ESTABLISHING AN INDEPENDENT HEART RHYTHM CENTER
ProMedica Toledo Hospital is a 600-bed tertiary hospital located in Toledo, Ohio. The center is currently undergoing an additional 450-bed expansion due to open in 2019. It serves as the flagship for ProMedica Heath System, a 13-hospital system with $15 billion in total assets, serving 2.4 million people in Northwest Ohio and Southern Michigan. ProMedica Hospital is also the primary teaching hospital for the University of Toledo Medical School. The cardiac electrophysiology service line at ProMedica Toledo Hospital has benefitted as the sole facility for the system and, as such, has a robust and growing volume. Our catchment area, however, remains underutilized for EP services. There are presently five cardiac electrophysiologists employed by ProMedica, with recruitment for a sixth and possibly seventh EP underway. We currently perform all EP procedures.
Prior to the opening of the Heart Rhythm Center (HRC), the EP labs at our facility were, as in many centers, an offshoot of the cardiac catheterization (cath) lab. While already established as a separate cost center with separate staff from the cath lab, our EP labs were originally designed as cath labs, later retrofitted to their EP function. We co-resided in very busy corridor with three cath labs, a neurointervention lab, and vascular intervention lab. This environment posed significant challenges for patient and staff flow as well as infection control. The area was remotely located from the operating rooms and, as such, this placed limits on our access to our anesthesia colleagues.
With this background, discussions began in the winter of 2016 about development of a world-class Heart Rhythm Center procedural facility that would allow for further anticipated growth opportunities and bring the level of care from high to truly superlative.
CREATING A NEW DESIGN AND FUNCTIONAL MODEL
From inception, the administrative effort to open the HRC was informed by the clinicians and clinical need. High levels of physician engagement drove administrative attention. We embarked on site visits to several top centers in the country and brought along high-level administration, including the hospital CEO and key finance staff. The benefits of these visits were multiple, but two are particularly worthy of mention: 1) These visits confirmed what we already knew, which is that there were few benefits of building the HRC next to the cath labs, and that we would be best served by relocating to the part of the hospital contiguous with the operating rooms (ORs) and immediately adjacent to the PACU; and 2) We should recruit an expert architecture firm with a proven track record of building EP labs.
We sought to build the HRC as an entirely surgical sterile environment encompassing the following within its 6,500 square feet: 3 EP ORs and support areas, including 4 small procedure rooms, a teaching conference room, physician dictating area, and efficient storage. The project came to fruition over 26 months, including 5 months of construction that required a tremendous amount of coordination between various contractors, subcontractors, and equipment vendors. The model was to have three identical EP ORs each with a separate paired control room, all identically equipped and fully capable of complex ablation, device implants, laser lead extraction and, if need be, open-heart surgery and cardiopulmonary bypass. With input from EP lab staff, anesthesia, cardiac perfusion, CT surgery, and EP physicians, our concept was to build one optimal EP OR layout and then replicate it three times. This critical reproduction of room layout was programmed to serve not only efficiency but also patient safety. Across the three EP ORs, all equipment and supplies were in identical locations, so that in an urgent and stressful situation, staff would not have to struggle to recall where equipment resided in that particular room.
We also wanted the ability to not have to move equipment between rooms. We had learned from previous experience in our old facilities that moving equipment between rooms led to not only significant prolongation of case turnover times, but also equipment breakage and staff burnout. We budgeted for three new mapping systems in all three rooms (including RF generators), as well as anesthesia and echo equipment to reside permanently in each room. This design would eliminate significant complexity when scheduling cases as well as allow flexibility if one piece of equipment were to break down in a particular room. Additionally, the choice between three mapping systems would allow operators to match ablation technology to the procedure at hand and help negotiate favorable pricing of consumables.
We specified that the environment be purposely built to reduce the potential for electromagnetic interference. This included individually grounded power lines, use of shielded conduit throughout, and a design layout in which no cabling would ever need to touch the floor. All major equipment was to be boom mounted, which allowed us to nearly eliminate the need for equipment carts. Additionally, all computer towers and powered equipment were located in separate temperature-controlled closets rather than in the control rooms. The air handling unit was custom built (for the sole use of the HRC) along with positive pressure laminar airflow, HEPA filtration, and UV sterilization lamps in the air vents. Floors and walls throughout were made of non-porous OR grade materials laser welded all the way up to the ceilings. Each EP OR had its own scrub room with separate entrance into the EP OR.
DESIGNING A LAB "WITH A HEART"
In the midst of all this technology, we never wanted to lose sight of the human side of design. We feared that this space could have easily come across as cold and foreboding. Therefore, it was critical that the HRC, at its core, have warmth, curves rather than only right angles, and simulations of natural materials as well as ample light. After an extensive search, we found an architect partner for these high aspirations who helped design and see our vision to fruition.
