It is critical to ensure that surgical theatres are fit for purpose and appropriate for rapidly advancing medical practices. Here Nic Di Santo, Sophie Rogers, Rachel Coleman and Paul Zuccherelli of Alinea, with Tim Molden of MESH Construction Consultancy, consider the issues and the costs
01 / Introduction
Innovation in medical technology has transformed operating theatres into high precision, streamlined spaces which allow for flexibility of equipment choice and changing work practices. Add to this an NHS in crisis, an increase in the number of people taking out private medical insurance and growing numbers of overseas visitors to some of the country’s prestigious private hospitals (driven, in part, by the fall in the pound), and it is easy to understand that the medical landscape in the UK is changing.
02 / Changing regulation
Established in 2009, the Care Quality Commission (CQC), saw the merger of three previous regulating boards. Brought together to foster regulation of the sector and safeguard minimum standards, the CQC carries out inspections as well as enforcement activities: fines; the application of special measures; prosecution; or the removal of registration.
The commission asks five key questions of all inspected services:
- Are they safe?
- Are they effective?
- Are they caring?
- Are they responsive to people’s needs?
- Are they well-led?
This basic framework ensures that the quality of service and cleanliness of the provider is checked, and the size and quality of the physical environment are fit for purpose.
One regulation covered by the CQC is the 2004 revision to the minimum space requirements for theatres and ancillary rooms in the updated Health Briefing Note 26. This was part of a move to increase flexibility of spaces in order to carry out various procedures, including minimally invasive operating techniques. This new standard increased the required space of theatres by 15m2 to 55m2, which is the size needed for a minimally invasive operation. Building all theatres to this minimum space standard ensures that all types of surgery can be undertaken in any theatre.
This increase in size is also driven by developments in robotic surgery and the associated addition of large, cumbersome equipment which, when in use, can require 10 clinical staff or more to be in the theatre.
Hospital buildings are large undertakings and often difficult to adapt without considerable disruption to key services. However, to continue to provide state-of-the-art services and facilities, as well as ensure that a hospital is fit and flexible for the future, many healthcare providers are re-evaluating their offering, and not just because regulations demand it.
03 / Key considerations
A new build hospital or surgery provision is in many ways an easier proposition than a refurbishment or extension of an existing facility. A number of considerations need to be taken into account to develop a cost model which is reflective of requirements and as accurate as possible. Below, we explore these in more detail, from the client brief and decision making process to designing the theatre for the future.
Client brief - The client brief will prioritise patients’ comfort and care throughout their journey in and out of theatre, alongside practicality and convenience for the surgical team. This journey involves many interactions and interfaces and, as such, requires considerable thought. Having clarity of brief, ongoing stakeholder engagement and a robust decision-making process is key for a smoothly-run project and a seamless transition to a new operating environment.
Creating a new facility - Due to the need for larger theatre spaces to comply with regulation and even larger spatial requirements for fully integrated technologically-advanced theatres, the refurbishment of existing theatres is seldom a viable option. To avoid these constraints and the revenue losses that would be incurred during construction works, an ideal scenario is to extend an existing facility, creating a new space for new theatres and ancillary functions. Clearly, there are still issues to consider, not least planning approval, interfaces with the existing building and the creation of new facilities within existing site constraints.
Shell and core - For an extension to an existing facility there are considerations in terms of the shell and core design. The location of the extension in relation to the existing infrastructure must be considered to ensure that patient flows and distances are optimised, with theatres closely located to the patient bedrooms, for example. Typically the frame is a 9m x 9m grid so that the theatres are column-free and a minimum floor to floor height of 4.5m is achieved to accommodate the services in the ceiling void. A steel frame will achieve the grid dimensions, equally a concrete frame could be used but with deeper beams. Floor slab loads tend to be a standard 7.5kn/m2 but consideration should be given for heavy equipment. External walls tend to be of solid construction with punched windows to deal with light transmittance, solar gain and other issues.
Fit out design - As with any fitting-out project, there are numerous scope and specification options available. With an operating theatre, there are some unique items that require close attention when cost planning due to the range of options and associated variances in cost and design requirements.
Technology in theatres is rapidly advancing, with an array of digital solutions, from a simple display and control platform to fully integrated image-guided surgery, where data synchronisation and seamless access to patient information during surgery are available at the touch of a button. A typical extra-over cost of converting a new conventional theatre into an integrated theatre ranges from £170,000 to £320,000 per theatre for the equipment alone, plus the consideration of rack space and infrastructure to house the nucleus of the end-user experience.
