Surgery and design

Hello, Behind the Knife listeners. My name is Cody Mullins. I'm a general surgery resident at the University of Michigan and one of the BTK surgery education fellows. I'm here today with my research mentor, Dr. Andrew Ibrahim, and I'm excited to dive into a topic with him in a conversation about health design.

And the interplay that it has with surgery and the environment that we work in as surgeons day in and day out. We're going to talk today about how new hospitals, operating rooms, and trauma bays are designed and the evidence behind them. Dr. Andrew Ibrahim is an associate professor of surgery, architecture, and urban planning at the University of Michigan, where he also works clinically as a general surgeon at the Ann Arbor VA Hospital.

He's the Maud T. Lane research professor, the vice chair of health services research in the department. The co director of the Center for Healthcare Outcomes and Policy at U of M is an editor at the JAMA Network, a member of the Board of Directors at Academy Health, and is the program director of the Health and Design Research Fellowship in the Department of Surgery at UM.

Thanks for joining us today, Dr. Ibrahim. Awesome.

Thanks to be here. So first for context, can you talk a little bit for the audience about how you found yourself in this interesting space between surgery, clinically, health services research and health design? Yeah, great question. So I grew up, I think, probably wanting to be an architect or an urban planner and didn't really have any role models around me or in our community.

And I was really close to my older brother who was a doctor. And when when I talked to my parents, told them I wanted to be an architect, they said, yeah, we don't really know anyone who does that. What would be your second choice? And I said, I'd be a doctor. And so they told me I could go, if I got into med school, I could do whatever I wanted.

So, I was over motivated, pre med, summer O Chem, the whole deal, and once I got into med school, I deferred, moved to London, and studied architecture at the Bartlett. The Bartlett is a world class architecture school in London quite famous for their foundational work, and when I came back from that, I went

to med school, I said, you know, who are the architects in the med school that help us figure out, like, how we design buildings, like, where a hospital should be, how many do we need.

And the response I got was like, Oh, you're interested in public health. That's what you're actually trying to study. So that's how I got down the health services train of work. And then when I got to being a resident, I was in my research time and wanted to get back to studying health in the built environment.

So I naively reached out to all the architecture firms and said, you know, who are the physicians that work in your firm that help you design these hospitals, figure out where they should go. And I said, we don't have any people in our practice who do that. And I said, well, don't you think it'd be valuable to have people who know how the buildings are built, how day to day clinical care works, and they said, yeah, it'd be valuable.

And I said, how valuable exactly? And I ended up becoming the chief medical officer of one of the largest design firms in the world for about six years and got to design airports, hospitals, stadiums all across the world. Awesome. So let's pivot to the healthcare space and

design specifically. And can you give us like a high level overview of how hospitals are designed and then specifically how surgeons can have a role in the design of the hospital beyond the number of operating rooms and how close surgeon's lounge.

Love it. I would say one thing that's fascinating about the whole design process, super complicated, tons of people involved. At a very high level, there is a first pre planning stage of like, do we need to build something or not? For the most part, oftentimes when someone says they want a new hospital building, they often don't need one.

They actually either need to renovate or use their existing capacity better. But once they get to the point of saying, all right, we need something, you go into a programming phase where you start to figure out like, what, how much do we need? Do you need like five ORs? Do you need like 10? Do you need like, There's a lot of formulas and equations for figuring that out, but

it ends up becoming like a pretty mathematical exercise.

And then you get into the fun part of like schematic design where you actually start to like sketch stuff out and figure out what it should look like. And then you finally go into detailed design where you start putting the pieces in the building and figure out where they should go. My personal bias is that physicians and other frontline users, nurses, frankly like maintenance facilities, should be involved in the whole process.

What typically happens is the architects designers will ask for input from the physicians in that first early schematic design, and then we kind of trail out. And I don't think it's ill intentioned that our design recommendations don't make it into the final building. But there's so many codes and regulations that everybody has to respond to that sometimes our ideas get designed out because we're not at the table to reinsert ourselves.

Gotcha. How do

we, like, reinsert ourselves into the process? Or do we? Yeah. In order to, Yeah. To design hospitals that we can optimally take care of for patients. I love it. So I would say at any of your hospitals where you work, there is a facilities team. There are almost always engineers or some are going to be architects.

