Factors Impacting the Size of the Surgery Suite

By Cynthia Hayward
Originally printed in the
SpaceMed Newsletter
Fall 2014
www.spacemed.com

BACKGROUND
The hospital surgery suite has undergone revolutionary change over the past
several decades. For a long time, the focus has been on shifting surgery to a lowercost outpatient setting. This has been replaced with a focus on lowering both the
costs and risks of surgery with the ongoing migration from invasive to less-invasive
surgery or noninvasive procedures. Minimally-invasive, image-guided, robotic, and
telesurgery along with intraoperative imaging techniques continue to replace
traditional surgical procedures.
Aside from the economies of scale achieved with larger surgical suites, the biggest
single factor contributing to the overall footprint of the surgery suite is the size and
specialization of the individual operating rooms (ORs). Other key factors include the
proportion of outpatient surgery performed in the suite and the efficiency of the
surgical suite layout.
CONVERGENCE OF SURGICAL, INTERVENTIONAL, AND DIAGNOSTIC
PROCEDURES
In the traditional surgery suite, general operating rooms were used for a wide range
of procedures with operating room specialization limited to cardiac surgery and
orthopedics. Cardiac surgery requires additional space for the perfusion team and
equipment while orthopedic surgery requires significantly more equipment than
most other surgical procedures.
For many years, real-time imaging has been a standard part of the operating room
using a mobile ultrasound or endoscopy unit or a c-arm (its name derived from
its shape) along with the associated technologists which requires more space
than in the traditional general or specialty operating room. Although the definition
can vary, the hybrid operating room is a revolutionary alternative to the conventional operating room and presents a unique planning challenge. The hybrid
operating room has permanently installed equipment such as intraoperative
computed tomography (CT), magnetic resonance imaging (MRI), and fixed c-arms
typically used in conjunction with cardiovascular, thoracic, neurosurgery, spinal,
and orthopedic procedures to enable diagnostic imaging before, during, and
after surgical procedures. This allows the surgeon to assess the effectiveness of
the surgery and perform further resections or additional interventions all in a
single encounter.
REVIEW OF THE TYPES OF SPACE WITHIN THE SURGICAL SUITE

The space within a surgery suite can be divided into six major areas as follows:

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Patient intake area includes the reception/registration function, visitor waiting,

and related support services and amenities. These spaces are usually located
off a primary public corridor and separate from the patient treatment area.
Patient intake space is generally proportionate to the number of ORs with minor
economies of scale for larger surgery suites.

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Factors Impacting the

Size of the Surgery
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Post-anesthesia care unit (PACU) also referred to as Phase I recovery

is where the patient is taken immediately post-surgery until he/she recovers
from a semiconscious state to being awake and alert and ready to be moved to
the Phase II recovery area prior to discharge home (outpatient) or to a nursing
unit (inpatient) for an overnight or multi-day stay. This space is generally
proportionate to the number of ORs with a ratio of 1.5 patient bays per OR.

Preoperative care/Phase II recovery area includes the presurgery

preparation and holding area, the post-anesthesia (Phase II) recovery area,
and associated support space. These areas are commonly co-located to
provide efficient staffing and flexible space utilization. The size of this area is a
function of the daily number of outpatients and the type and size of the patient
accommodations.

Operating room space includes all invasive surgical operating rooms that
require a sterile environment general, specialty, and hybrid operating rooms
along with scrub stations and associated control rooms and space for
ancillary equipment components.

Operating room support space includes the central control station, clean
core, supply/equipment storage, anesthesia workroom, and other support areas
that are generally located proximate to the operating rooms in semi-restricted
space. Operating room support space is generally proportionate to the number
of ORs.

Staff/administrative space includes administrative offices, staff lounges/

lockers, and other staff amenities which are typically located in unrestricted
space. Although there are economies of scale with larger surgical suites, larger
suites typically have more specialty programs which, in turn, require additional
staff. Some staff/administrative spaces may also be shared with other clinical
functions and/or even located on a different floor level.

