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PREPARATION OF THE
OPERATING ROOM
Rene Lafrenire, M.D., C.M., F.A.C.S., Ramon Berguer, M.D., F.A.C.S., Patricia C. Seifert, R.N., Michael Belkin, M.D.,
F.A.C.S., Stuart Roth, M.D., Ph.D., Karen S.Williams, M.D., Eric J. De Maria, M.D., F.A.C.S., and Lena M. Napolitano,
M.D., F.A.C.S., for the American College of Surgeons Committee on Perioperative Care
Todays operating room is a complex environment wherein a variety of health care providers are engaged in the sacred ritual of
surgery, controlling and modifying natures complicated orchestra
of disease entities. In what follows, we discuss certain key aspects
of the OR environmentdesign, safety, efficiency, patient factors,
and the multidisciplinary teamwith the aim of improving surgeons understanding and comprehension of this complex world.
In particular, we focus on emerging technologies and the special
OR requirements of the burgeoning fields of endovascular surgery
and minimally invasive surgery.
General Principles of OR Design and Construction
PHYSICAL LAYOUT
The basic physical design and layout of the OR have not changed
substantially over the past century. In the past few years, however,
major changes have occurred in response to continuing technological developments in the areas of minimally invasive surgery, intraoperative imaging, invasive nonsurgical procedures (e.g., endoscopic,
endovascular, and image-guided procedures), patient monitoring,
and telemedicine.
The exact specifications for new construction and major remodeling of ORs in the United States depend, first and foremost, on state
and local regulations, which often incorporate standards published
by the Department of Health and Human Services.1 The American
Institute of Architects publishes a comprehensive set of guidelines for
health care facility design that includes a detailed discussion of OR
design.2 The design of new ORs must also take into account recommendations generated by specialty associations and regulatory agencies.3-6 Finally, there are numerous articles and books that can be
consulted regarding various aspects of OR design.7-11
The architectural design process for modern ORs should include knowledgeable and committed representatives from hospital clinical services, support services, and administration. Important design considerations include the mix of inpatient and outpatient operations, patient flow into and out of the OR area, the
transportation of supplies and waste materials to and from the
OR, and flexibility to allow the incorporation of new technologies.
This planning phase benefits greatly from the use of architectural
drawings, flow diagrams, computer simulations, and physical
mockups of the OR environment.
For an operation to be successful, multiple complex tasks must
be carried out, both serially and in parallel, while care is exercised
to ensure the safety of both the patient and OR personnel.To this
end, it is vital that the OR be designed so as to permit patients, OR
personnel, and equipment to move and be moved as necessary
without being unduly hindered by overcrowding or by obstruction
from cables, wires, tubes, or ceiling-mounted devices. Before and
The ambient temperature of the OR often represents a compromise between the needs of the patient and those of the staff;
the temperature desired by staff itself is a compromise between
the needs of personnel who are dressed in surgical gowns and
those who are not. In Europe and North America, OR temperatures range from 18 to 26 C (64.4 to 78.8 F). A higher temperature is necessary during operations on infants and burn
Work-related musculoskeletal injuries are a major cause of decreased productivity and increased litigation costs in the United
States.23 In the OR, occupational injuries can be caused by excessive
lifting, improper posture, collision with devices, electrical or thermal
injury, puncture by sharp instruments, or exposure to bodily tissues
and fluids.Temporary musculoskeletal injuries resulting from poor
posture (particularly static posture) or excessive straining are less
commonly acknowledged by members of the surgical team but occur relatively frequently during some operations.
To reduce injuries from awkward posture and excessive straining, OR devices should be positioned in an ergonomically desirable manner, so that unnecessary bending, reaching, lifting, and
twisting are minimized. Visual displays and monitors should be
placed where the surgical team can view them comfortably.
Devices that require adjustment during operations should be readily accessible. Placement of cables and tubes across the OR workspace should be avoided if possible.The patient and the operating
table should be positioned so as to facilitate the surgeons work
while maintaining patient safety. Lifting injuries can be prevented
by using proper transfer technique and obtaining adequate assistance when moving patients in the OR.