Interface between the theatre surgeon’s panel, which brings together information on the operational state of the facility, and an ultra clean ventilation (UCV) hood is key. Not all products are compatible with an alternative supplier’s equipment and therefore these items will often need to be bought together. Early stakeholder engagement and a robust decision-making process will allow the design team to establish which product or manufacturer is preferred by the clinical team prior to initial design, avoiding abortive time and costs later.
The fabric of the operating theatre can also vary. For example, is there a need for laser protection which would involve adapting any non-reflective surfaces and the associated warning lights? Or is there a C-arm mobile scanner present (used for X-ray purposes), requiring the theatre to be lead lined?
Both the brief for the new facility and the existing condition will determine the scope of the project and its costs.
Flexibility for the future - As new technology is developed, the operating theatre may need to be adapted to accommodate updated equipment. Building flexibility into the design could help futureproof the facility and offset the need for later disruptive works, or at least minimise any impacts.
It is often recommended that new theatres have a double wall and ceiling to enable easy removal for future replacement of equipment, as technology develops. Although this adds to the capital cost of building a new theatre, it saves on the future costs of construction.
A theatre would ideally take a “universal room approach”, meaning the layouts are created to accommodate fully interventional processes. One would also ensure, where possible, that the building infrastructure such as stairs or lift shafts are on the perimeter in order to maintain a flexible zone within the theatre, without vertical infrastructure compromising work flow or spatial configuration.
Ancillary functions - The supporting space surrounding the theatres should provide a calming ambience for the patient whilst balancing functionality for the staff - as well as supporting scheme viability, of course.
The spatial planning of preparation and recovery areas adjacent to the theatres themselves plays a crucial role in the patient journey. It is important they are part of an efficient and comfortable flow without compromising flexibility.
An often-overlooked requirement is the extent of storage space required in a healthcare environment. This includes large equipment storage as well as homes for an array of consumables. Having an early understanding of the provision of storage space and the joinery or furniture used in making that space functional and communicating what is included in the cost plan will help everyone buy in to a baseline budget and its underpinning assumptions.
With operating theatres, the associated mechanical and electrical plant is a non-compromise area and there needs to be an allocation of suitable plant space, taking account of size, location, distribution routes and access for maintenance.
Specialist theatre fit out - There are generally two options when it comes to procuring the fit-out of the operating theatre: a traditional construction approach or a specialist prefabricated approach. Each has its own nuances and balance between cost, programme and certainty.
A specialist will prefabricate the theatre off site and deliver a box with cut-outs for services whereas a main contractor will build the theatre on site. A specialist approach would generally allow for a higher standard of workmanship due to a spacious off-site workshop environment, as opposed to the constraints of a construction site.
Depending on the logistics strategy, prefabrication can also bring programme advantages with fewer trades on site at any one time and an easier snagging process.
Set against this, one must be realistic when viewing the additional costs associated with prefabrication, which can typically add 50-100% to a traditional solution. Notwithstanding the potential programme and quality advantages, such a cost premium cannot be ignored. It is really a client’s role, with clear advice from the design team, to consider both the advantages and disadvantages against their unique business objectives.
Planning and logistics - It goes without saying that extending an existing live medical facility relies heavily on a carefully thought through logistics plan. How do you undergo noisy works in a building that runs 24/7 and whose occupants either need rest and recuperation or the ability to concentrate and make life-or-death decisions? How do you get materials and tradespeople in and out without compromising on cleanliness standards? These are just two fundamental questions to be addressed.
Creating and nurturing a collaborative project team is paramount. The client, stakeholders, design team and contractors need to work as a close-knit group to address needs from a healthcare perspective, as well as managing the construction activities. Clear phasing plans, detailed programmes and robust method statements should all be developed in good time. Throughout the process, the team needs to maintain clear lines of communication and manage expectations among the users of the facility, allowing full awareness of what impact the works will have on ongoing operations and the interfaces between the healthcare provider and the construction project.
Keeping the power on - Keeping the operating theatre live in the midst of possible equipment failures, power outages and the like is of critical importance. It is not just money and reputations at stake, it could come down to life or death.
An operating theatre is considered a Category 5 area (the category demanding the highest technical standards) by the Health Technical Memoranda (HTM), set by guidelines on design, installation and operation of engineering services used in the delivery of healthcare. The HTM advises best practice to be an isolated power supply (IPS) together with the provision of an alternative electrical supply within 0.5 seconds of failure, such as an uninterruptible power supply (UPS).
This is the minimum requirement but, generally, most healthcare providers have a more stringent view on the level of resilience required, the idea being to minimise or avoid a single point of failure. Ideally, an operating theatre will be fed from two separate IPS and UPS combinations.