They would love to have a clinician sit with them and think about the building. They take a lot of pride in stewardship of the building and making sure it's a safe place for us to do our work. But many of them don't have enough context for like what we actually care about and what we're worried about.

And so developing some relationships locally with your facilities people will go a huge long way that when it's time to design or renovate a space you already have a relationship with them and can weigh in. And It is not too difficult to think about the things that you would want in the space, but you have

to remember all the different trade offs that everybody else wants in the building.

I'll give you like a very, what seemingly is like a benign example, and it could totally derail a project. When you walk down a hallway in a building, a lot of people love the design of just a curved hallway. Aesthetically it looks more beautiful. It's better to walk. It seems like, gosh, that would be like a good idea to do that.

If you talk to a facilities person about how much more difficult it is to clean floors that are curved instead of straight, it takes them almost 20 percent more time. So all of a sudden you now, just by this simple design decision of like, do you want a straight hallway or one with a gentle curve?

You've now changed the number of FTEs facilities has to hire. to maintain the building. So each of the things that we all think about of wanting to make a room a little bit bigger, locate things may have trade offs with some other stakeholders.

Got it. So this is switching gears a little bit away from high level hospital design to a specific question that I've just kind of noticed, you know, there's cranes all over the country.

They were building new hospitals. We have one here in Ann Arbor building a new tower. All of them filled with windows. There's tons of windows on new hospital buildings that are being built. Is there a particular reason for that? Does it just look cool? And we're trying to look like we're building hospitals that look like skyscrapers.

Is there any evidence behind that? There's actually evidence behind it, but it's not the kind of evidence I think we would all hope for. There's a famous paper published in science and we can link it for you in the episode in the 1980s. So probably older than a lot of the listeners. It was a retrospective review of about 30 40 patients who had an open cholecystectomy.

Half the patients had a window view that overlooked this beautiful arboretum woods, and the other half of patients had a window view that basically looked into a concrete wall of another building. Compared them head to head, the patients who

had a window view went home faster, used less pain medicine, and complained less to their nurses.

The title of that paper is Views from a window may improve recovery after surgery. It's been cited over 5, 000 times. Every architect cites it. They go into every client and say, Look, we know windows help you recover. Yeah, it's kind of alarming that it's only 30 or 40 patients, but that's been like the bedrock staple for why we design a lot of our hospitals with huge windows.

And there's two ways to think about that. One is I really wish we had more robust evidence to connect specific design features to the way we design. But on a positive note, if we actually generate positive evidence, there is a very willing and eager body of architecture practitioners who will put it into practice.

We could start by looking at a more contemporary operation like a laparoscopic cholecystectomy rather than an open

cholecystectomy. And probably would now with our better methodologic approaches could use differences and we could risk adjust the patients too because that might have played into the findings of the study if they didn't do that.

So we talked about high level hospital stuff. We talked about windows. Let's like drill down a little bit more into some of the specific settings in which we as surgeons work. Can you talk a little bit about the specific intentional design behind intensive care units, If there's any evidence behind the design of those.

Intensive care units are another interesting place that have been subject to, actually, a little bit more scrutiny and some more robust evidence. There's a landmark paper published in CHEST that looked at patients who had corner rooms that basically had no line of sight to the nursing station. So, most ICUs are set up in almost like a square or a roundabout.

Thank you. And they looked at patients in those corner rooms

and found that they, even risk adjusting, Apache scores, the whole thing patients in those rooms with no line of sight had higher mortality rates than those who were located closer. So it is interesting because it's influenced our design in that when we design ICUs, we try to create direct lines of sight from the nursing station to any room.

The easiest way to create that is to put it in a half circle. But think about the trade off I just told you a few minutes ago, making a curved hallway versus straight one has just huge trade offs for how you like maintain that space. Yeah. And so every time we try to make some of these design improvements, there seems to be a trade off that holds us back a little bit.

And so the ICU is an interesting one that's been studied a fair bit and the more recent studies. are probably not detecting a difference because we have so much remote monitoring. You know, you're not looking in the room to see if the patient's gone into

AFib. You have a telemonitor that's bringing it right to your desk or maybe your phone even.

