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LONG READ | 10-12-2021 | Estimated reading time: 10 min

Good Vibrations – Enabling high quality eye surgery on top of a parking garage

In the early months of 2021, as winter lay over the city of Delft, Erik Middelkoop and his colleagues from Royal HaskoningDHV’s Advanced Technology and Research Group gathered at the newly constructed operating rooms of Reinier de Graaf Hospital. 

They had come to carry out tests – a combination of sophisticated digital modelling and old-school science – to see if all the work they had done over the last two years had paid off. 

As they gathered together in the new building’s reception, a stone fireplace sat waiting to be kindled; ready for new patients. Patients like Aart, a resident of Delft who would be among the first through the door - should Erik’s team be successful... 

“We were… nervous. Yeah, for sure.” Erik says, looking back a year on: “It’s nature, you cannot predict it perfectly - but the building was finished at that point, so failure was a scary prospect.” 

Across the city, Frank Bouhuis, Strategic Real Estate Director of Reinier de Graaf Hospital in Delft, waited to hear the results. He had surgeons ready to put this new building to use – and patients needing the high-quality care it promised:

“We were anxious to see if the building would react as predicted.” Frank says via video call: “We had faith in Royal HaskoningDHV – but faith, you know… faith is good, but when the stakes are this high, you need to be sure.”

As Erik’s team carried out their tests and the sensors and models did their work – the project team held their breath…

 

A vision for healthcare – resting on a parking garage

The metric that Erik and his team were testing for – and on which the entire project rested – was vibrations. It is not the usual factor on which the success of a building, particularly in healthcare, rests – but then not many operating rooms are built on top of a parking garage.

It was this initial challenge that Frank’s predecessor at Reinier de Graaf Hospital was seeking to overcome when they approached Nils Roovers, Associate Director for Healthcare at Royal HaskoningDHV, in the summer of 2018:

“We have multiple hospital locations in the Delft / The Hague area,” Frank explains: “and as you’d expect, all of these locations are tied together by a real estate plan and vision. This ensures that if we make changes at one location, we can ensure we have the capacity to meet the needs of our patients at other locations.”

“So, when we made plans to close one of our older hospitals about 10 miles from Reinier de Graaf, we had to expand the existing eight operating rooms in Delft to ten. We had accounted for future expansion of the hospital on the parking garage, but we knew that would take some big alterations/adaptations – so the hospital went to Royal HaskoningDHV, who had helped us scope out this expansion in the original building.”

 
 

 I’m getting a bad vibe…

Nils Roovers picked up the phone that summer and on the other end, Frank’s predecessor laid out the challenge.

Do you remember the potential expansion you helped us investigate at Reinier de Graaf? Well, we’d like to make it happen. We want to build two operating rooms above the parking garage – could you do a sketch design? 

The request was simple initially and Nils set about approaching the work as he would on any other project – looking at the boundary conditions, the location, what the hospital wanted to build. 

But as he worked, Nils, a structural engineer himself, saw something that didn’t look good. He wanted to be sure he wasn’t overthinking. He picked up the phone to his colleague Erik Middelkoop

Erik, can you take a look at this? 

 

It was a conversation that in another company may have taken weeks – with the need to find a third-party specialist and draw up contracts before getting to the work. But the multi-disciplinary nature of Royal HaskoningDHV, with experts across sectors and collaboration and cooperation encouraged between teams, meant that it took moments.

As Director of the Advanced Technology & Research Group (AT&R) at Royal HaskoningDHV, Erik leads a 60-strong team of highly experienced experts carrying out dynamics and vibration analysis. Usually, this analysis is related to earthquakes or explosions – but Nils’ question was altogether different: 

“It was a great spot by Nils – because his hunch was correct. We saw that cars moving through the parking garage were going to create vibrations in any structure we built above it. The level of vibrations might not be a problem for other structures, but when the structure you’re talking about is an operating room – it becomes a big factor.”

 

Into the unknown…

When the issue was presented to the hospital, the scale of the challenge facing them all rose before them. 

The hospital had decided to use the new operating rooms for day-treatments – specifically eye surgeries – making use of the parking garage below to create a ‘drive-in’ experience where patients could enter, have their treatment and leave within the same day and same building. 

Ophthalmologist at Reinier de Graaf, Fara Sortomme, discusses the implications: 

“When you’re operating on an eye, what you’re doing is so intricate that you can’t do it without a microscope. You’re maneuvering within tenths of millimeters so an unexpected movement, even a small one, can be disastrous.”  

Fara Sortomme

Ophthalmologist at Reinier de Graaf  Hospital

“It was another layer of challenge” Frank says, acknowledging the difficulties: “it’s almost the worst combination we could have faced in terms of difficulty. It wasn’t going to be easy.”

The success of the project rested now on finding a solution to this problem – a problem that had no precedent. They were stepping into unknown territory. 

With no best practice or guidelines to follow, Nils and Erik took the initiative. Together they decided they would carry out vibration measurements in the existing hospital building where the eye surgeries currently took place.

“We thought, well, if these levels are acceptable in current operations and have been for years” Nils says: “– then this will be our baseline and target for vibrations in the new building.”

Then Nils and his team did something very different – they went further and met with the surgeons themselves, holding group sessions as well as individual discussions.

 

The surgeon will see you now…

Sitting under the clean white light of Fara Sortomme’s room – where weeks earlier resident, Aart, sat for consultation on his eye surgery – Nils and his team could’ve been mistaken for patients awaiting a diagnosis, surrounded by medical equipment and walls adorned with charts and public health announcements.