Equipment
The electrosurgical device is a 500 W radio-frequency generator that is used to cut and coagulate tissue. Although it is both
Table 1
For support
of patient
For support
of surgeon
For support
of OR team
The field of vascular surgery has rapidly expanded over the past
decade to encompass a wide variety of both established and innovative endovascular procedures that are new to the OR environment. Such procedures include complex multilevel diagnostic arteriography, balloon angioplasty (with and without
stenting), and endoluminal grafting of aortic aneurysms. Many
of these procedures can be performed in the radiologic intervention suite as well as in the cardiac catheterization laboratory.
However, the sterile environment, the option of performing combined open surgical and endovascular procedures, and the opportunity to provide one-stop diagnostic and therapeutic care
make the OR the favored location for efficient and safe management. Although most OR personnel are familiar with fluoroscopic procedures as well as simple diagnostic arteriography, the
development of a comprehensive and successful endovascular
program in the OR requires significant personnel training,
commitment of resources, and preparation. In what follows, we
review certain basic considerations in the evolution of such a
program, focusing primarily on space and equipment. Technical details of endovascular procedures are addressed in
more detail elsewhere [see 6:8 Fundamentals of Endovascular
Surgery].
RADIATION SAFETY
Table 2 ICRP-Recommended
Radiation Dose Limits43
Dose Limit
Occupational
Effective dose
Annual equivalent dose in
Lens of the eye
Skin
Hands and feet
Public
1 mSv/yr
150 mSv
500 mSv
500 mSv
15 mSv
50 mSv
mSvmillisievert
Units of Exposure
Radiation exposure is expressed in several ways. One of the
most commonly used terms is the rad (radiation absorbed dose),
defined as the amount of energy absorbed by tissue (100 erg/g =
1 rad). In the Systme International, the gray (Gy) is used in place
of the rad (1 Gy = 100 rad).The newest of the units in current use,
the millisievert (mSv), was introduced as a measure of the effective absorbed dose to the entire body (accounting for different sensitivities of exposed tissues).The amount of radiation generated by
the x-ray tube is determined by the energy generated by the beam,
which in turn is determined both by the number of x-ray photons
generated (measured in milliamperes [mA]) and by the power or
penetration of the beam (measured in kilovolts [kV]). Most modern fluoroscopes automatically balance mA levels against kV levels on the basis of the contrast of the image so as to optimize image
quality and minimize x-ray exposure.
Exposure of human beings to radiation is broadly categorized as
either public (i.e., environmental exposure of the general public)
or occupational. The International Commission on Radiological
Protection (ICRP) has established recommended yearly limits of
radiation exposure for these two categories [see Table 2].43 A 2001
study determined that with appropriate protection, radiation
exposure for busy endovascular surgeons fell between 5% and 8%
of ICRP limits, whereas exposure for other OR personnel fell
between 2% and 4%.44 Average radiation exposure for patients
undergoing endovascular aneurysm repair was 360 mSv/case
(range, 120 to 860).44
Basic Safety Rules
A few simple rules and procedures can help ensure a safe environment for patients and OR staff. The simplest rule is to minimize the use of fluoroscopy. Inexperienced operators are notorious
for excessive reliance on fluoroscopy. Such overutilization results
both from needing more time to perform endovascular maneuvers
than a more experienced surgeon would need and, more important, from performing excessive and unnecessary (and frequently
unintentional) imaging between maneuvers.The use of pulsed fluoroscopy and effective collimation of the images will also minimize
the dose of radiation administered. Minimal use of high-definition
fluoroscopy and unnecessary cine runs (both of which boost radiation output) are desirable. Most important, surgeons and OR
staff should maximize their working distance from radiation
sources. Radiation scatter drops off rapidly with increasing distance from the fluoroscope.
Safety Equipment and Monitoring
All OR personnel should wear protective lead aprons (0.25 to
Table 3
EQUIPMENT
Imaging Equipment
There are two fundamental physical designs for OR imaging
equipment. The first is the fixed ceiling-mounted system that is
also employed in catheterization laboratories and dedicated radiologic interventional suites. The second is a system using portable
C-arms with dedicated vascular software packages designed for
optimal endovascular imaging. Each of these systems has advantages and disadvantages.
