Surgical Suite Design Guide

2010 2011 Operating Room Manual
CHAPTER 1
THE DESIGN PROCESS
Lead Author: Cary Sweat; Architect

Richmond, VA
The Mission
At the core of any construction project are the issues and needs that the new facility is
intended to address. This is often simplified to a statement such as an operating room (OR)
suite capable of supporting a given number of cases, but the most thoughtful and effective
facilities come from much more complex considerations. It is appropriate to think of a building
as another tool of the health care professionals whom it serves. At its best, their facility can do
much more than provide a roof under which to work. A great medical facility enables its staff,
makes them more capable, and makes their work more effective. So, the most meaningful goals
are essentially formalized thoughts of what is missing, broken, or inadequate in the status quo.
The facility itself is to be a built response to what is limiting our medical professionals in their
daily work, what new capabilities we can provide, and, certainly, how we can better address the
health of our communities.
Sometimes the issues to be addressed have a clear answer that simply needs to be built, but it
is also perfectly valid to raise issues that have no foregone conclusion and ask that they be
considered as part of the design process. In either case, the first step in responding to those
needs is naming them, defining them, making them less amorphous and more tangible.
Furthermore, the team members selected to fulfill the projectthe architects, engineers,
interior designers, consultants, and construction contractorshave devoted their careers to
understanding the myriad aspects of design and construction. They are instrumental pieces of
the puzzle as translators, using their respective capabilities to turn the words of the owner into
a built, real solution. And while they can propose possibilities, it is ultimately the owner who
must determine the priorities. While many of the design and construction professionals have
specialized expertise in medical facilities and larger trends, the health care providers
themselves will have a far more intimate understanding of their own working patterns and
methods. So, it is critical that each area of medical specialization be represented and involved
throughout all phases of a project. Furthermore, the owner can be empowered in the process
by understanding what information is most important as the project proceeds.

Design Issues
The following are some of the more common issues related to OR design. They can serve as a
useful way for an owner to prioritize his/her own needs and gauge the success of built projects
(both the owners own and case studies used in preliminary research). As a general statement,
there is a famous axiom in the construction world: Cost, quality, time. Of these, an owner may
prioritize any two, but never all three; the third will inevitably suffer for the sake of the others.
That is not to say that the owner will have to accept one of these items being beyond any
control; it is a three-way balancing act. While it is completely feasible to keep all three qualities
in check, the owner should be aware that the degree to which one or two become
extraordinarily important will have evident repercussions elsewhere. Beyond this
acknowledgment, some of the more specific issues are aesthetics, design qualities, space
assignment, microactivity assessment, flow, flexibility, and support.
Aesthetics
Aesthetics are the qualities of a project in which the value is intended to be psychological or
emotional rather than directly functional (at least in any directly measurable way). Aesthetics
are an admittedly tricky issue in health care work, being heavily subjective, and the ephemeral
qualities of a place are often difficult to discuss in a way that can be shared and considered with
the same clarity as physical fact. It is simple enough to describe the material reality of a place
its dimensions, colors, noisiness, and temperaturebut language fails when trying to describe
how it feels. We are forced to speak in metaphors that are neither quantifiable nor reliable,
often sounding more like a snake oil sales pitch (is there any definitive way to confirm that a
given lobby is, in fact, gracious, peaceful, or inspiring?). Also, when considered strictly in the
context of the core procedures being performed in an OR, aesthetic considerations can,
understandably, be relegated to an unnecessary luxury (and a correspondingly difficult cost to
itemize on a patients bill).
Aesthetic Design
Because of the issues mentioned above, aesthetic design is often limited to one of two
functions: 1) decoration (e.g., a pattern in floor tile or an accent color for vinyl corner guards);
or 2) marketing (e.g., the public face of a business, a built icon, etc.). But if approached with
seriousness rather than frivolity, the results of aesthetics can be very real, meaningful, and even
pragmatic (albeit difficult to measure). Increasingly, facilities are putting value in design
qualities associated with emotional welfare, pursuing enriching environments for their patients
and staff as part of an holistic approach to health care (with due care not to interfere with the
professionals practice, of course). Consideration may be given to careful daylighting and
connections to life outside the walls of the OR, often in lieu of luxury-priced interior materials.
The degree to which an owner values these qualities has become an important factor in the
selection of the design consultants and choosing where to spend the projects finances.

Space Assignment
There must be a proper assignment of spaces to support the mission of the facility. Effective
space assignments must be predicated on a careful evaluation of the procedures to be
performed, the projected volume of cases, and the equipment and staffing levels required. For
preliminary planning, rules of thumb such as 1000 cases per OR per year or two-to-one
recovery beds per OR may be used, but these should be tested against actual turnover rates
and patient recovery times. Statistical databases should be used for projections if possible, but,
more importantly, staff experienced in the specific operation proposed should be consulted.
Microactivity Assessment
The square footage, proportions, and ambient atmosphere of each space must be
commensurate with the task to be accomplished in that space. This involves an analysis of the
microactivity of each space and encompasses equipment; work space requirements; zoning;
ergonomics; anthropometry staffing levels; patient and visitor volume; communications; life
safety systems; occupational safety systems; heating, ventilating, and air conditioning systems;
lighting; infection control; supplies; and maintenance.
Flow
There must be good flow. This is the vascular system of the facility. The importance of good
flow cannot be overemphasized, and planning involves the acceptance, segregation, controlled
interface, distribution, and discharge of patients, medical staff, paramedical staff,
pharmaceuticals, equipment, sterile supplies, nonsterile supplies, normal refuse, biohazard
(red bag) refuse, instruments, facilities engineering, and biomedical engineering.
Flexibility
The spaces and systems must be flexible and capable of responding to change with minimal
disruption. Provisions must be made for modifications of the initial design resulting from finetuning, miscalculations, or medical practice evolution. Suggestions include:
Structural design to facilitate vertical or horizontal expansion
Life safety design to facilitate occupancy and licensure upgrades
Shell space within the facility for future internal expansions
Soft space within the facility (i.e., spaces that can be used readily by adjacent spaces as
the need arises)
Modular furnishings and partitions, as opposed to hard walls and millwork

