Designing Safety and Engineering Standards for the Non–Operating Room Anesthesia Procedure Site

Initial Planning

The following ASA guidelines when providing anesthesiology services in NORA sites need to be considered during the design process :

• 1.

  A source of oxygen for the duration of the procedure, preferably piped from a central source

• 2.

  A source of suction, preferably one that meets operating room standards

• 3.

  A scavenging system if inhalational gases are used

• 4.

  A self-inflating hand resuscitator bag, anesthesia drugs and equipment, monitoring equipment, and an anesthesia machine maintained to operating room standards

• 5.

  An adequate number of electrical outlets for anesthesia equipment with isolated electric power or electric circuits with ground fault circuit interrupters if needed (i.e., in “wet areas” such as birthing rooms or cystoscopy rooms)

• 6.

  Adequate lighting of the patient and anesthesia equipment

• 7.

  Sufficient space for necessary imaging and anesthesia equipment and all personnel that allows easy access to the patient

• 8.

  An emergency cart with a defibrillator, emergency drugs, and rescue equipment

• 9.

  Adequate staff to support the anesthesiologist and reliable two-way communication to request assistance

• 10.

  Observation of all applicable building and safety codes and facility standards

• 11.

  Appropriate postanesthesia care, including personnel and equipment

The Guidelines for Design and Construction of Health Care Facilities by the Facility Guidelines Institute, popularly known as The Guidelines, is a useful guide to the design and construction of health care facilities. It contains recommendations for minimum space, patient handling, infection control, equipment needs, surface and furnishing needs, and criteria for plumbing, electrical, and heating, ventilation, and air-conditioning systems for a variety of health care facilities. The Joint Commission (TJC), many federal agencies, and most states use The Guidelines as their building code when approving and licensing newly constructed health care facilities.

When designing a NORA site within a larger facility, imaging areas should be located on a ground floor because equipment, ceiling height requirements, electrical services, and future expansion are most easily accommodated there. The best building level on which to keep radiographic imaging equipment, with the exception of magnetic resonance imaging (MRI) equipment, is on a floor that can be easily accessed from above and below for the myriad of cables required to run it. NORA locations also should be easily accessible for patients coming from an emergency room, surgical suites, cystoscopy, and outpatient clinics. Innterventionalists, anesthesiologists, nurses, engineers, and administrators, as well as technicians, all need to work with medical architects to design the non–operating room space that best meets the budgeted needs of the space.

Postanesthesia care units (PACU) are dictated by sedation and anesthesia. If general anesthesia is given to a patient, he or she needs to recover in a fully equipped PACU. Because many procedures are remotely performed from the main operating suites, transport of recovering patients may be over long distances unless a separate PACU is available for patients undergoing these procedures. Care needs to be taken when planning for patient recovery, because regulating agencies such as the Centers for Medicare and Medicaid Services and TJC have specific guidelines on where patient recovery can be done. Remote PACUs must be of the same high standard as traditional PACUs.

The amount of space required for a NORA site depends on the services performed in the area ( Table 2-1 ). For example, a general radiography room needs to be only 180 square feet according to The Guidelines, but a cardiac catheterization room needs to be a minimum of 400 square feet. For comparison, a traditional operating room is a minimum of 400 square feet. Anesthesiologists need a minimum of 64 square feet for personnel, an anesthesia machine, and a supply cart. A NORA site needs to have a minimum of 3 to 4 feet on three sides of the scanning table to allow for easy access to the patient. Additionally, doors in the room should not violate this space, the equipment, or ease of patient movement and transfer. All diagnostic imaging areas require a radiation protection area with view windows with at least 42 inches between the exposure control and the outside partition edge.

Medical equipment dictates the layout of a room. Once the medical equipment vendor is selected, the area layout can be planned. Selection of exact equipment must be the first step in the design process because each manufacturer and system is engineered based on specific power requirements, cable diameters, and cable lengths. For example, each manufacturer has its own specifications for the maximum distance of cables between the x-ray generator and the imaging equipment.

