orientation of the patient/exposure site/surgical table and movement of different staff and equipment in his OR during craniotomy procedures versus spinal procedures. After the mock-up session, we then observed this same surgeon conduct an actual craniotomy procedure in his favored OR (which happened to be almost perfectly mirrored in plan from his least-favored OR).

Timelapse of the scaled mock-up exercise (with B+H Architects and STH Health Architecture). Surgeons and staff discussed equipment movement and placement in relationship to patient placement and orientation.


View into the OR from the craniotomy from the sterile core. The epicenter of the room is established over the patient body and the real estate in the ceiling and square footage adjacent to the patient is a premium once movement in the room settles, but during setup square footage is needed throughout the room. Sightlines are also key as clinicians are distributed around and about the room.

Several key observations during this procedure and in this particular OR included:

  • During room and patient setup there is an abundant amount of movement of staff and mobile equipment (electronic and non-electronic)
  • At this academic institution there can be up to 10-12 people in the OR at a time between the lead surgeon, anesthesiologists, circulating nurse, table-side nurses, fellows, residents, students, and techs
  • The circulating nurse is called circulating nurse for a reason, they move around quite a bit
  • There is a good deal of movement around the patient on the table as lines are being setup and equipment being positioned, but once the procedure starts the epicenter of the room is the patient and most movement ceases
  • There is a great deal of equipment in the rooms and the pathways for equipment setup are critical
  • The anesthesiologist prefers visibility to the head of the patient, but also requires positional connectivity to gas infrastructure, anesthesia machine, monitors, supplies, and other caregivers as well
  • Various imaging equipment and displays are distributed throughout the room – some moveable, some not
  • Gas columns, booms, and lights seem to reduce the visual connectivity across the room between the various staff members present – sightlines to each other, imaging displays, physiological monitors are critical – and who is primarily focusing on what varies

These are just a few of the functional observations we had as the craniotomy proceeded. And it was clear in discussions with the lead neurosurgeon that the room setup we saw for that procedure was very different from what we would have observed for a spinal procedure where the patient would be oriented 90 degrees differently.

The OR is the likely the most intense clinical environment with a great deal to consider and study. The topics of study are truly numerous. And, as intraoperative image-guided ORs become more and more prevalent and the line between imaging and interventional procedures blurs further, we will need to understand the impacts of patient and major machine movement within the space as it relates to patient safety, infection control, quality of outcomes, etc., while also being mindful of effective operations and use of physical and human resources. The bottom line is that Dr. Roger Ulrich is right. While there is a good deal of opinion- and experience-based literature related to the OR and surgery department at-large, we need to empirically study the OR environment in a basic research format much more.

Topics for further study I think are very important are:

  1. Visibility requirements between caregivers in the operating room and infrastructural impacts to sight lines between caregivers
  2. Patient safety implications of moving the patient to the intraoperative imaging modality in iORs
  3. Infection control impacts of moving intraoperative imaging modalities to the patient in iORs
  4. Variability of patient orientation to OR access doors, anesthesia machines, and other major equipment by service line

What other topics should we pursue related to the OR environment? Are you finding your clients asking for more evidence on certain OR-related topics? It would be wise of us to narrow the focus to most-impactful topics we need to address and hypothesize.

In the meantime, here is a sampling of the peer-reviewed articles that do exist concerning the surgical built-environment, some focused on process, occupational safety and general room configuration:

Nicholas Watkins, Mark Kobelja, Erin Peavey, Stephen Thomas, and John Lyon. “An Evaluation of Operating Room Safety and Efficiency: Pilot Utilization of a Structured Focus Group Format and Three-Dimensional Video Mock-Up to Inform Design Decision Making.”  HERD, October 2011; vol. 5, 1: pp. 6-22. Web 23 November 2015. <>

Mullett, H. Synnott, K. Quinlan, W. “Occupational Noise Levels in Orthopedic Surgery.” Irish Journal of Medical Science, 1999; vol. 168, 2: p. 106.

Mansour, M.A. “The New Operating Room Environment” Surgical Clinics of North America, 1999, vol. 79, 3: pp. 477-487. Web 23 November 2015. <>

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  1. After reading your post it occurred to me that on the whole as architects we have been involved in the design of the OR insofar as the configuration and the size of the room, but the most prevalent role is just the coordination of the systems that are housed within it. It has typically fallen to the medical organization to pick a vendor/provider of technology and equipment, and we just fit it in… lights, booms, airflow, table and peripherals, all orchestrated around a function.
    It has been a vital and unique role that cannot be understated or diminished, but your suggestion clearly points to the potential for even a higher degree of collaboration and involvent between designers, providers, vendors and strategists. The ground rules for the design of future ORs will depend on the quality and rigor of the information upon which they are based, and as such -it is clear to me now- the new frontier of research is clearly laid out.

    Thank you for the eye opening post.

  2. Alejandro Iriarte on July 30th, 2016 at 11:26 am
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