The key question to ask at early cost planning stages is, what level of resilience is required and how far down the distribution path? Potentially doubling up on plant, distribution networks, incoming utility supplies and provision of automatic transfer switches will have considerable cost effects.
Infection control - The control of air within theatres also needs careful consideration. The number of air changes, provision of humidification and level of filtration, whilst having a minimum set out in the HTM guidelines, will be subject to enhanced requirements set out by healthcare providers’ internal infection control departments.
Typically, an operating theatre with a UCV system would require a minimum of 25 air changes per hour. To put that into context, that compares with two-to-three air changes per hour for a typical office building. This has a knock-on effect for plant and ductwork sizing, adding to space-take and costs.
An operating theatre will have its own dedicated air handling plant and UCV hood within the theatre ceiling. It is important to understand the filtration requirements and where they sit in the system. For example, will there be primary, secondary and tertiary filters sitting in the plant and at the terminals, and do these need to be High Efficiency Particular Air (HEPA) or lower grade filters (or a combination of both)?
Medical gases There are numerous specific medical supplies required in an operating theatre including: oxygen, nitrous oxide, nitrogen/surgical air, carbon dioxide, anaesthetic gas and medical vacuum. The number and types of supplies, the routes, control valves, scavenging equipment and associated plant all need to be considered carefully. If any of these are connected into existing systems, associated costs can be high due to the degassing and specialist equipment needed to do this.n Medical equipment Medical equipment generally captures the pendants, surgeons’ panels, system integration, operating tables and a whole ream of other items with a purely medical application. The technological elements of this category are the areas that warrant most attention and caution.
Medical science and the integration of technology has advanced hugely over the last 10 years. Cutting edge equipment attracts surgeons and patients to use the facility. Engaging with a specialist medical equipment consultant, although uncommon in these projects could be advisable; they will be able to advise on the range of specifications available, what competitors are installing and what manufacturers are developing for future release. A healthcare provider may well have an internal medical equipment specialist who can be engaged to undertake this advisory role.
It is an inherent challenge in construction, and highlighted in such a highly technical environment, to design and deliver a facility with the future in mind; one that can adapt and grow with the advancement of technology. Ultimately this comes down to a delicate balance of cost, risk and flexibility. How far ahead can one reasonably aim to be?
Medical equipment is procured in three groupings: Group 1 is supplied and installed by contractor; Group 2 is supplied by the client and installed by the contractor; and Group 3 is supplied and installed by the client. The allocation of items within these groupings needs to be undertaken carefully – for example because anything procured by the contractor will attract its overhead and profit (OH&P) and some preliminaries, whereas Group 3 items will require the client to internally manage procurement and installation.
04 / Procurement
The strategy for designing and purchasing such a project needs careful thought prior to committing to a procurement route.
It is common to see a sizeable project with complexity procured under a two-stage arrangement, with the preferred main contractor appointed under a pre-construction services agreement (PCSA) due to the interfaces and complexity of connecting into the existing facility. This provides the benefit of planning the sequence of works to minimise disruption to ongoing clinical operations, and allows surveys and validations to be carried out. It also enables the contractor to take advantage of the pre-construction time to carry out non-disruptive enabling works.
Alternatively, for a smaller/simpler project, a single-stage design and build route could be considered, providing the market has the appetite for it and should the client wish to obtain earlier cost certainty. Our cost model at the end of this article provides such an example, based upon a single stage design and build contract for an extension to an existing facility, with a clear buffer zone between existing and new, and a relatively lower value.
In all instances, a project/client specific procurement strategy needs to be developed to explore other routes available, considering the client’s attitude to risk and priorities for time, cost and quality. The strategy should fundamentally take into account the constraints of the specific site, location, logistics, age and interface with existing services and the information available about the existing building.
Consideration should also be given to the advantages of bringing a preferred mechanical, electrical and plumbing (MEP) contractor and, if the procurement dictates, a specialist theatre fit out contractor, on board under a PCSA, to work together with the main contractor.
The early involvement of these key specialist trades will help inform decisions around distribution routes, interfaces, co-ordination and, in terms of the theatre fit out, structural and volume dimensions that will facilitate the prefabrication of the theatre fit-out.
Currency fluctuations - In the current market, any cost plan must take into consideration the volatility of currency. With operating theatre projects, the majority of medical equipment and much of the MEP plant is procured from mainland Europe. In recent years the US has become more prevalent as a source for plant and equipment, so sensitivity analysis should be applied to both US dollar and euro exchange rates. Given the volatile economic climate, we would strongly recommend that a specific risk allowance is set aside to manage currency fluctuations.