Support
The design must maximize support at minimum staffing levels. With an emphasis on minimizing
full-time employees and maximizing productivity, more patient and facility coverage per staff
member will be needed. Centralizing functions and command points to the greatest extent
possible will be mutually beneficial to patients and staff. Design suggestions include nurse
station/bed station pods, shared preoperative/stage II recovery cubicles, adjacent centralized
nurse work and administration stations, and computerized information transfer for charts,
medical records, and supply tracking.
The Players
Once good design has been defined as it applies to the prospective project, consideration
should be given to the entities required to plan the project. In broad terms, these are the
owner, users, consultants, authorities having jurisdiction, and contractor.
Owner
Owner refers to the individual or collection of individuals for whom the project is being planned
and constructed. The owner is the visionary who provides land, time, money, the design
mission statement, and the method of project delivery. The owner may or may not be the user
of the facility. Typically, the following are also included in this category, although they may be
contracted to, rather than work in the direct employ of, the owner: attorneys, accountants,
lenders, insurance carriers, security forces, and facilities maintenance. The owners influence
and control over the planning and construction process is greatest at the projects inception
and progressively diminishes over time as more and more people become involved in the
process. Conversely, the owners vulnerability to cost is least at the projects inception and
greatest as construction nears completion.
Users
Users are those individuals and groups who will occupy the facility that is to fulfill the mission
statement formulated by the owner. They include executive management, administration,
medical personnel, pharmacy, infection control, medical records, admitting and discharge,
clinical engineering, biomedical engineering, and materials management. To fulfill the owners
mission statement, the users must be committed to the project design. A communications
system and incremental signoffs are crucial to progress and the users ultimate satisfaction. It is
important that realistic expectations consistent with the owners original mission statement,
schedule, and available resources be maintained within this group.

Consultants
Consultants are individuals or groups who are directly retained by the owner or subcontracted
to another consultant or contractor depending upon the project delivery method selected by
the owner. Areas of expertise in which they furnish services include marketing (e.g.,
demographics, statistics, and preferences), facility analysis (e.g., utilization, efficiencies,
resource assessment, and time/motion studies), predesign service (e.g., code compliance, code
analysis, and space programming), cost control (e.g., budget formulation and tracking),
regulatory assistance (e.g., Certificate of Need [CON] assistance, health department, zoning
department, and building department), planning (e.g., facilities master plan, traffic, and
environmental), surveying, architecture (e.g., building and landscape), interior design, graphic
design, engineering (e.g., geotechnical, civil, structural, fire protection, mechanical, electrical,
and plumbing), equipment planning (e.g., medical and food services), conveyances and material
handling (e.g., elevators, dumbwaiters, and track cart systems), telecommunications, data
systems, and audiovisual systems.
Consultants are responsible for analyzing information furnished by the owner and users and
transforming that information into useful documentation that is consistent with the owners
mission, appropriate design practices, and all applicable laws. It is important to recognize that
consultants are mechanics who are highly skilled in assembling the parts given to them by the
owner and users. In the absence of specific information, they tend to rely upon their best
judgment from previous projects, but those best judgments may not coincide with the owners
and users perception of good design. Hence, it is important to define good design as
previously discussed and track and comment on the consultants work at each increment of
planning development.
Consultants have a large amount of information to coordinate and, consequently, an enormous
impact upon the functional and financial success of the project. Therefore, it is essential that
they have substantive experience in the project types being proposed and demonstrate solid
reliability through good performance references from previous project owners. Retaining local
consultants will facilitate accessibility and reduce costs, but when local talent is not available
and it becomes necessary to obtain out-of-town consultants, it is advisable that they have
experience in the local code jurisdiction.
It is a good idea to tour as many projects as possible and solicit recommendations from the
widest possible spectrum: contractors, chief executive officers, administrators, users, and the
facilitys personnel. Recommendations should speak not only to the design competency of the
consultant but also to costs incurred as a result of errors and/or omissions. It is advisable to
tour the consultants office to ascertain personnel and equipment resources, understand
methods of project delivery and construction follow-through, and see examples of
communication capabilities. Many owners and users do not understand blueprints but are
reluctant to admit it. It is important that the communication skills of the consultant be
compatible with the owners level of design and construction expertise so that there is mutual
confidence in the appropriateness of the end product.
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Authorities Having Jurisdiction

There are many authorities having jurisdiction over any single project. The list that follows will
vary from state to state. For example purposes, the state of Florida is referenced here and
excludes agencies involved in raw land development, which, in itself, is a very time-consuming
process. Authorities having jurisdiction may include:
State CON program office (not required in all states)
State health department (operational licensure, plans, and construction review and
approval)
State insurance commissioner and/or fire marshal
State department of environmental regulation (water, air quality, extension of sewer
systems, incinerators, gas-fired boilers, asbestos, and ethylene oxide sterilizers)
Regional water management district office (protected waterways and wildlife)
Local planning and development department (zoning)
Public utilities (water, sewer, solid waste, and electrical)
Public works (traffic, storm water, and solid waste)
Local building department (local building code enforcement; local fire marshal; building
permits; structural; heating, ventilation, and air conditioning; plumbing; electrical;
handicap accessibility; energy consumption; and elevators)
The above entities have direct legal authority with regard to all project reviews and approvals.
Project circumstances will dictate compliance as well as, potentially, specific review and
approval by agencies such as:
Public lenders (federal, state, and local grant and bond and tax authorities)
Private lenders (endowments, trusts, and banks)
Insurance carriers (factory mutual)
US Department of Justice (Americans With Disabilities Act)
US Department of Labor (Occupational Safety and Health Administration)
US Environmental Protection Agency (asbestos, polychlorinated biphenyls, and
carcinogens)
Federal and/or state energy efficiency agencies
Federal building standards (Veterans Administration, US Department of Defense, US
General Services Administration, and US Department of Health and Human Services).
Organizations that have no legal mandate but whose standards must be met for voluntary
accreditation include Medicare/Medicaid, the Joint Commission on Accreditation of Healthcare
Organizations, and the Accreditation Association for Ambulatory Health Care, Inc. The planning
process will be greatly facilitated by meeting with all the various authorities having jurisdiction
at an early stage of development and keeping them in the communication loop throughout the
planning and construction process.

