Redesigning the operating room for safety

Why design matters?

We have been designing hospital operating rooms (ORs) for nearly 300 years. One of the first such spaces was designed with seats so that observers at St Thomas Hospital in 1751 could watch and learn. Consequently, even today, ORs are often referred to as operating theaters.

Prior to the establishment of ORs, surgical procedures took place on hospital wards, patient homes, or in doctors' consulting rooms. As medicine discovered important concepts such as antisepsis, and surgical techniques advanced, specifically designed rooms became a necessity. The size, layout, and design of these rooms have changed enormously over time to accommodate for the ongoing evolution in surgical practice and medicine. Today, ORs are expected to facilitate an increasingly diverse variety of procedures. However, there is relatively little understanding about the impact of design on human error, and evidence showing effects of OR design on surgical outcomes is scarce. Given the rising complexity of surgical procedures and the introduction of robotic and hybrid procedures, these complex interactions between humans and machines become even more important. Understanding how design impacts errors will allow healthcare architects to create safer spaces for an ever-complex procedural environment. One type of error is described as a flow disruption, which is defined as an obstruction of the ideal workflow. Importantly, these flow disruptions have been linked to adverse patient events. ^, It stands to reason that if through optimizing the built environment we can reduce flow disruptions, then we can improve patient and provider outcomes.

Is there an optimal OR design?

Little empiric evidence exists on the optimal layout and design of the hospital OR. It is imperative that design, size, and layout not lag behind surgical advances, a task difficult to achieve when hospital structures are built to last for decades while surgical changes occur more rapidly. The optimal OR environment is free from physical hazards to patients and workers; optimizes personnel flow; minimizes adverse events; provides optimal conditions for sterility, communication, concentration, efficiency, and comfort; prevents stress; and incorporates best practices to reduce environmental contamination. Key principles can be generalized as: standardize the position of the head of the table and the handedness of the room, provide adequate space for staff and equipment to move around, establish and maintain a line of sight for personnel to the patient at all times, and use technology to help workflow. ^, Many experts highlight these key points, but few studies provide a link to better outcomes. The following sections will take a closer look at studies and the importance of the physical space and ergonomics.

Components of an OR

Layout

When a new OR is being designed, its layout will be influenced by its anticipated use balanced against available space and the cost of construction. Optimal layout in the OR should be guided toward facilitating personnel flow while maintaining patient and workers safety. Evidence exists that the layout of an OR can influence movement patterns as well as flow disruptions. ^, These disruptions in workflow during a surgical procedure have been linked to higher levels of stress, a higher perceived workload for surgical staff, increased surgery duration, and negative patient outcomes. ^, In one study, OR layout was the most frequent cause of flow disruptions.

Key factors in the overall layout of ORs need to be divided into static factors such as overall size, storage cabinets, doors, access to gas and electrical supply, ventilation versus variable factors such as the placement of surgical and anesthesia equipment based on the anticipated surgery, the patient position, and the number of personnel.

Existing literature on the relationship between architectural layout and healthcare outcomes has primarily focused on understanding the dynamics of movement patterns at the unit level such as across surgical suites, across the hospital, or within units such as the general medical or surgical units and outpatient clinics. Little work has focused on the movement patterns within small-scaled rooms, such as the OR. However, when developing the optimal layout, it is important to focus on the contribution of spatial adjacencies to work patterns and flow disruptions at a microsystems level. Architectural diagrams aimed at monitoring movement and interactions of OR personnel have been developed to help diagnose and address potential system design issues and to facilitate workflow within the operating unit. In order to analyze working patterns and flow within the OR, Ahmad et al. categorized the OR into eight different zones :

1.
Console zone
2.
CN zone
3.
Anesthesiology zone
4.
Sterile zone
5.
Supply zone 1
6.
Supply zone 2
7.
Transit zone 1
8.
Transit zone 2

Floor plans of different operating rooms with assigned zones {Bayramzadeh:2018hv}.

Circulatory nurse (CN) movement analysis during surgical procedures in different OR settings helped identify the need for adjacency between these specific zones. The CNs workstation serves as the central hub for CN activities. Due to the frequent need to provide additional equipment, direct proximity between the CNs workstation and the supply zone where key supplies are located is recommended. Indirect adjacency between the CNs workstation and the areas surrounding the surgical table is also suggested. This allows for a timely response while maintaining a safe distance from the sterile zone, thus avoiding contaminating the area. Unsuitable adjacencies need to be avoided to prevent the number of zones through which a CN travels. During video analysis by human factors engineers, transitional zones, those areas where two zones interface, were identified as high-risk zones for flow disruptions as they need to accommodate both equipment and personnel travel. These findings provide scientific evidence to support certain principles :

1.
The importance principle: components and equipment that are vital to the achievement of a procedure or task should be placed in convenient locations
2.
The frequency of use principle: components and equipment that are frequently used during the completion of a procedure or task should be located in close proximity and be easily accessible
3.
The function principle: components, equipment, or information/displays that serve the same function or are commonly used together to make decisions or complete a task should be placed in similar locations or close to one another
4.
The sequence of use principle: during completion of a procedure or task, certain tools and technology may be consistently used in a set sequence or order and should therefore be arranged in a manner to facilitate this process

It is important to note that the location of various equipment and other OR components may interfere with communication between nurses, anesthesia providers, and surgeons. Therefore, research (Realizing Improved Patient Care Through Human-Centered Design in the Operating Room RIPCHD.OR, AHRQ HS24380) is ongoing evaluating the optimal architectural layout based on human and equipment interactions in the OR.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here