And so some of these line of sight things that we thought were super important, It may not be as relevant as we incorporate new technology. Got it. But they're, the proxy is being able to monitor the patient remotely. Exactly. The principle's there. It's like, can you monitor the patient? And before our remote monitoring, direct line of sight was a key way to do it.

I was just thinking about how the surgical ICU where I went to medical school was set up and it was very much essentially like a big semi circle with, The center being the nurses station so that they could all look out and see the patient room to presumably look at the monitors before we had all this remote monitoring.

And then our surgical intensive care unit at U of M is a U shape, but there's a bunch of nurse stations so that the nurse taking care of the patient learned they have that direct line of sight like you're talking about, albeit both older buildings. Yeah. Awesome. Awesome. So.

Let's talk a little bit about trauma bays.

Trauma bays, another interesting space. We spend a ton of time in it. And it's full of a number of trade offs that we'd love to optimize, but can be frustrating. And the probably obvious thing that we try to do is to put a door to the emergency room next to the trauma bay and ideally close to the OR or the elevator to the OR.

In a perfect world, all those things would be under this umbrella of strategic adjacencies or. Those would all be next to each other so you're not pushing an acutely sick patient 10 or 15 minutes to get them to an OR. What interestingly happens in the life cycle of a hospital to design it is one, it often takes 5 to 7 years from the time you start sketching to like opening day.

And a lot can happen in that time, including something trivial like

the beds that you ordered have changed. So, there was a big push a few years ago by a number of bed manufacturers to make the beds bigger, because patients are a little bigger more patients are overweight, so they're bigger beds. The size of the newer, larger beds were not always taken into account when the building was originally designed.

So there are examples of hospitals where the elevator shaft could not fit the new bed that was now purchased by the whole hospital. For So the hospital either had to make a decision to buy new beds or to replace the elevator shaft. Either way, super expensive design decision that we didn't quite get right in the name of trying to improve the efficiency of the design.

Got it. So, you talked about trauma bays and going to the operating room. Let's transition a little bit to the operating room specifically. I have to imagine that there are lots of thoughtful

folks who design operating rooms, the technology that is in them, and some things that we may or may not be aware of despite spending most of our waking hours in the operating room.

Super thoughtful space, and I'd encourage any of you, sometime when you have a break between cases, to go into an empty operating room. and just look up at the ceiling. The ventilation of an operating room is incredibly sophisticated and the general idea is that the air coming into an OR is clean filtered sterile air over the OR bed and all the exit vents are in the corners to create this beautiful laminar pattern of keeping a sterile field including the ventilation.

You might be thinking, Andrew, what is like the evidence for that? The evidence for that design. is all in simulations and theoretical models where they take a tracer particle, put it in the air and figure out how much do we have to filter the air to clear 99.

9 percent of whatever that particle is. The idea that you maintain a sterile field over the patient.

Interestingly, the goal is to prevent surgical site infections. So this is a group of super motivated engineers who are super. They're passionate about making the hospital a safe space. They want to be good stewards of the building. So the O. R. s in the United States by code are ventilated at 20 air changes per hour.

That means at a minimum, every two to three minutes in an operating room, all of the air has been evacuated and new filtered air is brought in. There is no evidence connecting that level of air filtration. to any improvement in actual human patients and reduce surgical site infections. But it's been such a theoretical concept that's so embedded.

We now literally design our ORs with entirely

different ventilating air condition systems, just to be able to ventilate at this super high rate. And we have no idea that it benefits anyone. And to make you pause about it some more, the code says 20. Most hospitals run at 30 to 40 error changes per hour because they want to avoid any infections.

Every added 5 error changes per hour is roughly 10, 000 to 15, 000 per OR per year. So if you think about 30 or 40 ORs at our main campus, there's probably close to a million dollars of Spending on ventilation. That's probably unnecessary. That's over code and there's no evidence to suggest that it's any benefit to surgical site infection.

So it's another example of like very good intention, very motivated designers, but we haven't done a good enough job inserting ourselves with real evidence and patient facing data

to say, Hey, we love the effort, but maybe we don't need to emphasize. That as much, and we can put that valuable money and resources into other things in the OR.