Notable benefits of the fixed ceiling-mounted system include
higher power output and smaller focal spot size, resulting in the highest-quality images. Larger image intensifiers (up to 16 in.) make possible larger visual fields for diagnostic arteriograms; thus, fewer runs
need be made, and injection of dye and exposure to radiation are reduced accordingly.The variable distance between the x-ray tube and
the image intensifier allows the intensifier to be placed close to the
patient if desired, thereby improving image quality and decreasing
radiation scatter. Fixed systems are accompanied by floating angiography tables, which allow the surgeon to move the patient easily beneath the fixed image intensifier. It is generally accepted that such
systems afford the surgeon the most control and permit the most effortless and efficient imaging of patients.
Unfortunately, fixed ceiling-mounted systems are quite expensive (typically $1 million to $1.5 million), and major structural
renovations are often required for installation in a typical OR.
Perhaps more important for most ORs, however, is that these systems are not particularly flexible. The floating angiography tables
and the immobility of the image intensifiers render the rooms
unsuitable for most conventional open surgical procedures.
Consequently, fixed imaging systems are generally restricted to
high-volume centers where utilization rates justify the construction of dedicated endovascular ORs.
As endovascular procedures in the OR have become increasingly common, the imaging capability and versatility of portable
Diagnostic
arteriography
Balloon stent
angioplasty
Endovascular
aneurysm
repair
PHYSICAL LAYOUT
Aortic Extender
Contralateral Leg
Trunk/Ipsilateral Leg
Iliac Extender
Figure 1
stocked for everyday use, with the remainder ordered on a case-bycase basis. The expense of establishing the necessary inventory of
equipment can be substantial and can place a considerable burden
on smaller hospitals that are already spending sizable amounts on
stocking similar devices for their catheterization laboratories and
interventional suites. Fortunately, many companies are willing to
supply equipment on a consignment basis, allowing hospitals to
pay for devices as they are used.
Aortic Stent Grafts
Endovascular repair of an abdominal aortic aneurysm (EVAR)
is the most common and important endovascular procedure performed in the OR [see 6:11 Repair of Infrarenal Abdominal Aortic
Aneurysms]. As of spring 2003, three EVAR devices had been
approved by the FDA for commercial use, with numerous others
at various stages of the FDA approval process. All EVAR grafts are
expensive (> $10,000). Although busy hospitals may maintain an
inventory of devices, most grafts are ordered on a case-by-base
basis. The favored devices are configured as bifurcated aortoiliac
grafts. Most such grafts are modular in design, comprising two
main pieces [see Figure 1], though one unibody device has been
approved. Nonbifurcated grafts connecting the aorta to a single
iliac artery are available for special circumstances. Grafts are constructed of either polyester or polytetrafluoroethelyne (PTFE)
and have varying amounts of stent support. Proximal fixation is
accomplished in different ways, ranging from friction fit to the use
of hooks and barbs. Various extension components for both ends
of the graft are available; in many cases, these components are
necessary to complete the repair.
Endovascular therapy is a rapidly evolving field within the discipline of vascular surgery. Many operations traditionally performed as open surgical procedures are increasingly being sup-
With the advent of laparoscopy, it has become necessary to reevaluate traditional OR concepts with the aim of determining how best
to design a surgical environment suitable for the demanding requirements of advanced minimally invasive surgical procedures.
As noted (see above), until the early 1990s, ORs were constructed
in much the same way as they had been for nearly 100 years.The effect of the explosion in minimally invasive surgical procedures that
occurred in that decade, along with the demonstration that patients
benefited from significantly reduced recovery times, was to force OR
personnel to move rapidly into a new age of technology, with little or
no preparation. During the early days of laparoscopic surgery, surgeons noted significant increases in turnover time and procedural
down time.45 Adding to the problem was that the OR environment
was becoming increasingly cluttered as a consequence of the addition of endoscopic video towers and other equipment.This equipment often proved to be complicated to use and expensive to repair.
The increasing expenditure of money and time, coupled with an operating environment that increasingly promoted confusion rather
than patient care, constituted a clear signal that the OR, as designed
a century before, had been stretched beyond its capabilities and
needed to be redesigned.