Contractor
The contractor, although referenced in the singular, is a conglomeration of many
subcontractors, tradespeople, and vendors. Frequently, in order to simplify contractual ties and
provide centralized management, a general contractor is retained; the owner singularly
contracts with the general contractor, who, in turn, executes and manages all other
subcontracts. This arrangement simplifies the owners task because the general contractor is
the single source of delivery and liability in connection with the construction of the project. The
general contractor is compensated for the assumption of overall management and liability by
adding overhead and profit fees onto each subcontract and the work performed by the general
contractor. Costs can be reduced in proportion to the degree the owner separately contacts,
manages, and assumes liability for individual tradespeople and vendors.
Selection of the delivery method is an important consideration in the planning stages because
some methods introduce the contractor into the planning process as it is developed, and each
method requires different methods of approach and documentation. The various project
delivery methods are detailed later in this article. The contractor, as transformer of drawings
and words into physical construction, has tremendous influence over the quality and cost of the
project. Like the consultants, it is essential that the contractor have substantive expertise in the
proposed project type, demonstrate solid reliability, and have experience in the local code
jurisdiction. A careful investigation into the contractors track record, including financial
history, bonding capability, and past litigation, is crucial.
The Process
The planning process is analogous to molding and then putting together a jigsaw puzzle, but
with a systematic approach. Starting with a mission statement, individual pieces with
amorphous edges are developed, each contributing a fractional element to the overall design.
Once the elements are defined, their proximity and continuity to each other is tested and the
edges are shaped, then a continuously interlocking picture is developed. With this as a mental
picture, the process is systemized as follows.
Strategic Planning
Strategic planning in its purest form is a written and committed goal statement in which the
owner identifies target markets, assesses the products and services needed to serve the
markets, compares the required resources to the available resources, and develops a step-bystep strategy to invest the additional resources over set increments of time. The strategic plan
should clearly itemize the objectives and remain consistent with the philosophy of the
institution it serves. This level of planning is generally executed by the founding or executive
management of the health care organization with the help of outside marketing, financial, and
facility analysis consultants as required to supplement the owners expertise.

Master Planning
Master planning assesses the land and facilities available to meet the strategic plan and, by
written and graphic means, projects the required land use and facility expansion over set
increments of time. The expansions should be ordered and located in a manner that will not
impede successive expansion yet will take advantage of and maximize the utilization of existing
infrastructure and resources. The steps taken in master planning generally are:
1. Evaluate the physical condition of the existing facility and its suitability for current and
future uses.
2. Analyze past utilization and volume from historic data.
3. Formulate future utilization and volume projections validated against the strategic plan.
4. Update the strategic plan, if necessary.
5. Identify major planning groups (e.g., surgery, radiology, laboratory, examination,
procedures, admitting, administration, etc.).
6. Develop a program for space, identifying the square footage requirements of each
planning group.
7. Determine phasing and land usage.
8. Develop graphic blocking plans that depict planning groups and phasing.
9. Evaluate infrastructure renovations and expansions.
Certificate of Need
Not every state has a CON law, and not every health care facility is subject to CON review. The
CON process is mandated by individual state legislatures. The intended goal is to maintain
reasonable parity between health care services provided in a region and the needs of that
regions population. The process is highly bureaucratic, at times unavoidably subjective, and
often subject to political pressures and challenges from both opponents and proponents.
Processing of CON applications varies, but a reasonable allowance would be 5 months.
Generally, the process consists of:
1. Letter of intent
2. Application:
a. Site plan
b. Small-scale schematic plan
c. Code compliance data
d. Space-to-workload ratios
e. Building program
f. Cost analysis (e.g., renovation costs, new construction costs, financial feasibility,
and source of funds)
g. Project schedule, including design, construction, and operations
3. Submission fee

A reasonable allowance for preparation could be a year to a year and a half. Typically,
consultants specializing in CON regulations are retained and receive support from various other
consultants, such as professional estimators, planners, programmers, and architects.
Building Programming
Building programming involves a written analysis of how each operation in a major planning
group functions and a description of the space associated with that function. Each functional
space is identified and described in detail as to the number of people, number of workstations,
equipment, environment, material stored and processed, functional goals, and adjacency
priorities. The floor area allotted to each space at this stage will be heavily based on
assumptions of sufficiency. Because it is very difficult to enlarge the areas needed for spaces as
the project proceeds, it is important to consider whether there is any reason to doubt that
these initial assumptions will suffice. Spaces in a department are added together to establish
the net department square footage. This is multiplied by a circulation and wall factor varying
from 1.20 to 1.65 to yield the gross department square footage. Ultimately, the sum of all
department areas is multiplied by a factor of 1.15 to 1.35 to include exterior walls and support
areas, such as mechanical services spaces, elevators, and building structure. The circulation and
wall factors are derived from historic design patterns. Under the most basic contract terms, the
owner will be responsible for the majority of the effort with assistance provided by the design
consultant (usually the architect), but it is often shifted more to the design consultant as an
additional service.
Project Budgeting and Scheduling

At the conclusion of building programming, a construction estimate is prepared. Generally, this
estimate is based on comparative costs for other facilities of a similar scope. By contract, the
designer is usually required to provide this as a basic service, but only with a relatively low
degree of accuracy. Therefore, professional estimators (who may be independent specialists,
employees of construction management firms, or general contractors) are commonly hired as a
worthwhile additional service.
The resulting total project budget should include land acquisition; building construction;
equipment (e.g., medical, nonmedical, fixed, and movable); data, voice, and video systems;
conveyance systems; testing; jurisdictional fees; furnishings; graphics; art; the owners services
(e.g., project management salaries, office expenses, and reimbursables); professional services
(e.g., estimating, surveying, geotechnical engineering, design consultants, etc.); and reasonable
contingency allowances for bidding, construction, and scope creep. In addition, a project
schedule, incorporating all stages of planning, design, jurisdictional reviews, and construction, is
prepared.