Handover and soft landings - The level of detail and attention to handover of the finished product is vitally important and the theatres must be defect-and-snag-free. There is no leeway for slipping standards. The use of soft landings for handovers is advised.
It is important that adequate time is set aside to train maintenance staff and theatre operatives in commissioning of the theatres and ensure that all snagging and defects are cleared off before handover.
The commissioning of the theatres, including clinical deep clean and air quality tests, are critical for them to be operationally ready.
Programme interfaces between contractor and operator need to be managed to achieve this in an optimum time.
05 / Variances to the above mentioned considerations
Our cost model is based on an extension of an existing facility, providing operating theatres with a traditional construction approach. It is also worth noting some of the many key variances one may see on a similar project, as set out below.
Hybrid theatre - A hybrid operating theatre is a combined operating room containing large imaging equipment, such as MRT and CT, which enables intra-operative diagnostics.
If provided for, in the hygiene and theatre concept, the hybrid operating theatre can also be used purely as a diagnostics room, or as a classic operating room. The additional equipment therefore necessitates a bigger room, equipment which as a minimum is 75m² in size, alongside differing interfaces and requirements for mechanical and electrical plant and medical equipment. The additional cost of this could range from around £1m to £2m per theatre.
Modular theatres - The promoters of modular theatres have some way to go to convince
clients that this approach would work as an extension to an existing facility and meet the healthcare provider’s requirements. They would be better suited for a new build or larger schemes where the benefits of a shorter programme can be achieved.
For such theatres to work effectively, their design and processes need to be carefully planned as once they are built, the flexibility to make changes is lost. Clinical engagement in the brief and design process early on is key as design freeze will need to be achieved early enabling prefabrication to start with certainty.
Alternatively modular providers have in-house design capabilities and experience of delivering on numerous projects to guide the design end process along. They often provide turnkey solutions which will need to be considered by the healthcare providers.
Complex extension in the heart of an existing facility - The inherent constraints, interfaces with existing fabric, and the operational-side adds further complexity.
Decanting works, client internal staff costs, phasing and sequencing of the works and longer programme are key drivers of cost. Due to noise levels and vibration, stoppages of the works are inevitable and thus represent a real risk.
Choice of medical equipment - The choice of medical equipment could vary and really depends on a number of factors: existing servicing agreements, IT interfaces, clinical use, supplier post purchase training and support, brand preference, and so on. All of these factors can drive a range in costs for medical equipment of up to 30%.
06 / About the cost model
- The cost model is based on the following:
- A scheme that is an extension to an existing facility. The layout is in a single storey accommodation comprising three theatres, recovery and plant space located within the mansard roof space
- The existing facility and extension is located in the south-east of England, outside Greater London
- The shell and core includes piled foundations due to ground conditions, reinforced concrete ground slab, reinforced concrete frame 4.5m high, reinforced concrete slab for the plant space, mansard roof, solid face brick external walls with powder coated aluminium windows and doors
- Dedicated air handling plant with Ultra Clean Ventilation (UCV) canopy serving each theatre, plus an AHU serving ancillary areas. Dedicated chiller and boiler plant for extension
- New electrical switchboard backed up by standby generator, dual feeds throughout distribution path via 2nr UPS, 2nr sub boards and 2nr isolated power supplies serving each theatre
- Conventional theatre fit out including the supply and installation of Group 1 medical equipment and installation only of Group 2 medical equipment
- All rates are base dated Q1 2017
- Procurement is based on a single stage design and build contract.
Exclusions from the cost model include:
Demolitions, site clearance, break through and interfaces with existing, supply of Group 2 & 3 medical equipment, fees, external works, incoming utilities adjustments, section 106/278 agreements and VAT.