RADA Architects built upon extensive experience, including recent complex EP lab design projects at the University of Chicago Medicine and the University of Illinois at Chicago Medical Center. They used this knowledge and creativity to propose elegant and bold design solutions to highly technical problems. The HRC was designed with efficiency and functionality, but also to be a bright and cheerful healing place, and a stimulating work environment.
Within the myriad constraints of existing structural columns, mechanical shafts, and limited ceiling height, the architect created the three identical EP ORs with paired control rooms. These three rooms are grouped around a main corridor, which is designed to draw the eye to nature, with repeated scenic windows with simulated natural light. The front part of the suite allows for immediate access to the patient holding areas and support spaces. The main scheduling and “control” desk is designed to be visible from the HRC entrance and also in direct line of sight to the small procedure rooms. A curved glass enclosure containing a multimedia conference room is designated for education of the lab staff, house staff, and visiting physicians alike. The physician dictation room, conference rooms, and control desk feature live video feed from the three EP ORs. The EP ORs are designed in the core of the sterile expanse of the HRC, away from traffic to maximize infection control.
The main corridor within the HRC features a “winding path” expressed in ceiling shapes and floor pattern. It is flanked by large backlit high-resolution photo murals of birch trees with the purpose to simulate a forest path. The disruptive introduction of curvilinear forms and wood laminate accents within an otherwise rigid grid floor plan create excitement. Small curved sofas and “resting nooks” in the physician dictation and conference rooms give more restful seating alternatives to the typical offerings of conference tables and computer desks also offered within the HRC.
Within each EP OR, we afforded extensive attention to all design details. Each EP OR features backlit panoramic “window” panels with abstract mountain peaks, similar in concept to the birch trees in the hallways. The purpose of these “with nature” sceneries is to keep patients and staff relaxed throughout the day. This design approach provides important counterbalance to the otherwise seemingly ubiquitous technology. The nature scene “window” panels are constructed in the same location and size in each EP OR, yet each room features different color schemes, including matching color-accented flooring sections and countertop finishes. These EP ORs are known as “Grey, Orange, and Blue”, rather than “1, 2, and 3.” These repetitive color schemes within each EP OR were designed to serve as constant reminders as to where you are, in rooms that are otherwise identical.
An integrated, custom built, prefabricated modular ceiling structure in the EP ORs allows for extended ceiling height as well as a light grid with variety of dimming and color options for improved visual clarity and diminished operator eye fatigue. Control room chairs were sourced from an audio engineering and recording studio furniture company, borrowing ergonomic tips from a seemingly dissimilar work environment. Extensive audiovisual equipment was specified that allows for multimedia and multiplatform remote collaboration between physicians, as well as live broadcast of EP procedures both within and outside of the ProMedica campus. Efficient planning was key for accommodating ample support space, individual control rooms for each suite, and scrub areas. The equipment space demand for such a facility was daunting, and outside observers expressed their doubts more than once that our requirements could be accommodated within the allowed project space. The HRC was designed to take advantage of every available square centimeter, and became known as the “Swiss Watch.”
The execution of the Heart Rhythm Center hinged upon three mandates: 1) To maximize patient safety; 2) To accommodate both significantly expanded EP procedure volume and the potential for future new EP procedures; and 3) To create an inspiring and comfortable work environment for staff and physicians alike. We believe that we constructed not only the EP facility of the future, which succeeds in meeting these three mandates, but also that we succeeded in building a lab “with a heart.”
TEN BEST PRACTICES FOR PLANNING AND CONSTRUCTING AN EP LAB
- Make it an electrophysiologist-led process, but also encourage significant input from EP staff as well as other team members, such as anesthesia, CT surgery, and perfusion, who will work collaboratively in this space;
- Develop and clarify your institution’s EP service line goals;
- Identify and align with key administrators;
- Understand the economics of your EP lab, as this is key to budget approval;
- Plan for flexibility and breadth of procedural scope;
- Visit other “centers of excellence” with key administrators — this is especially important for smaller centers or centers with more remote geographic locations (where administrators may be less likely to be familiar with top-level EP facilities);
- Be extremely detail-oriented in your specifications and planning, and schedule enough time (our HRC took 26 months to plan, obtain funding, design, and execute);
- Plan the space primarily with a patient-centric focus (safety and experience), but also consider staff experience;
- Recruit expert architectural and medical engineering input — this will make or break the process — and use an architectural firm with experience building an EP environment;
- Do not underestimate the logistics of moving from the old EP environment to the new one.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.