Project Delivery Strategy and Consultant Design Team Selection
The formulation of the delivery strategy and the selection of the design consultant must be in
concert with the budget and schedule. In fact, the budget and schedule should be considered as
tentative until consultant selection and the delivery strategy have been determined and
reviewed by the owners project management and the consultant leaders. The method of
project delivery will be influenced by the following:
The scale and complexity of the project
The capabilities and availability of the owners in-house design and project management
resources
The owners business plan
The degree of control the owner wishes to exercise over the management of the project
and the corresponding degree of risk the owner is willing to accept
The magnitude and breadth of input and options the owner wishes to consider
The jurisdictional review process
Government and/or finance-driven restraints
Methods of project delivery include conventional design/bid/build, fast-track design/bid/build,
and design/build.
Conventional design/bid/build. In the conventional method, the owner contracts with the
design consultants, the project is completed through contract documents, and bids are
solicited. Generally, the architect serves as the lead consultant, with many, if not all, of the
consultants hired as subcontractors. The responsibility for design coordination is solely
delegated, or single sourced, to the architect. Construction bids are submitted on a competitive
basis, with the award going to the lowest-priced or highest-valued bid allowed for in the
bidding documents. The owner contracts with the chosen general contractor, who in turn
subcontracts with the tradespeople required to complete the construction. This single sources
the construction, coordination, and liability to the general contractor. Professional cost
estimators perform cost checks to meet the budget at the conclusion of programming,
schematic design, design development, and document completion. This method of delivery is
advantageous because it maximizes the potential for the owners input and control in the
design process and allows adjustment of the project scope before committing to a construction
contract. Success of this method is highly dependent upon a complete and well-coordinated set
of contract documents.
If the owners in-house level of design and construction expertise is limited, consideration
should be given to the program management approach. In this permutation, the program
manager provides all development, management, and design services for the entire project.
Program management is offered by some architects but mostly construction firms. This method
relies upon the program manager becoming intimate with and being committed to the owners
philosophy and strategic goals. The owners confidence in the program managers
understanding of the owners objectives is crucial.
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If the owner wishes to become more directly involved in the individual trade contracts and has
in-house contract management resources, then consideration should be given to the
construction management approach. In this plan, the owner contracts with a construction
manager at the outset of the design process to act as an agent of the owner and make
recommendations in the owners best interest. The construction manager provides continuous
value and cost analysis of the design as it is developed. The construction manager then solicits
bids from individual trade subcontractors and assists the owner in the analysis of bids,
schedules, and contracts. This method is advantageous for large projects requiring multiple-bid
packages for continuously phased construction such as may be encountered in existing facilities
requiring renovations and/or additions with minimal disruption to ongoing operations.
Fast-track design/bid/build. In the fast-track method, it is of prime importance to expedite the
construction completion. The owner contracts with a general contractor on a fixed-fee basis for
the general contractors services. The design and construction documents are prepared in
packages consistent with the construction sequence of the project, and the general contractor
bids the packages, which are then awarded through change order additions to the general
contractors contract with the owner.
A variation on this method of delivery is for the owner and general contractor to agree upon
accomplishing the project for the sum of the cost of the individual scope packages plus the
general contractors fee, with a guaranteed maximum price. This method relies upon the
owner, designer, and contractor acting in close concert to negotiate and keep the quality and
quantities included in the overall scope contained within the budget maximum.
Design/build. In the design/build method of delivery, the owner and general contractor agree
on a guaranteed price based on the description of the project scope set forth in an owners
request for proposal. All design consultants and construction trades are subcontracted to the
general contractor. The advantages of this method of delivery are that the contractor has direct
control over the design product and can maximize economics and scheduling to meet the
dictates of the owners request for proposal. The success of this method is highly contingent
upon the development of the owners request for proposal and the owners corresponding
ability to live with the quality and quantity of design elements included by the design builder
when those elements are not specifically addressed in the owners request for proposal.
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Schematic Design
Schematic design is the graphic transformation of the written building program into spatial
form. It should communicate how the designer intends to meet the owners needs at a
diagrammatic level, with realistic provisions for the building systems, equipment, structure, and
furniture that will be designed and selected at a later stage. Before proceeding into this phase,
it is essential that the building program and budget be revalidated through formal signoff by
the owner and users. If the program and budget are not acceptable, they should be reworked
before further design drawing proceeds. The detailed arrangement of equipment, furniture,
and cabinetry within each space is not usually developed at this stage, meaning that the areas
allotted to each function by the building program will be assumed to be sufficient. If the owner
sees any doubt in this regard, either by past experience or knowledge of changing space needs,
it may be preferable to confirm area requirements by additional detailed design for select
spaces. While such reworking will cause a delay, it may result in time, coordination, and cost
economies in the long run.
Schematic design is begun by studying the relative sizes and adjacencies of the functional
spaces to each other. Bubble diagrams allow arrangement of the spaces that are
interconnected by lines of varying line weight to depict the hierarchy of interconnectedness
and scale. As these interrelationships are validated, the forms of the bubbles are molded to
approximate the lines and aspect ratios of wall construction, structural column grids, and
functional space proportioning. The design multipliers for circulation and infrastructure support
previously applied in the building program are translated into space geometries and distributed
within the interconnected bubbles. The total is then transformed into block diagrams from
which hard line overlays showing the spaces, corridors, walls, and openings of the building floor
plan can be generated.
From this floor plan, interior and exterior elevation studies are generated for concept review
and acceptance. At the same time, the relationship of the project is evaluated against its
existing context through the development of a small-scale site plan. Finally, the quality of the
material and systems proposed for use are organized by narrative sections in an outline
specification book.
This schematic design package is validated against the building program and reviewed by the
project team for the owners edification and satisfaction. The schematic design, at this point, is
cost-estimated for comparison to the budget, still reserving all design, construction, and scope
contingencies. Again, the owners approval should be formalized by signoffs. Jurisdictional
review and signoffs are recommended and may be mandatory.
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Design Development
The design development fleshes out the schematic design through the creation of more
numerous and larger-scale floor plans, elevations, wall sections, system details, and expanded
specifications. By the end of this stage, the design team should be able to answer all questions
related to how the building will be built and function, with only specific details and product
selections remaining to be fulfilled. Layers of added information and coordination include:
Construction systems (e.g., foundations, superstructure, code classifications, load
classifications, vibration isolation, wind, seismic resistance, and special construction)
Civil systems (e.g., utility grid, infrastructure expansion, drainage, grading, excavation,
roadways, sidewalks, exterior lighting, and other site features)
Life safety systems (e.g., occupancy loads, exiting and egress, stairs,
compartmentalization, fire extinguishing, alarms and initiating devices, flame spread
and smoke ratings, wall construction types, and fire ratings)
Architectural systems (e.g., doors and hardware; windows; millwork; casework;
plumbing fixtures; fixed equipment; movable equipment; owner-provided equipment;
finishes; furnishings; ceiling materials and layout; special construction features,
particularly those requiring coordination by other consultants; acoustical treatment;
elevators; and conveyance systems)
Mechanical systems (e.g., heating, ventilating, and air conditioning systems; pressure
zones; fire and smoke dampers and detectors; ductwork; equipment; smoke control
systems; and operation sequences)
Electrical systems (e.g., fire and smoke detection, activation, and alarm systems;
electrical riser and diagrams; service voltages and conductor systems; equipment;
audiovisual equipment; data and telecommunications equipment; normal and
emergency power systems; and lighting)
Plumbing systems (e.g., life safety fire protection equipment, plumbing equipment,
risers and distribution, medial gas systems, and waste systems)
Special systems (e.g., food service, radiation protection, and owner-provided
equipment)
In many instances, a book is prepared with a section devoted to each room of the building. In
each section, a floor plan, ceiling plan, and all wall elevations are shown with all equipment,
cabinetry, furnishings, lighting, critical dimensions, etc. In addition, a checklist of features is
itemized along with special notes. Just as in schematic design, this package must be reviewed,
priced, approved, and given a formal signoff. Again, jurisdictional reviews are advisable and
may be mandatory.
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Contract Documents
The contract documents are the legal attachments to the contract for construction between the
owner and the constructor. They must fully define the scope of the work to be provided in
accordance with all applicable laws and commonly accepted engineering practices and are
composed of the drawings and specifications prepared by the design consultants. The drawings
are organized by design discipline; the specifications are organized by a 16-division industry
standard developed by the Construction Specifications Institute. These divisions are only for
reference convenience because the integrated sum of the drawings and specifications
represent the scope of the work. This is particularly important when the project delivery
method utilizes packages, by which cost and contract aggravation can become significant owing
to the increased potential for gaps in coordination responsibilities between packages.
By the commencement of the contract documents phase, all of the basic design and
component selection decisions should have been made. This phase represents an exponential
increase in the complexity of coordination, documentation, and production work hours from all
previous phases. A single sheet of drawings on average represents a minimum of 40 work
hours. A single change affects an average of 20 sheets of drawings and their corresponding
specifications. Changes in design during this stage can be expected to have a significant impact
on corresponding costs and schedules. This being said, however, it is significantly less costly to
make changes at this stage than to wait until construction.
It is important that the owner remain involved in the review of the contract documents,
although the emphasis will move away from the medical design team to the owners project
manager and facilities and technical staff. At the conclusion of the contract documents phase,
the owners technical department heads and each department to occupy the facility should
receive the documents, be given ample opportunity to review them, and then review all
comments or questions with the project management and consultant teams. Only with final
approval of the owner should the documents then be released for final bidding and
construction.
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Hints for Success
1. Become involved in the design process as early as possible, even as early as the
strategic-planning phase, in order to maximize your influence.
2. Put a project manager in place as early as possible, but absolutely no later than the
programming phase. It is imperative that a single source who has a detailed
understanding of the owners goals and is the full-time advocate is in place.
3. Interject the right types of thinkers at the right moments of development. Basically, use
your global thinkers when the process is global and your detail thinkers when the
process is in its detail phase.
4. Put your managers and staff who will run the proposed facility in place as early as
possible. People who will actually work in the facility will have the commitment that
comes from being given a charge and knowing that they will have to live with and in it.
People who do not actually have to work in the facility tend to interject their expertise
from a more political and detached perspective.
5. Share concepts with and get to know jurisdictional authorities as early as possible. They
are far more cooperative with teams that include them than those that regard them as
an impediment or necessary evil.
6. Investigate case studies. Chances are very likely that your projects needs have already
been considered by other facilities, with varying degrees of success. Learn from their
experience, and pass that knowledge to the design team by either your own input or
including them in the research itself.
Organize the unresolved issues as the design work proceeds from schematic to detail so that
they can all be addressed and incorporated when their time comes. Doing this, the owner and
users can gain confidence in the final success to come from the process.
Bibliography
American Institute of Architects Academy of Architecture for Health. Guidelines for
Construction and Equipment of Hospital and Health Care Facilities. Washington, DC: AIA Press;
2010.
Dickerman KN, ed. Florida Project Development Manual: A Guide to Planning, Design &
Construction of Healthcare Facilities in the State of Florida. Jacksonville, FL: Health Facility
Publishers Inc.; 1993.
15
CHAPTER 2
THE ANESTHESIOLOGISTS OVERVIEW OF THE OPERATING ROOM
Lead Author: Jan Ehrenwerth, MD; Professor of Anesthesiology; Yale University;
New Haven, CT
Checklist
1. A single anesthesiologist should be designated to consult with the architects throughout
the design and construction process.
2. The operating room (OR) should be designed to facilitate the flow of patients, family,
staff, and equipment.
3. The ORs must be large enough to permit the procedures that will occur therein.
4. The OR lighting design should consider the specific requirements of surgical procedures,
surgeons, nursing, and anesthesia personnel.
5. Adequate storage space for present and future equipment is crucial.
Security measures to control access to the operating suite and the sterile area should be
considered as part of the design process.
Introduction
Many health care facilities are currently in the process of building new ORs, remodeling old
ones, or converting existing space into general work areas (such as one-day surgicenters).
Anesthesiologists are frequently called upon to participate in the design and development of
the new ORs. This is important for both safety and practical reasons. Unfortunately, most
anesthesiologists have little or no experience in working with architects, interpreting blueprints,
or designing new ORs. It is, therefore, imperative that the anesthesiologist obtain as much
advice as possible before assisting in this process. By the time the anesthesiologist is asked to
participate in such a project, it is likely that many of the preliminary decisionssuch as the size
of the project, the site, the budget, and selection of the architectwill already have been
made. Nonetheless, it is extremely important that the anesthesiology department be prepared
to participate from the outset. To facilitate that process, the department should select one of
its members to represent it at the various meetings and grant to that individual decisionmaking authority.
Although several members of the anesthesiology department may be involved in various
aspects of the project, it is vitally important that one person be the spokesperson and decision
maker for the entire project. That person must be aware of what is happening in every
subcommittee and must be provided with the time away from clinical duties to attend the
numerous meetings.
16