A key component of OR redesign for laparoscopic surgery is the
placement of patient contact equipment on easily movable booms
that are suspended from the ceiling.This arrangement makes rooms
easier to clean and thus speeds turnover. All patient contact equipment and monitors are placed on these booms, and all other equipment is moved to the periphery of the surgical suite, usually in a
nurses command and control center.Thus, control of all equipment
is at the fingertips of the circulating nurse, and the disruption and inconvenience of manipulating equipment on carts is avoided.
Rearranging monitors is much simpler with the easily movable
booms than with carts, and there are no wires to trip OR personnel, because the wiring is done through the boom structure.
Furthermore, because the wiring moves with the equipment, there
is less risk that settings will be accidentally changed or wires
unpluggedand thus less wear and tear on equipment and staff.
The booms are easily moved to the periphery of the room, allowing the room to be used for multispecialty procedures, including
nonminimally invasive procedures [see Figure 2].
LAPAROSCOPIC SURGICAL TEAM
The issue of time efficiency in the OR is at the heart of 21st-century surgical practice. Prolonged operating time, excessive setup
time, and slow turnover can all affect productivity adversely. As
managed care continues to evolve, less productive health care
providers will be left behind. The right equipment and the right
room design provide the basic foundation for a more productive
OR. Without the right team, however, time efficiencies cannot be
optimized.To achieve quick turnover time and efficient procedural flow in the laparoscopic OR, it is critical to inculcate a team orientation in all OR personnel.46
It is clear that a team of circulating nurses and scrub techs specially designated for minimally invasive surgical procedures can
accomplish their tasks more quickly and efficiently than a random
group of circulating nurses and scrub techs could. The time savings can be channeled into a larger volume of procedures and a
more relaxed, patient caredriven OR environment.
Training seminars to improve the OR staffs familiarity with
and performance of laparoscopic procedures should be given.
Sessions in which surgeons present the technical issues involved in
advanced laparoscopic procedures, including room setup, choice
of equipment, and procedural steps, are beneficial. Video-tower
setup and troubleshooting can be taught in small group sessions,
with an emphasis on solving common technical problems by a
process analogous to working through a differential diagnosis.
EQUIPMENT
sible to produce cameras that are smaller and less expensive than
three-chip cameras; however, resolution and sensitivity are both
compromised.
The trend in laparoscopic surgery has been toward smaller
scope diameters. In particular, there has been a large migration
from 10 mm to 5 mm rigid scopes. As a result, it is essential to
choose a camera that can perform under the reduced lighting conditions imposed by the use of 5 mm devices.The nature and intensity of the light source must be factored in as well.When a laparoscopic procedure is being performed through 5 mm ports, it is
often preferable to use a xenon light source so as to maximize light
throughput and optimize resolution.
Surgeons Control of Equipment:Touch Panels,Voice Activation,
and Robotics
There are some inherent shortcomings in the way OR equipment has traditionally been accessed, and those shortcomings have
been exacerbated by the advent of minimally invasive procedures.
Because most of the equipment needed for minimally invasive
surgery resides outside the sterile field, the point person for critical
controls became the circulating nurse. Often, the circulating nurse
would be out of the room at the precise moment when an adjustment (e.g., in the level of the insufflators CO2) had to be made.
Surgeons grew frustrated at the subsequent delays and at their
inability to take their own steps to change things. Additionally, nurses grew weary of such responsibilities; these constant interactions
with the video tower pulled them away from patient-related tasks
and from necessary clerical and operational work. The answer was
to improve surgeons access to these critical devices via methods
such as touchscreen control and, more recently, voice activation.
Development of voice activation began in the late 1960s. The
goal was a simple, safe, and universally acceptable voice recognition system that flawlessly carried out the verbal requests of the
user. However, attempts to construct a system capable of accurately recognizing a wide array of speech patterns faced formidable technological hurdles that only now are beginning to be overcome. Although voice recognition is not yet a mature technology,
it is clearly here to stay, and it has begun to permeate many facets
of everyday life.
Benefits to surgical
team
Benefits to hospital
Benefit to patient
given the known inherent problems with surgeons voluntary selfreporting of infections occurring in the ambulatory surgical setting.47 Each infection is estimated to increase total hospital stay by
an average of 7 days and add more than $3,000 in charges.