Well, the next time I have to present at Death and Complications Conference for a surgical site infection, I might have to look back to the operating room to see that the ventilation system was working appropriately to hedge why that patient might have gotten an SSI. Well, that data, just to, like, make this more ridiculous, JCO requires these ventilation rates to be monitored.

Oh, wow. Every OR in the United States, you will find a log of measuring air changes per hour every 60 seconds in every OR all the time. Should Jayco show up, you can have a record of that on hand. And I think a lot of us would agree if you've done that emergency colectomy in the middle of the night, you're probably pretty confident that like stool you spilled in the wound is probably why they got a surgical site infection, not whether or not the air was whirling.

At 20 or

30 or 40 error changes per hour. So there's probably like a real opportunity there for us to actually just right size some of these design interventions that are super well meaning. The other one related to the OR that I think is important to talk about. We love bigger ORs. Like if anyone like we just working in OR that's like 40, 50 years old.

You're like, gosh, I can't even fit in here. Every time you like open the door, it like hits something. So the newest ORs have gotten bigger and bigger. Now you're thinking about like making room for the robot, making room for other equipment. One of the interesting trade offs of that, you might intuitively think, okay, a bigger OR is great.

One of the challenges of bigger OR, one, you're ventilating way more air, so just like way more expensive to uptake. But two, it's also harder. to clean a larger O. R. Think about the O. R. where you have all that equipment lined up on the sides. Do you think like every square foot of that gets

cleaned perfectly every time?

The bigger you make the O. R., the harder it is. So, there's been some pretty compelling data in orthopedics out of Europe that larger O. R. s actually have higher surgical site infection rates. And the authors of those studies postulate That's because the rooms probably don't get cleaned as well as the smaller rooms, which has some real face validity.

So all of a sudden we're thinking like, gosh, I want to give my patients the best care environment for me to do my job, reduce infection rates, and we're putting a lot of resources in the air ventilation that may not matter. We may advocate for bigger rooms that may have some drawbacks, and probably most of us haven't had like a heart to heart conversation with our cleaning facilities teams.

for listening. And learned, like, what would make their job easier. Right. So, there's a lot of opportunities for us to make our space design better and safer. Totally. One other thing that we all notice when we look up in the operating room, aside from maybe the ventilation system, are the big and heavy

booms on the ceilings in the operating rooms.

I notice them when I'm trying to get things out of the way or try to get the cottery a little bit closer to the, to the table so that the bovie will reach. Can you talk a little bit about how and if those booms are strategically? Why the heck those came to be? Yeah. Exactly right. So it's a great question.

The concept behind the booms was you want to be able to clean the floor between every case and if you can get things off of the floor, you've now made it easier for people to clean the floor. So in an ideal world, everything would be up on booms and you could move them out of the way and just wipe down all the floors quickly.

What's practically happened is we put some things on booms and then we still have like 10 other things that need to be in the room that are on wheels and or maybe not on wheels. And so it's sort of made the booms almost obsolete in the sense of unless you're putting most of the stuff on there, You're probably still going to have these

other barriers to clean, but the spirit of them was to make it easier to clean the floors.

Is there great evidence behind like cleaning the floors for the operating room between cases, cases diligently, and if you don't get like certain square footage cleaned, then you know the next case your patient's going to be SSI or some type of complication or Is that more of a gestalt? More of how a lot of these studies are done.

Remember most architects and engineers don't have like access to charts and don't have access to clinical data. Right. So they go to the next best thing that they can get access to is they'll often either take an air sample or swab areas of the room. So many of the studies that kind of underpin what we described about larger rooms and concern about infection relate to either air samples or samples taken in between cases on the ground.

But I'm not

aware. And if there are, there are very few studies that actually connect it to a patient level outcome. Sounds like we're identifying some research gaps. Yeah. So let's say you're a general surgeon working in your local community hospital. You know, we've talked a lot about. Hospital design, operating room design, trauma bay design.

What practical pearls do you have for the general surgeon who's working at their hospital? They hear that they're building a new tower or, you know, some big renovation to the hospital. What are some practical tips and pearls that you as a design expert would impart onto that general surgeon to make sure that the spaces that we work in are optimized for our patients and for the delivery of the care that they need?