The architects and administrators will be present at all meetings, and if a member of the
anesthesiology department is not present at each meeting, decisions will be made without the
departments input. Because many changes will take place during the design phase of the
project, it is necessary to carefully assess and understand the impact of the changes so that any
problems arising from them can be corrected at the next meeting. The anesthesia
representative should have a long-term commitment to the institution because the time from
the initial meeting until the completion of construction will be at least 2 and possibly as many
as 8 years.
Architects
If possible, the spokesperson for the anesthesiology department should meet with the hospital
administration prior to the selection of the architectural firm. The architect who is selected
should have experience and expertise in the design and development of health care facilities,
especially ORs. Because there are particular challenges unique to OR design, it should not be
assumed that architects who have previously built health care facilities are capable of designing
an OR. The OR is completely different from other hospital areas, and it must be designed with
particular regulations and requirements in mind. It is also crucial to review the architectural
firms prior work. For example, the anesthesiology department representative should speak
with and/or visit members of the anesthesiology department in facilities where the architect
has previously designed and built ORs.
The architectural firm that is selected should have expertise in all aspects of OR design. This
includes the initial planning (e.g., schematic and design development), drafting of the blueprints
and room layout (e.g., floor plans, electrical, heating, ventilating and air conditioning, and
plumbing coordination), and the development of the construction documents (especially
development of the specifications). The firm should be able to provide examples of previous
ORs it has designed and make recommendations about what has worked well in the past.
The architect must deal with an additional set of problems if the existing ORs that will be used
during construction are adjacent to the construction zone. The operational part of the OR must
be isolated from the construction area, and plans must be made for infection control, dust
containment, noise abatement, and establishment of negative pressure in the construction
zone.
17