SSIs have been divided by the CDC into three broad categories:
superficial incisional SSI, deep incisional SSI, and organ/space SSI
[see Table 5 and 1:2 Prevention of Postoperative Infection].48 Factors
that contribute to the development of SSI include (1) those arising
from the patients health status, (2) those related to the physical
environment where surgical care is provided, and (3) those resulting from clinical interventions that increase the patients inherent
risk. Careful patient selection and preparation, including judicious use of antibiotic prophylaxis, can decrease the overall risk of
infection, especially after clean-contaminated and contaminated
operations.
HAND HYGIENE
Table 5
1. Purulent drainage from the deep incision but not from the organ/space
component of the surgical site
2. A deep incision spontaneously dehisces or is deliberately opened by
a surgeon when the patient has at least one of the following signs or
symptoms: fever (> 38 C [100.4 F]), localized pain, or tenderness, unless site is culture negative
3. An abscess or other evidence of infection involving the deep incision is
found on direct examination, during reoperation, or by histopathologic
or radiologic examination
4. Diagnosis of a deep incisional SSI by a surgeon or attending physician
Notes:
1. Report infection that involves both superficial and deep incision sites
as deep incisional SSI
2. Report an organ/space SSI that drains through the incision as a deep
incisional SSI
Organ/space SSI
Infection occurs within 30 days after the operation if no implant* is left in
place or within 1 yr if implant is in place and the infection appears to be
related to the operation, and infection involves any part of the anatomy
(e.g., organs or spaces), other than the incision, which was opened or
manipulated during an operation, and at least one of the following:
1. Purulent drainage from a drain that is placed through a stab wound
into the organ/space
2. Organisms isolated from an aseptically obtained culture of fluid or
tissue in the organ/space
3. An abscess or other evidence of infection involving the organ/space
that is found on direct examination, during reoperation, or by
histopathologic or radiologic examination
4. Diagnosis of an organ/space SSI by a surgeon or attending physician
*National Nosocomial Infection Surveillance definition: a nonhuman-derived implantable foreign body (e.g., prosthetic heart valve, nonhuman vascular graft, mechanical heart, or
hip prosthesis) that is permanantly placed in a patient during surgery.
If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin or soft tissue infection, depending on its depth.
ments is the implementation of the CDCs universal precautions,52 designed to prevent transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens.
These precautions involve the use of protective barriers (e.g.,
gloves, gowns, aprons, masks, and protective eyewear) to reduce
the risk that the health care workers skin or mucous membranes
will be exposed to potentially infectious materials. Performance
standards for protective barriers are the responsibility of the FDAs
Center for Devices and Radiological Health. These standards
define the performance properties that these products must exhibit, such as minimum strength, barrier protection, and fluid resistance.The current CDC recommendation is to use surgical gowns
and drapes that resist liquid penetration and remain effective barriers when wet.
Compliance with universal precautions and barrier protection is
notably difficult to achieve. A 2001 study, however, found that educational interventions aimed at OR personnel improved compliance significantly, particularly with regard to the use of protective
eyewear and double-gloving. Furthermore, such interventions
were associated with a reduced incidence of blood and body fluid
exposure.53
INFECTION SURVEILLANCE PROGRAMS
SSIs completely, but by sharing information and influencing subsequent behavior, it is certainly possible to reduce their incidence.
A 2002 study documented successful institution of a surveillance program after a period of high infection rates in an orthopedic surgical department.54 This program contributed to a significant reduction in SSI rates after elective hip and knee replacement
procedures and was successful in creating awareness of infection
control practices among hospital staff members.
ANTIMICROBIAL PROPHYLAXIS
OR design can be helpful in this regard. In a 2003 study, significant improvement of intraoperative antibiotic prophylaxis in prolonged (> 4 hours) cardiac operations was achieved by employing
an automated intraoperative alert system in the OR, with alarms
both audible and visible on the OR computer console at 225 minutes after administration of preoperative antibiotics.59 Intraoperative redosing of antibiotics was significantly more frequent
in the reminder group (68%) than in the control group (40%;
P < 0.0001).The use of an automatic reminder system in the OR
improved compliance with guidelines on perioperative antibiotic
prophylaxis.