COMPARISON OF DGSF PER OR FOR DIFFERENT TYPES OF SUITES

The figure on the following page compares the department gross square feet
(DGSF) per OR for medium and large surgical suites with outpatients representing 60 to 65 percent of the cases to a smaller ambulatory surgery suite with
general operating rooms. DGSF represents the footprint of the surgical suite and
includes the net square feet (NSF) of all individual rooms, the width of the
walls/partitions, and internal circulation corridors.
A surgical suite with eight to twelve ORs will require between 2,700 and 3,500
DGSF per OR depending on the size and specialization of the ORs. The space required for a larger surgical suite may range between 2,400 and 3,200 DGSF per
OR because of economies of scale. However, most larger surgical suites include a
wide range of surgical specialties and perform complicated procedures that require
more than a general operating room. Up to 800 DGSF per OR is required to accommodate specialty and/or hybrid operating rooms compared to a surgical suite
with general operating rooms. On the other hand, ambulatory surgery suites may
more commonly use general ORs. However, they require proportionately more
space for pre-operative preparation and Phase II recovery.

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Comparison of Department Gross Square Feet Per

Operating Room (OR) By Type of Space
3,750
3,500
3,250

3,200 DGSF
Per OR

3,500 DGSF
Per OR

3,200 DGSF
Per OR

800

3,000

800

2,750
2,500

1,250

2,250

1,200

2,000
1,750

1,200

400

1,500

275
600

750

Post-Anesthesia Care Unit (PACU)

Pre-Op/Phase II Recovery Area
Staff/Administrative Space

800

1,000

OR/Support Space
(General ORs)

Patient Intake/Visitor Waiting

325

1,250

Incremental OR/Support Space

(Specialty and/or Hybrid ORs)

200

525
150

500

550

250

100
300

425

Ambulatory
Surgery Suite
(4-6 ORs)
100% Outpatients

Typical
Surgery Suite
(8-12 ORs)

Large
Surgery Suite
(14-20+ ORs)

60-65% Outpatients

OPERATING ROOM SIZE

Today, 400 NSF is considered the minimum size for a general operating room. The
Facility Guidelines Institute recommends that operating rooms for image-guided
surgery or surgical procedures that require additional personnel and/or large
equipment be at least 600 NSF. In addition to the incremental space for the larger
ORs, additional storage space is required for related supplies and the specialty
equipment when it is not in use. The minimum size increases to 650 NSF for a
hybrid operating room. The footprint of a hybrid operating room becomes even
larger when a control room and equipment component room for transformers,
power distribution equipment, computers, and associated electronics are added.
For example, a surgical suite with all specialty operating rooms would require an
additional 500 DGSF per OR compared to a suite with general operating rooms.
Hybrid operating rooms require contiguous control rooms (minimum of 120 NSF)
and equipment component rooms (typically 100 NSF) as well as additional space to
store related supplies and other equipment when not in use. With a hybrid OR, an
additional 800 DGSF per OR is required compared to a general OR accounting
for the incremental room size, control and equipment rooms, and additional
equipment and supply storage.

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Factors Impacting the

Size of the Surgery
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OUTPATIENT PHASE II RECOVERY SPACE

Another factor that contributes to the overall DGSF per OR is the proportion of
outpatients and the type of patient care spaces in the prep and Phase II recovery
areas. A higher percentage of outpatients treated in the surgical suite increases the
number of prep and Phase II recovery spaces which, in turn, increases the overall
DGSF per operating room. The use of larger private rooms for outpatient Phase II
recovery and/or presurgery preparation also requires more space. An ambulatory
surgery suite with private rooms for prep and Phase II recovery may require up to
400 DGSF more per OR than a surgical suite that serves inpatients primarily using
semi-enclosed bays.
NET-TO-GROSS SPACE CONVERSION FACTOR
The design of a surgical suite requires the use of a large net-to-gross space
conversion factor to account for circulation between unrestricted, semi-restricted,
and restricted areas and the need for wider corridors to accommodate stretcher
traffic which further compounds incremental space increases for individual
rooms. The net-to-department gross space conversion factor for the surgical suite
generally ranges between 1.55 and 1.60 but may be as high as 1.80 depending on
the design. Use of a single-loaded corridor results in less overall space for
circulation while designs with pods of ORs and/or a perimeter corridor result in a
higher net-to-gross conversion factor. The efficiency of the design can impact the
overall size of the surgical suite by 10 to 15 percent.
Cynthia Hayward, AIA, is founder and principal of Hayward & Associates LLC.
REFERENCE
Facility Guidelines Institute (FGI). 2014.Guidelines for Design and Construction of
Hospitals and Outpatient Facilities. Dallas: Facility Guidelines Institute.

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