Two theatres in one

What do you do when you want to provide your hospital with two brand new state-of-the-art ultra-clean operating theatres, equipped with the most up to date medical equipment, but only have enough space for one? Two into one just won’t go... or will it?

The answer chosen by Salford Royal NHS Foundation Trust when considering the layout of its new £5.5m theatre complex, currently underway and due for completion early in the new year, was barn theatre

Salford Royal Trust is highly regarded and has many nationally and internationally renowned clinicians who are pioneering the latest techniques and treatments, and its reputation has been confirmed by a number of independent organisations:

it is the second Trust in England to receive a top accreditation for patient safety and quality from the NHS Litigation Authority

it has also been confirmed as the top performing hospital in the North West and among the top 4% in England by the Healthcare Commission.

As part of its continuing commitment to delivering the best possible facilities and service, in 2004, Salford approached consultants Tribal to carry out a study on theatre usage. The results showed the hospital needed three additional theatres and more UCV (Ultra-Clean Ventilation) facilities, but with the very restrictive building space available, this seemed an impossible aim using conventional design. Salford also wanted enhanced training opportunities, particularly of anaesthetists, to be an inherent element of the new complex. Necessity is ever the mother of invention, and the idea was born to construct a barn theatre within which two operations can be conducted simultaneously, leaving sufficient space for one further standard trauma theatre.

The Salford team knew exactly who to approach to make their idea a reality, the company who had been responsible for two of the hospital’s existing theatres - clean air engineers Howorth Medical. The team had already seen, and been impressed by, Howorth’s four-table barn theatre at Broadgreen Hospital and Cardiothoracic Centre, Liverpool, which was installed last year. The company was commissioned to provide the full theatre package, with total design responsibility.

An important element in the hospital’s decision to award the contract to Howorth, was that the team had the opportunity to visit and test a fully-fitted operating theatre, complete with working UCV systems, at Howorth’s recently launched showroom. Being able to have “hands on” experience so early in the negotiations meant they were able to ensure they were making the best decisions right from the start.

Barn theatres

The concept of barn theatres is still relatively new to the UK. A barn theatre is one space in which a number of ultra-clean operating tables can function as efficiently next to each other as they would in separate theatres; in other words, a suite of operating theatres without dividing walls.

There are two early barn theatre designs, at Birmingham’s Royal Orthopaedic Hospital, Woodlands, and the Robert Jones & Agnes Hunt Orthopaedic Hospital in Oswestry, with the more recent Broadgreen theatre taking the concept to new levels of complexity. However, the engineering is still so new that all involved in the design and installation have to be prepared to think “outside the box”.

The open plan design of barn theatres can offer the ideal operating situation, with potential for:

• Opportunities for enhanced team working
• Greater peer awareness of contemporary surgical practice and standards
• Improved supervision for non-consultant surgeons
• Opportunities to develop non-doctor anaesthetists in a safe environment
• Efficient space utilization
• Reduced infection rates through improved theatre discipline

However, for multiple operations to take place in a single open space, it is essential that the ventilation system provides the protection against cross-contamination that would normally be provided by the intervening theatre walls - the most effective method of achieving this is by the installation of UCVs, and this is exactly why Howorth Medical’s involvement is crucial to the success of the design.

The Facts and Figures

In the region of 22,000 m3/hr of air passes through the barn theatre suite, with some 9,900 m3/hr being total loss fresh air. The barn theatre is served by two supply air conditioning systems, one per UCV. Two heat recovery extract units are incorporated to provide the required room pressures and air flow patterns, with air being drawn from the clean corridor, anaesthetic and some 1600 m3/hr from the barn theatre via high and low level grilles.

Will it Work?

At present, no HTM standards exist for barn theatres, but the aim is for all barn theatres to reach the same UCV performance and requirements of HTM 2025 as a standard operating theatre. At the Broadgreen installation, extensive smoke tests were undertaken by Howorth’s engineers and by Malcolm Thomas, the independent validation engineer appointed by the Royal Liverpool & Broadgreen University Hospital NHS Trust, to establish the effectiveness of the installed systems.

The simulations included:

• The effects of running the UCVs at different operating speeds (operational and setback)
• The effects of temperature variations
• The effectiveness of the theatre extract

Tests were also undertaken to establish the required operating conditions to allow the UCVs to be used in setback condition for non-orthopaedic work, while still eliminating entrainment within the operating zones.

In every case, the Exflow UCV systems fulfilled their required performance. The Salford barn theatre will be subjected to the same raft of tests prior to handover, and there is every reason to believe it will perform as successfully as its predecessor.

The future

When it is complete, the barn theatre at Salford Royal NHS Foundation Trust will facilitate a substantial change in the way the hospital is able to handle orthopaedic surgery. It is envisaged that services currently provided off-site at the nearby Trafford Trust will be repatriated, and that all orthopaedic work will be moved to Level 1 of the theatre complex, which will house seven theatres, thus relieving pressure on the eight theatres on Level 3 and providing an enhanced service through improved patient flow. The new complex will be something of which the people of Salford can be justifiably proud, putting the hospital at the forefront of theatre design.

Barn theatres are designed to help hospitals treat more people more quickly, safely and cost-effectively. The unique concept means that more operating theatres can be put into smaller spaces and shows that two, or three, or even four into one really will go.