NONPHARMACOLOGIC PREVENTIVE MEASURES
19861989
19901996
(N=16,727)
(N=17,671)
Staphylococcus aureus
17
20
Coagulase-negative staphylococci
12
14
Enterococcus species
13
12
Escherichia coli
10
Pseudomonas aeruginosa
Enterobacter species
Proteus mirabilis
Klebsiella pneumoniae
Candida albicans
Bacteroides fragilis
Table 7
OR Cleaning Schedules
dal agent and wet-vacuumed before the first case of the day and
between cases; in the experimental rooms, cleaning consisted only
of wiping up grossly visible contamination after clean and cleancontaminated cases. Both rooms had complete floor cleanup after
contaminated or dirty and infected cases. The investigators found
that bacterial colony counts obtained directly from the floors were
lower in the control rooms but that counts obtained from other
horizontal surfaces did not differ between the two OR groups. In
addition, wound infection rates were the same in the control
rooms and the experimental rooms and were comparable with
rates reported in other series. Another study found that floor disinfectants decreased bacterial concentration on the floor for only
2 hours; colony counts then returned to pretreatment levels as personnel walked on the floor.70 These investigators recommended
discontinuing routine floor disinfection.
Even when an OR floor is contaminated, the rate of redispersal
of bacteria into the air is low, and the clearance rate is high. It is
unlikely, therefore, that bacteria from the floor contribute to SSI.
Consequently, routine disinfection of the OR floor between clean
or clean-contaminated cases appears unnecessary.
According to CDC guidelines for prevention of SSI, when visible soiling of surfaces or equipment occurs during an operation,
an Environmental Protection Agency (EPA)approved hospital
disinfectant should be used to decontaminate the affected areas
before the next operation.71 This statement is in keeping with the
OSHA requirement that all equipment and environmental surfaces be cleaned and decontaminated after contact with blood or
other potentially infectious materials. Disinfection after a contaminated or dirty case and after the last case of the day is probably a
reasonable practice, though it is not supported by directly pertinent data.Wet-vacuuming of the floor with an EPA-approved hospital disinfectant should be performed routinely after the last operation of the day or night.
DIRTY CASES
In this era of capitated reimbursement and managed care, containment of health care costs is a prime concern; consequently,
OR efficiency has become a higher priority for many institutions.77
No OR environment can even function, let alone improve its efficiency, without data. Data control every facet of the activities within the OR environment. For evaluating procedural time, OR utilization and efficiency, OR scheduling, infection rates, injury prevention, and other key measures of organizational function, it is
essential to have current, high-quality data.
To obtain good data, it is necessary first to determine what
information is required. For example, assessment of OR utilization
and efficiency depends on how utilization is measured. Before an
OR can meaningfully be measured against a target figure, it is necessary to know exactly how the organization calculates utilization
and how the parameters are defined.There is no accepted national standard. The future of the organizationnot to mention the
jobs of the people who work theremay depend on how well it
understands and controls OR utilization.
It is generally agreed that 80% to 85% is the maximum utilization level that an OR can be expected to reach. At higher utilization levels, the OR loses flexibility, and the hospital should consider adding capacity. It is important that utilization of all OR
resources by the various sectors of the institution be reasonable
and balanced, because higher OR utilization can be achieved only
when this is the case. To improve the use of OR time, it is important (1) to limit the number of ORs available to the number
required to achieve good utilization, (2) to have nurses rather than
attending surgeons control access to the surgical schedule, (3) to
The necessary data must be not only available but also accessible in a rapid and convenient manner. Total automation of
OR data management is critical for ascertaining patterns, managing productivity and resources, and providing solid informational bases for future decisions. Only through automation
tools can relevant, timely, and accurate statistical data be generated to facilitate problem solving, trend spotting, forecasting,
and revisioning.81
A long-standing question in OR utilization was how many historical data points were necessary or ideal to make appropriate decisions regarding OR staffing via statistical methods. In a
2002 study, statistical analysis of 30 workdays of data yielded
staffing solutions that had, on average, 30% lower staffing costs
and 27% higher staffing productivity than the existing staffing
plans.82 The productivity achieved in this way was 80%, and this
figure was not significantly improved by increasing the number
of workdays of data beyond 180. These findings suggest that in
most OR environments, statistical methods of data acquisition
and analysis can identify cost-lowering and productivity-enhancing staffing solutions by using 30 days of OR and anesthesia
data.
OR SCHEDULING
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Acknowledgment