Initial Planning
Once the scope of the project has been defined, the initial planning can begin. The size of a
project can vary from the remodeling of a few ORs to the building of new ORs, delivery rooms,
and ambulatory surgical centers. If there will be multiple new or remodeled areas, it is crucial
that the same architect be responsible for designing all of them. The importance of this cannot
be overstated. Dealing with two or three different architects means having to reinvent the
wheel with each one. This wastes time and leads to costly mistakes.
The members of the anesthesiology departments design team and the architects will have a
great deal of interaction. They must learn from each other, and they will have to set standards
and make compromises throughout the project.
The initial phase of the project will consist of having all of the users submit: (1) a list of their
needs; (2) the amount of space required for those needs; and (3) projections for future needs.
Each user should state how he/she will function in the space and what the anticipated flow
patterns will be within the space. Projections about future needs are difficult because needs
can dramatically change over time. The percentage of outpatients can change, equipment can
change, and even changes in managed care can impact future needs. For example, it would
have been difficult for anyone to have predicted the development of the surgical robot, which
occupies a very large amount of floor space. However, if an architect who previously designed
an OR had considered the possibility that future developments in technology might require the
use of significant amounts of floor space, the introduction of this type of technology would not
have been a problem. Indeed, changes in technology, or anything for that matter, only become
a problem when the design fails to account for future needs. This list is essentially a wish list;
rarely will all requests be fulfilled. One should, therefore, not underestimate his/her needs at
this stage.
After all lists are completed, an initial plan will be devised and the cost of the project estimated
(some projects will have the cost predetermined). The plan will then be scaled back so that it
comes within the projected budget and available space. Once the initial plans are drawn, it is
vital to determine exactly how much of what was initially requested remains in the plans. This
will be the best and probably the only opportunity to reinsert into the budget something that
was removed. The architects initial drawings may consist of several designs with different ideas
on how best to satisfy everyones needs and stay within the allotted space and budget. Space
for future expansion must also be included at this time. Key representatives from
anesthesiology, nursing, surgery, biomedical engineering, and administration must work with
architects to create a space that will best meet the needs of all groups and the proposed
budget. Compromises will be necessary.
18

Anesthesiologists must ensure that adequate space is allotted for the department to carry out
its functions. In particular, space must be allotted for an anesthesia workroom and storage (for
bulk supplies and spare equipment). At this time, there should be agreement as to the total
number of ORs and postanesthesia care unit (PACU) beds that will be developed. In addition,
space must be allotted for a preoperative holding area, locker rooms, call rooms, lounges,
offices for the nursing and anesthesia staff, storage areas, waiting rooms, a control desk, and,
possibly, a biomedical repair shop. At this stage, all desired space must be designated in the
plans. Failure to do so will result in severe space constraints when the final compromises are
made.
This is also an excellent time to discuss general design principles with the architects. An oftenoverlooked principle is the overall flow of patients, staff, and materials into and out of the OR.
A good example of efficient design is illustrated by a theater. There, action takes place on a
stage and is visible to the entire audience. This corresponds to areas that are utilized by
patients and their family members. Also, an enormous amount of activity takes place backstage
and is not visible to the audience. This corresponds to areas that are used primarily by staff that
patients and their families normally do not see. There should be a method to bring materials
into the OR and remove trash and soiled linen without these items coming in contact with the
public. Also, the physicians and staff should be able to enter and leave the OR without having to
encounter the families in the waiting area.
Security is also a major issue today. If the space is not going to be used on a 24-hour basis,
there must be a way to easily secure it when the schedule is finished. It is also essential to have
a method of controlling access to the ORs so that unauthorized personnel do not intentionally
or unintentionally wander into the sterile area. Cameras in the front desk area and waiting
room are an important part of any security plan. Similarly, hallway surveillance may be
indicated.
Finally, it is important to remember that most anesthesiologists are not familiar with the
construction process and will, therefore, require on-the-job training. One has to work with
tiny diagrams in which one-quarter of an inch represents a foot, and it is very hard to visualize
from a two-dimensional drawing exactly how the facility will look when completed. It is very
helpful if the architects can provide some kind of mockup of the space before the plans are
finalized.
19

Operating Room Size
A general-purpose OR must have a minimum of 400 square feet, and a special procedure room
(e.g., a heart room) must have at least 600 square feet. Although 400 square feet may seem like
a large room, in many instances it is inadequate for contemporary surgical and anesthetic
practice. Ideally, the minimum size room should be 600 square feet, with special procedure
rooms sized at 800 to 1000 square feet. There is more equipment in ORs now than ever before,
and the process is not slowing down. The result of more microscopes, x-ray machines, video
carts, surgical robots, etc., being introduced into the room is that the anesthesiologist is
crowded into a continuously decreasing amount of space. Be wary of the argument that a room
can be designed to be small because it is just for outpatients or pediatric patients. There is a
common misconception that pediatric patients need smaller ORs or that ambulatory
procedures require less equipment. The equipment used for arthroscopy can occupy more than
one-third of the available floor space. The fact that the room is intended to be used for only
one purpose at the time of the design phase does not reflect the fact that needs might change
or that the room will be used for many functions and surgical services over time. Obviously, the
larger the room, the easier it is to work in it (Figure 1).
20