But as they pulled out their plans and laid them on the table, the strangeness of the situation gave way to an informal and friendly conversation over coffee – as they discussed the needs of the surgeons and charted a way forward:

 

“It was a lot of fun to be a part of those early discussions” Fara says, recalling her part in realising the unique facility: “We don’t always get to be that involved. We were able to really be creative about what our ideal theatre layout would look like – and the team listened. They didn’t try to assume what our needs were, they spoke to us and took our feedback on board.”

“That was a really great and special part of the project.” Nils says, looking back: 
“I work in our healthcare group here at Royal HaskoningDHV, but I don’t often get to speak to the people on the ground. Seeing how our work was going to impact them and the patients they help was something I really enjoyed.”

Nils Roovers

Projectmanager and Associate Director

Such discussions make the difference for patients too: 

“As an eye surgeon our procedures usually take around ten minutes, don’t require general anaesthetic, and patients return home the same day.” Fara continues: “That can be quite an intense process for them, so fear-reduction is a big part of our thinking – how can we make the experience for the patient as calm, comfortable and relaxing as possible.” 

“It was nice to see that our specific niche of patients were taken into consideration so much. It’s a small specialisation within the hospital – but it was very clear that the project team were trying to tailor the whole process towards the needs of our patients as well.” 

Through their discussions with staff, using their insights to confirm the requirements of the new building, Nils and his team had their targets. Now it was time to find a solution. Nils turned to Erik and his team of experts to find a way… 

Digital modelling, simulations – and a bag of sand

By now, the Advanced Technology & Research team were fully invested in finding a solution to this vibration conundrum. In doing this, Erik’s team combined the new and old in science and analysis:

“We created a digital model of the proposed building and garage, so that we could run simulations on potential solutions and see how they worked – but we needed to understand what vibrations the garage would be producing so we knew what our solution would have to counteract.” 

This required a back-to-basics approach – and so Erik and his team found themselves in the parking garage of Reinier de Graaf Hospital, putting up sensors and monitors. They drove around the garage and measured the vibrations – and in true classroom-science style dropped a bag of sand from a staircase to measure the output of vibrations. 

“In our day-to-day we’re working with earthquakes or explosions – and for obvious reasons we can’t physically test or model these things! So this was a really interesting approach for us – and it shows that sometimes, digital and traditional approaches can work in harmony to get the best results.”

Springs like a cartoon…

Now that Erik and his team had carried out their analysis they moved to the solutions phase, exploring various solutions that could counteract the vibrations – making the building lighter, stiffer, or putting a structure between the garage and the new building. In the end, the solution they came to was deceptively simple:

“We saw that if you put a cushion of some kind between the structures, it would help. So, what we ended up in our model was springs – classic steel springs almost like you’d see in a cartoon. We paired this with some dampening – because you can imagine if we just had springs and it starts vibrating it would never stop!

“We tuned and tailored these springs to the building, so they were stiff enough, but not too stiff, to absorb and nullify the vibrations from the garage. When we ran the simulations, the vibrations came in below our target – and we knew we had our solution.”

 


 

Making the complex simple…

Through knowledge, expertise and collaboration – Nils, Erik and their teams had found the solution to a problem that had threatened not just this project, but Reinier de Graaf’s current and future development plans. 

They presented their findings and solution to Frank and other board members at the hospital and took great care in explaining things clearly and simply: 

“At Royal HaskoningDHV we want to bring our clients along with us – so we worked to ensure our discussions with surgeons or with board members were clear and understandable. We’re not there to confuse people into accepting our solutions – we want them to believe in them as much as we do – and feel that confidence and assurance.

Frank testifies to the approach: “When you’re working together, you can have your doubts. For me, I always say it’s like I see a red light blinking that says – ‘something’s wrong here’ – but with Royal HaskoningDHV I never had that. They were very reassuring.”

The board approved – and construction of the solution and the hospital began. And yet, despite all assurances and confidence – the team would not know if they were successful until the build was complete. 

 

The moment of truth…

And so, at the beginning of 2021, having seen their work come to fruition – Erik returned with his team to carry out the tests that would cement their success… or failure.

They could not tell whether what they felt in those moments as they waited for results was anxiety or excitement. 

The readings came in – they were below the threshold. They could breathe. Their solution had worked.

On the 1st of April, 2021, the one-of-a-kind operating rooms opened their doors to staff, surgeons and patients alike. 

 

Bridging the gap between vision and reality…

On the day of his surgery, Aart passed through Reinier de Graaf’s day-treatment centre without ever realising the work that went into making it happen. From the parking garage, an elevator took him up a floor to be welcomed by the warm colours of the reception walls and the faint crackle of a fire. All aspects have been geared towards a patient experience that ensures comfort and safety.

“Perhaps that is the best compliment you can have, that nobody notices it” Frank Bouhuis says: “- it’s the beauty of this solution. It has allowed us to create a unique operating centre here in Delft – the first high end drive-in treatment centre. Royal HaskoningDHV’s solution was the key to unlocking it all.”

Fara Sortomme shares the sentiment: “That’s the ultimate goal as a surgeon – that you don’t just do a perfect surgery, but also that the experience around the surgery is pleasant. We’ve noticed, since the centre opened, that patients are more relaxed – and that’s amazing.”

In the months since the hospital opened, Nils has had the chance to reflect on its success: “This project taught me that you should not hesitate. Nobody had done this before – but we trusted ourselves and each other to see it through; and what we’ve created at the end of it is special. I’m very proud.”

What else can we achieve if we embrace the unknown together?

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