|Theatres and recovery||802|
07 / The cost model
Demolition / site preparation
|Site clearance including demolition of existing||Excluded|
|Excavation including disposal (802m³ @ £50/m³)|
|Piling mat including disposal (802m² @ £45/m²)|
|450mm diam reinforced concrete piling including rig establishment, disposal of pile arising’s off site, trimming tops of piles, pile integrity testing (92nr @ £2,000)|
|Pile caps (264m² @ £250/m²)|
|Concrete ground slab 200mm including ground beams, hardcore, mesh reinforcement, insulation, dpm, insulation (802m² @ £180/m²)|
|Allowance for drainage below slab (802m² @ £50/m²)|
Frame and upper floors
|Reinforced concrete frame 9 x 9m grid, concrete beams and columns (1,152m² @ £115/m²).|
|200mm in situ reinforced concrete upper floors (Plant space) (350m² @ £120/m²)|
|Mansard roof comprising roof trusses, 70 degree pitch, rainwater gutters and downpipes (802m² @ £260/m²)|
|Louvres to plant space (item @ £20,000)|
|Fire barriers (item @ £7,500)|
External walls, windows and doors
|Cavity wall; facing brick outer skin; 50mm thick insulation; plasterboard on stud inner skin (485m² @ £250/m²)|
|External doors, powder coated aluminium, double glazed units including ironmongery (item @ £12,500)|
|Windows, powder coated aluminium, double glazed units (item @ £30,000)|
|Film on windows (item @ £5,000)|
Internal walls, partitions and doors
|Internal walls; 2 layers of 12.5 thick gyproc wall board; 70 mm wide metal stud; acoustic isolator (1,363m² @ £85/m²)|
|Allowance for glazed screens; metal frame; integral blinds (item @ £12,000)|
|Allowance for pattressing; plywood; 25 thick (item @ £7,500)|
|Allowance for lead lining one theatre; code 3 (item @ £25,000)|
|Allowance for wc cubicle partitions (item @ £5,000)|
|PVC clad fully encapsulated system - single leaf door and frame (29nr @ £1,200 each)|
|PVC clad fully encapsulated system - leaf and a half door and frame (3nr @ £1,600 each)|
|PVC clad fully encapsulated system - Double leaf door and frame (19nr @ £1,800 each)|
|Extra over for lead lined doors (for one theatre) (item @ £7,500)|
|Extra for automatic door controls (6nr @ £2,500 each)|
Internal finishes - walls
|Plaster; skim coat; 5mm thick; one coat (4,100m² @ £15/m²)|
|Johnstones Acrylic Eggshell to wall (4,100m² @ £10/m²)|
|Extra over white rock theatres (3nr @ £25,000 each)|
|White rock to other areas (item @ £15,000)|
|Mastic; anti bacterial (item @ £10,000)|
Internal finishes - floors
|Screeding & DPM (802m² @ £40/m²)|
|Vinyl & latex (802m² @ £35/m²)|
|Coved skirtings (926m @ £15/m)|
|Paint to plant room flr (350m² @ £15/m²)|
|Barrier matting (item @ £500)|
|Mastic; anti bacterial (item @ £5,000)|
Internal finishes - ceiling
|Metal pan ceiling to theatre / scrub / anaesthetic / prep (330m² @ £60/m²)|
|Washable ceiling throughout; plasterboard MF system (472m² @ £45/m²)|
|Plasterboard bulkheads (item @ £7,500)|
|Mastic; anti bacterial (item @ £5,000)|
|Theatre reception desk, directional signage, fittings for Theatre and Scrub, Theatre Change Male & Female, Recovery, Anaesthetic, Clean and Dirty utility, Theatre managers office, sundry items (item @ £77,000)|
|Clinical WHB; including tap, WC, Sluice unit; including tap, Scrub sink, Showers in theatre change, Whb in theatre change (item @ £45,000)|
Surveys and validations
|Dedicated boiler incl all primary pumps & distribution, located adjacent to new theatres|
Space heating and air conditioning
|Ductwork heater batteries, additional chiller plant to supplement existing and cooling to UPS rooms|
|Dedicated AHU’s for each Theatre with UCV hoods and extract fans plus AHU and distribution for ancillary areas|
Electrical installations - LV switchboards, UPS and IPS
|New main panel backed up with new generator, feeding dual sub panels, isolated power supplies and UPS arrangement|
Electrical installations - LV distribution & small power
|General LV distribution and small power, plus bedhead trunking, surgeons panel and theatre pendants.|
Electrical installations - lighting
|General & emergency lighting including operating lights|
|Oxygen, Nitrous Oxide, Surgical Air, Co2 and Medical Vacuum|
|Fire and Voice alarms incl new repeater panel|
Communication and control installations
|Incl data, BMS, nurse call and theatre intercom systems|
Testing and commissioning (@ 2% of £2,171,000)
Sub contractor preliminaries (@ 12% of £2,171,000)
|Fire stopping (item @ £40,000)|
|Access hatches (50nr @ £200 each)|
|Supports for services (item @ £20,000)|
SUB TOTAL SHELL & CORE & FIT OUT
Preliminaries and contingencies
|Main Contractor Preliminaries and General @ 13%||545,000||473.09||10.08|
|Main Contractor Overhead and Profit @ 5%||245,000||212.67||4.53|
|Design & Construction Contingency @ 5%||258,000||223.96||4.77|
TOTAL SHELL & CORE & FIT OUT
Cost per theatre (1nr @ £1,803,000 each)
Extra over for digital theatre