Figure 1
Figure 1 depicts a large multipurpose OR that is designed for special procedures, such as
cardiac surgery. The room is large enough to accommodate any equipment that is needed.
Note the extra gas and electrical drops for use by the pump team.
Because the amount and size of equipment that is brought into the OR is ever increasing,
building a larger room today will undoubtedly pay dividends in the future. The size of the door
to the OR is of particular importance. Very large items, such as specialty beds, orthopedic
fracture tables, and heart-lung bypass machines, must be brought into the OR. It is, therefore,
advisable to have a large main door and a second, smaller door that can be opened when
needed (Figure 2).
21

Figure 2
Figure 2 depicts a two-part OR door. The main part is used for regular stretchers, while the
additional section can be opened to accommodate special OR tables or extra-wide beds. Note
that the wooden doors have no protection from damage by stretchers and movable
equipment.
The two-part door works very well because the entryway can be enlarged when needed, but it
does not have to be opened for regular beds. If windows are going to be placed in the doors,
then provisions should be made to cover the window with a shade. Also, when using wood
doors, the lower door panels and edges should be protected with a stainless steel overlay or a
kick plate with edge guards (Figure 3). Otherwise, the movement of beds in and out of the room
will damage the wood.
22

Figure 3
Figure 3 depicts a two-part OR door with the addition of stainless steel overlays to protect
the doors.
Another consideration in new construction is patient movement. How patients are going to be
moved on and off of the OR table should be considered in the design phase. Because bariatric
patients are an increasingly large segment of the patient population, consideration should be
given to installing some mechanical lifts in some of the ORs.
Heating, Ventilation, and Air Conditioning

The number of air exchanges in the room must be at least 20 per hour; at least four of these
exchanges need to include fresh outdoor air. Relative humidity can be as low as 30% but cannot
exceed 60%. It is best to have a separate system for scavenging that is independent of both the
ventilation and vacuum systems. The air return ducts should have a HEPA filter built into the
system.
23

The ability to change the room temperature easily is very important. As recent studies have
shown, keeping the patient warm is highly beneficial during most types of surgery. The heating
and air conditioning systems must allow the individual room temperature to be raised or
lowered rapidly as needed for patient and surgeon comfort. This must be accomplished without
large overshoots in the desired temperature and can be accomplished by using individual
reheat coils in each OR. Also, it may be beneficial to have the temperature sensed at several
different points in the room.
Lighting
Often, the architects are very concerned about the amount of room lighting. However,
excessive fluorescent lighting can be problematic. With the vast increase in the amount of
endoscopic surgery, the entire concept of room lighting needs to be carefully planned. It makes
more sense to have lights on dimmers or provide separate switches for different lights so that
some can be turned off during a procedure. In rooms where all the lights must be turned off
(e.g., when the operating microscope is being used), special procedure spot lighting can be
installed for both the anesthesia staff and the scrub nurse (Figure 4). This lighting can be
directed at areas that need illumination, such as the instrument table or the drug cart.
Figure 4
Figure 4 depicts a special procedure light (spot light) that can be adjusted for use by the scrub
nurse or anesthesia staff.
24

Another technique is to install two banks of fluorescent tubes in each fixture. A separate wall
switch would control each bank so that half of the lights can be turned off while the other half
remains on (Figure 5).
Figure 5
Figure 5 depicts special fluorescent lighting whereby half of the lights can be turned on or off
as needed. Note that excessive lighting causes glare on the remote monitor, making it
difficult to see.
Some of the newer OR integration systems have lighting controls that can be configured for
different lighting schemes; these schemes depend on which light fixtures are switched together
as one unit and which are switched separately. In addition to light intensity, glare on monitor
displays from room lights can be a major issue. The greater the individual control over different
lights, the more adjustable will be the work environment. The downside is cost and complexity
of use. A battery-powered source of emergency lighting must also be installed. Lighting can be
dealt with in many innovative ways during the design phase, but if it is not planned, it is difficult
to add later.
25

Fire Safety
Fires continue to be an ever-present danger in the modern OR. This is true even though
virtually all ORs in the United States are designated as nonflammable anesthetizing locations
(i.e., no flammable anesthetic agents or medications are allowed). The ECRI Institute estimates
that there are between 500 and 600 OR fires each year in this country. The combination of
three factors commonly found in the OR can easily result in a fire: (1) an oxidizer, such as
oxygen or nitrous oxide; (2) a flammable substance or fuel, such as paper drapes, plastics,
alcohol-based prep solutions, or gel pads; and (3) a heat source, such as electrosurgical pencils
or lasers. When designing or remodeling an OR suite, fire safety should always be considered.
This includes locating fire extinguishers and fire alarm boxes near each OR. In addition, zone
valves to shut off medical gases and electrical panels should be conveniently placed outside
each OR.
Space for storing numerous compressed gas cylinders needs to be provided. These cylinders
must be in a proper holder because rupture of a tank can flood an area with an oxidizer, such as
oxygen, and create a hazard from high-velocity metal projectiles. Depending on the size of the
OR suite, compressed gas cylinders may need to be stored in multiple areas. Gas storage areas
have specific fire-rating construction needs.
While every OR will have a smoke detector and sprinkler system, the location of these items is
important. Because a fire is most likely to start in the vicinity of the patient, the smoke detector
and sprinkler should be placed as close as possible to the OR table. Fires in the OR frequently
produce a lot of smoke and toxic fumes but not a lot of heat. Therefore, if the sprinkler is
placed in the back of the room, it may not activate until very late in the course of the fire. The
National Fire Protection Association (NFPA) provides many other useful ideas and guidelines
regarding fire safety in its publication NFPA-99: Standard for Health Care Facilities.
Substerile Areas (Scrub Rooms)

There are four basic items that will occupy the substerile area: sinks, an autoclave (note that
newer recommendations suggest that all autoclaving be done in a central sterile area, which
may greatly reduce the need for autoclaves in each OR area), storage for supplies, and a
telephone/intercom. Other possible items include a blanket/fluid warmer, ice machine, and
refrigerator.
26