I love it. It is so valuable to reach out to the design team facilities people, ideally well before you're actually designing a project to build those relationships, they will be ecstatic

to have like your frontline clinical input. And also remember they have like some real expertise and other considerations.

And I think one thing that I think we do well. As clinicians and surgeons is manage like multiple competing inputs and try to like move a decision forward. Being able to learn like what's the facilities person worried about? What's like nursing worried about? What's like the lighting maintenance person worried about?

What's the structural engineer person worried about? And then what am I worried about as the provider in the room? If you can start to listen to what everyone else is worried about and figure out where your seat is at the table. It's incredibly valuable. But somehow staying involved in the process longitudinally, we tend to like give our input early in that schematic design pre planning and then we kind of disappear until opening day and then we get frustrated when it doesn't look like what we told them we wanted.

Somehow we fall off in that middle there

and finding ways to continually stay involved would be super valuable. Got it. So you wear a lot of hats, right? You're A busy clinical surgeon, you do a lot of high level health services research and you also wear this health and design hat. Can you talk about the through line of the kind of those three aspects of your career and kind of the impact that you ultimately want to have on American surgery?

Yeah. Great question. My fundamental belief is that everything we design and build can influence your health. Whether that's schools, offices, hospitals, and to take that one step further, I think anything we design and build can measurably improve health, and I think I have an obligation as someone who's formally trained in rigorous health services research methods to try to bring quantitative analytics to the space of design to be able to

say with some level of certainty, designing our ORs this way actually made it safer for patients.

Or, Creating our neighborhoods a certain way made it easier for people to access care because they're more connected with their neighbors, knew they could ask someone for a ride and. So, my overall career goal would be that we think of the built environment as like an intervention, just like we do with surgery and that we think about it with a real outcome like health.

Part of what resonates with me about architecture. is the same as surgery is that you make a consequential decision and it's almost like permanent like you build a skyscraper in the middle of town you're not gonna take it down next week it's there for two or three decades you reverse someone's ostomy and it leaks and you divert them again like that's a decision that has like consequences for a long time so i think our surgical training makes us comfortable with making these decisions that have long ripples and I think

architecture has the same responsibility.

Never thought I'd hear the words ostomies and the skyscraper in the same sentence. I love it. So, if some listener out there is interested in having a similar career trajectory or is interested in health design and surgery, I mentioned it in your very lengthy bio that you're the program director at U of M for the Health Design Fellowship.

Can you talk a little bit about that and if folks are interested where they can find more resources if they are interested. Yeah. We'll put a couple links in the chat to this of we've written a couple papers about how to do research on using patient level outcomes to evaluate the quality of hospital design.

I think that's like a great space to lean into that a lot of us should do. Certainly reach out to me if you want to spend some extended time in this space. We have our fellowship here to train. People in design and health services work. And I'll leave you with maybe just one higher level, broader comment about surgery.

And if you have maybe like an

atypical interest, there's no question that for our generation of surgery to be at its best, we need everybody at like 110%. We need everyone bring in their full game, everything they know how to do best. And so it's worth each listener thinking about. Like, what is the thing that, like, I really care about that I know how to do?

If it's sustainability and the environment, I promise you, you have a big seat at the table in American Surgery. If it's qualitative interviewing on patient reported outcomes, that's great. If it's architecture and design, also great. To be able to achieve impact in these other domains, you have to shore up your foundational knowledge.

ability in surgery. So no one's going to listen to me as a surgeon doing architecture and design. If I can't safely do my cases, if I can't take care of patients, or if my partners are worried when I'm on call. And so you need to foundationally be an

excellent surgeon. And then that actually gives you the confidence to say, I want to bring this new thing to my field.

To be able to move it forward. I love it. I can't think of a better way to conclude this awesome conversation. I know you super well from the research side of things and we meet like multiple times a week to talk about that work and I didn't know about more than half of the stuff that we just had the opportunity to talk about.

So I hope all the listeners enjoyed this. Dr. Ibrahim, thank you for your time. And until next time, I'll let Dr. Ibrahim take it away and say it. When you see our picture in the hospital that can be improved, you should dominate the day.