Hybrid OR Green Heart Hospital

Building on a (small) postage stamp

Fixing an aneurysm today is lightning fast. Whereas a patient used to occupy a hospital bed for ten days, today it is at most one day, and soon it may even become a day treatment. Building a new OR in this day and age is also faster than in the past, at least that is how it went at the Groene Hart Hospital (GHZ) in Gouda. In April 2023, the first pile was driven into the ground in a patio of the complex for the new hybrid OR, and on September 4, 2024, the first (vascular) surgery was already a reality. A matter of careful planning, close coordination with the surrounding departments, the use of proven technology and working with permanent construction partners.

The new hybrid OR was given a special place in the 40-by-14-meter patio near the restaurant. "Thus, this addition connects to the existing OR complex on the second floor, where there are eight generic ORs," said Josbert Kamerbeek, GHZ Construction Office Project Manager. "So all existing facilities, such as the holding and recovery rooms, are close at hand for the new OR. The OR room itself is on the second floor; all the facilities are housed on the roof floor. The nice thing is that you really can't tell from the outside that it's new, because the existing facade construction has been copied exactly."

Growth forecast

The hybrid OR was initially set up to combine vascular surgery and interventional radiology. "The GHZ is a regional hospital that is still growing because Gouda is a growth town with a lot of new construction," says Peter Schlejen, a vascular surgeon at the GHZ since 2011. "Add to that the aging population and structural increase in diseases such as diabetes and you can certainly expect a substantial growth in the number of patients in the field of vascular surgery. So we need more capacity in that area and we must continue to innovate. One way we do that is by bringing vascular surgery and interventional radiology together in this hybrid OR. We can thus combine two disciplines that you would otherwise have had to do in phases. And if you can do two treatments at once, patients need to visit the hospital less often and the risk of complications decreases. It's basically a catherization room in an OR, with all the facilities available as an inpatient."

Table and C-arm

The new OR measures 7 by 10 meters and is set up with a focus on vascular surgery and interventional radiology. Schlejen: "The C-arm and the free floating table are central to this. The C-arm takes X-rays and 3D images in all positions and can screen a patient's entire body during surgery. C-arm and table are linked. As a result, the C-arm knows exactly the patient's position and can, for example, perfectly image a blood vessel. It can also use previously made CT scans. With this modern imaging, the radiation exposure is significantly less. All around are large movable screens to monitor and compare everything well. This makes it possible to perform even more treatments through the blood vessels, leading to fewer complications and shorter hospital stays." 

The new OR is equipped with the Opragon system as the ventilation system, where the familiar bulbs in the ceiling in the entire OR provide an ISO class 5. The lighting system can turn the entire OR into a green color, which is less tiring for the doctors and OR staff. 

Proven technology

Thanks to intensive preparation, the GHZ's hybrid OR was realized in a very short time. "In a very difficult location," Kamerbeek adds. "The new room is now in the best location, near all OR facilities, but in the most difficult place to build. In the end we succeeded within budget and without a day's delay. The secret is in the preparation and good cooperation. With the medical staff, we visited several hospitals to select the best proven technology and find out if it would work for us and if it was the right size. For the patient location, the design team (EGM architects, Deerns, Aronsohn and OKCN; ed.) accelerated a design that was then worked out into a technical design with the executing parties in the second half of 2022. The executing parties are all parties we have worked well with before; we reinforce each other and achieve results faster. That's a nice experience. The permit came at Christmas and in April 2023 the first drilling pile went into the ground. Eighteen months later already, the first patient was treated."

Minimal inconvenience

The construction itself was a story in itself. Kamerbeek: "Space was scarce and the hospital had to be able to go about its business undisturbed. That was a serious puzzle. With contractor J.P. van Eesteren we decided to place the tower crane in another patio and to do most of the supply of equipment and materials over the roof, all in smaller quantities and sizes. To that end, a protective structure was made on the roof with outriggers, EPS blocks and dragline bulkheads to protect the roof and installations. The piling rig that drilled the piles welded together was lifted into place over a weekend. Construction work - especially that causing noise and vibration nuisance - was done in close cooperation with the ORs and surrounding departments. We had walk-in consultations for employees every week, which worked very well. The result was almost no complaints, while occasionally an operation was going on five meters away. That's the way it should always be from me."