After the specific imaging equipment is chosen, the interventionalist determines its relation to the control room. The parallel orientation is often chosen in academic institutions; it allows for teaching, with almost everything to be seen from this positioning. According to The Guidelines, whichever orientation is chosen, the control operator should always have full view of the patient, including the head, through a window.

Ergonomics

When planning a NORA site, consideration of ergonomics is integral to the process. Ergonomics is the science of the relationship of humans to their tools and work environment. The ASA has guidelines for proper ergonomics and workflow in the operating room. Although the ASA has no specific statement on standards in the NORA sites, it is prudent to recommend that these same standards of ergonomics and workflow for the operating room be incorporated in NORAs. Proper ergonomics allows for maximal efficiency and safety with minimal stress on users. The following questions should be addressed in the planning phase of NORA design:

• 1.

  How will patients, supplies, and equipment move through the facility?

• 2.

  Which tasks will be performed in the facility?

• 3.

  Does adequate communication occur within the facility and to the outside?

• 4.

  Is the lighting adequate for the procedures that will be performed in the facility?

• 5.

  Is adequate environmental pollution control provided?

• 6.

  Is provision made for different temperature zones?

• 7.

  Is control adequate for electrical power and compressed gases?

Movement

When considering the flow of patients into and out of a facility and, more specifically, a NORA site, simulation should occur in the design phase of planning. The flow of the areas should minimize effort for both patients and staff. For example, a changing room located near an induction room that is close to the MRI scanner is the best layout for patient privacy and flow. A staff entrance that is separate and out of sight from a public waiting area is optimal for workplace efficiency. Actual supplies, instruments, storage areas, and work surfaces should be in their proposed layout when possible to ensure easy access to them. During this phase of planning, pharmaceutical management should be considered; will a satellite pharmacy be near the NORA site, or will an automated dispensing system be used in the NORA site? Movement in the NORA site could differ with each of these setups.

Finally, a clear and sensible evacuation route for all people in the facility should be planned, in case of an emergency. Devising this route can be a greater challenge in NORA sites because of their often remote locations within a facility.

Tasks

The tasks performed in the NORA site guide optimal room design. NORA suites are designed to be task-specific, unlike a general-use operating room. Forethought on how the area might be used in the future also can guide design. For example, if a large number of pediatric radiation oncology procedures are planned in a radiotherapy suite, space should be allocated for anesthesia personnel and equipment, the proper number of electrical outlets, and medical gases. Consideration should be given as to whether the area would be for ambulatory patients only or for hospital patients. If there is a possibility that the area could someday be used as a hybrid operating suite, additional space and gas outlets should be added to the design.

Communication

Adequate communication potential is imperative for safe patient care in the NORA. A strong communication system to outside of the NORA site is potentially more important than communication within the NORA location because these areas are often located in more remote areas of the hospital and medical response could take longer than usual. Once additional assistance from medical response personnel is available, it is important that they have easy access to personal safety equipment; having these items at the point of entry is essential. Easy access to anesthesia personnel, supplies, and equipment is imperative, so the best room design necessitates the anesthesia working area being close to the entry door to eliminate the need to climb around large imaging equipment, instrument tables, and cables.

A well-designed communication and information technology system will result in efficiency. The number and locations of network outlets, telephones, intercoms, computers (wired versus wireless, portable versus fixed), information boards, cameras, monitors, and code buttons should be carefully planned. It is most convenient for anesthesiologists to have a separate computer and phone in their allocated work area to avoid crossing through or around the interventional work area and to allow for timely access for help in an emergency. Easy access to information relevant to patient care by the internet and electronic records is also important in the NORA setting.

Lighting

NORA areas often have dimmed lights. This makes interpretation of diagnostic images easier, but working is more difficult for everyone else in the room. Adequate bright light is a necessity for anesthesiology and nursing-related tasks. Separate lights that have a dimmer switch or lamps where nurses and anesthesiologists work may be helpful because the rest of the room could be dimmed for the interventionalists. Attention must be paid to ceiling-mounted light booms so that they do not interfere with other equipment in the room such as video monitors, intravenous poles, scanning equipment, and medical gas lines. Budgets should allow for consideration of light-emitting diode (LED) lights, because fluorescent lights are becoming obsolete.