Progress

Vascular surgeon Schlejen is extremely pleased with the new OR. "We can take another step in improving our field and that's going to benefit patients above all," he says. "We can perform more and more treatments non-invasively with this hybrid facility. That means better and shorter treatments with less risk of complications and shorter hospital stays. Not long ago, replacing an aorta meant an open reconstruction and ten days in the hospital, now that is done through the groin and will soon even be a day treatment."  

Integrally designed, future-proof design

Knocking down an OR means working together at a high level. At Cleanroom Combination Group, they know all about that. The company cooperated in the realization of the new hybrid OR of the Groene Hart Hospital (GHZ). The result is an extremely functionally finished room in which all modern technologies and facilities are tightly integrated.

Cleanroom Combination Group (CCG), also involved in the construction (and maintenance) of eight generic ORs for the GHZ ten years ago, was approached by J.P. van Eesteren in 2022 to co-design the hybrid OR. CEO Michiel van Kooten: "We then sat around the table with the GHZ, EGM Architects, Deerns, OKCN, ULC and the contractor to create an integral design, with each party contributing from its own specialty. This with (among other things) the goal of eliminating risks and setbacks during construction as much as possible. You have to deal with many suppliers and equipment, such as screens, warming cabinets, a C-arm and other installations. 'Fit-not' during construction was not an option, because that costs time and money. The intensive preparation resulted in a very beautiful and functional hybrid OR that was within budget and future-proof."

Up-to-date

For the walls, the choice fell on a finish with modular frames and Trespa Toplab wall panels. "Those panels guarantee high chemical resistance, impact resistance and scratch resistance and are excellent to clean and disinfect," explains project manager Bart Flaman. "CCG's system is easy to adapt, so you get an OR that is up-to-date for a long time. The recovery room and sterile storeroom were also finished this way, and there, too, installation technology had to be integrated with the finish. Then it's nice that we design in 3D Revit, so we can (have) everything prefabricated properly."

Floor and ceiling

Cleanroom Combination Group finished the floor with Forbo Colorex tiles. These are static dissipative, electrically conductive, easy to maintain and replace per tile. "The ceiling was finished last," Van Kooten concludes. "That always requires the most coordination, in this case mainly because of the setup of the OR and Philips' C-arm. The new hybrid OR looks very nice, so we are very proud of the final result."  

Permanent team completes complex work. Installation technology hybrid OR Green Heart Hospital

Building a new OR is normally already a pretty complicated job. If that also takes place between two existing building sections, on a small area near eight - two of which are adjacent - operating ORs and with the task of being as little of a nuisance as possible, then it really is a complex job. "In that case, you're certainly glad you get to do it with a team you've been working with for 10 years," said Aad Wepster, senior project manager at ULC Installatietechniek. "Without a strong team that works well together you don't get that done without a hitch and on time
for each other."

In the construction of the new hybrid OR at the Groene Hart Hospital in Gouda, ULC Installatietechniek was responsible for all electrical and mechanical installations. Wepster: "It is a fixed team with the client, J.P. van Eesteren, EGM architects and consultant Deerns. They form one party with the same starting points, where everyone's interests are equal. Then you come to a well-designed planning; everyone knows exactly what and when something had to happen and this way you avoid unnecessary and costly delays. The complexity was mainly in the logistics, where equipment had to be hoisted over the roof. But also in the fact that you are right next to a working OR center. At one point, we had to make necessary adjustments to the controls of the main power distributor. For this, the entire hospital, except for critical parts such as the ICUs and SER room, had to be disconnected from power for more than three quarters of an hour. That too went well and in doing so we immediately made adjustments that will be needed in the future." 

Short lines

For the new hybrid OR, ULC installed new air handling units with the necessary control technology in the engineering layer and connected them to the rest of the hospital. "The electrical engineering included the power supplies for the OR, especially the C-arm, the data network and all connections with the SER room and fire alarm system," says Wepster. "The advantage of a technology room immediately above the OR is the short lines in technology. The number of ducts and pipes under the ceiling is minimal for an OR, which is nice when you need to do maintenance. The ceiling incorporates the Opragon system. That provides a very clean work area for the OR staff, even with an X-ray machine moving in the airflow. As with all parts of this work, everything has been considered, and that will pay dividends for years to come."