Scrub sinks are not of equal quality. Some are far better at containing the water in the sink,
which avoids a wet and slippery floor. Many surgeons are used to having a window above the
scrub sink so they can watch the patient while scrubbing. While this may seem like a good idea,
the reality is that the window occupies a large amount of valuable wall space. Often, it will not
be possible to place all the necessary cabinets, electrical panels, etc., in the walls and still have
a window. In addition to the autoclave, some ORs need a warming cabinet for solutions and
blankets. There may also be a sink for decontaminating instruments prior to autoclaving, but
having the autoclaving activity in a central location may obviate the need for a decontamination
sink adjacent to the OR.
Most substerile rooms will have some storage space. This can be used for general supplies or
equipment unique to that OR suite. If a pass-through cabinet is going to be installed, then
sliding doors should be avoided. Although they do not require swing-out space, sliding doors
tend to come off the tracks, and oversized items will inhibit the ability to open or close the
doors.
Storage Rooms
Storage space is one of the most important requirements for the modern OR. However, it is
often overlooked or reduced in the cost-cutting phases of the project. The amount of
equipment that is in the OR today is probably double that of 10 years ago. The introduction of
video surgery has resulted in numerous television monitors, carts, and videocassette players
that have to be stored in and moved to different rooms. There are specialized OR tables,
microscopes, instrument carts, lasers, coagulators, and a host of spare devices (e.g., anesthesia
machines, monitors, and electrosurgery units) that need storage space. This does not include
the supplies and materials that are needed on a daily basis, as well as setups for emergency
cases. Future storage needs are difficult to predict; the more storage space that is planned, the
less likely the hallways will be jammed with equipment and supplies 2 or 3 years later.
Because OR space is very expensive, it may be possible to provide some storage room in close
proximity to the operating suite. In addition, some services that are traditionally in the OR may
be moved to create additional space. For example, the area for processing and sterilizing
instruments can be located outside of the operating suite. That area can be on a different floor
(above or below the OR) and have two dedicated elevators to bring in sterile supplies and take
out dirty supplies. This would allow one central processing area to serve several of the inpatient
and outpatient ORs as well as the labor and delivery rooms. It is best if the OR and the
anesthesiology department have separate storage areas. There may need to be one or two
large areas and several smaller areas spread around the OR suite. If there is a room for large
movable equipment, provisions need to be made for easily getting equipment into and out of
the room.
27

Communication
Communication is another important aspect of OR design. Telephones, intercoms, and

computers are all necessities for any modern OR. Also, television cameras and monitors may be
used for teaching or teleconferencing. The amount (and location) of each of these devices
should be determined by the nursing, surgical, and anesthesia staff.
There are many different ways to design a communication system. An effective communication
system can greatly enhance the safe and efficient running of the OR. Every hospital has unique
needs, and the system for a particular OR requires careful planning to achieve the desired goals.
Well-designed information technology is essential for the efficient operation of the modern OR.
Robust wireless and wired networks are needed for communication, access to the Internet, cell
phones, and various patient management tools. Some sort of electronic patient management
system (e.g., NaviCare) can greatly enhance the timely coordination of patients and staff.
In a large OR, it may be preferable to have a dedicated OR intercom as well as a telephone in
each OR and one on the anesthesia machine. The communication system must provide for a
simple and reliable way to obtain extra help in an emergency. This can be accomplished with a
dedicated OR page system or a separate alarm system.
Materials Management
One often-overlooked aspect of OR design is materials management. This encompasses all

sterile and nonsterile supplies, dirty instruments, trash, and any materials to be recycled. The
OR should be designed to allow the smooth flow of materials into and out of the area. If
possible, clean and dirty supplies should not mix, and the delivery and removal of supplies
should not interfere with patient movement. There needs to be space to unpack crates and
boxes of supplies as well as storage for enough supplies until the next delivery. This is true for
OR as well as anesthesia supplies. Complete isolation of pathways is impossible, but careful
planning can minimize the interference.
Special Functions
There are a number of special functions that may require space in or near the OR. These include
space for the pathologist to do frozen sections; an area for the perfusionists to assemble, clean,
and test the cardiopulmonary bypass machines; and space for blood bank refrigerators. It may
also be advantageous to have a laboratory to perform a selected number of tests and a
dedicated area for a biomedical technician. Space may also be required for a drug dispensing
machine(s), a narcotics return lock box, and a scrub suit distribution system. These functions
must be considered during the design phase, or something will have to be deleted later to make
room for them. Other support functions, such as call rooms, locker rooms, lounges, and offices,
are covered in other chapters of this manual.
28

Security
Security is a subject that has increased in importance in recent years. It is important that only
authorized personnel gain access into the OR suite, especially the sterile areas. There needs to
be a means to ensure that visitors and family members do not wander into sterile areas. Also,
the OR personnel need to feel safe during nights and weekends. In addition, family members
will want access to the front desk personnel. Controlling who has access to the OR area should
be part of an overall security plan.
Quality of Materials
It is important to consider what types of materials will be used. This should be determined
during the planning process because higher quality products will be more expensive. A good
example of this are OR cabinets; stainless steel cabinets with glass windows are more expensive
than laminated particle board with plastic windows (Figure 6). Over the life of the OR, the
stainless steel will be the better value.
Figure 6
Figure 6 depicts stainless steel OR storage cabinets with glass doors. These cabinets are easy
to clean and will last for many years. Also, any supplies stored in them are easily accessed
from the swing-out doors. Other equipment must be kept far enough away from the doors to
allow access to the supplies.
29

The materials for the OR walls and floor are also important. They should be easy to clean, blood
and stain resistant, and able to maintain their appearance for many years.
Also, the floor and the wall should not meet at right angles, as this creates an area that is
difficult to clean. Rather, the floor should seamlessly continue up the wall for 4 to 6 inches
(Figure 7).
Figure 7
Figure 7 depicts an example of an OR floor that extends several inches up the wall. This floor
is easy to clean because dirt cannot collect at the junction of the floor and the wall.
30

Construction Documents
Once all of the different components of the room have been determined, the architects will
prepare the construction documents. These are the detailed plans that show exactly where
everything will be in the walls, ceiling, and floor. At this time, the nursing, surgical, and
anesthesia staff should carefully examine each OR to determine if the placement of the OR
table, the cabinets, and any special equipment makes sense. Even though many rooms are the
same, each one must be inspected because important components may be left out or
changed.
The nurses need room to set up their sterile tables in a location that does not interfere with the
patient entering the room or the staff members obtaining supplies from the cabinets (Figure 8).
Figure 8
Figure 8 depicts a room that has the anesthesia supply cart located in front of the storage
cabinets, making it difficult for the nursing staff to access the supplies. The room should have
been designed so that movable equipment was kept away from the supply cabinets.
31

It is advisable not to place OR supply cabinets behind the anesthesia team; however, if it is
unavoidable, then the anesthesia gas drops should not interfere with obtaining supplies from
the cabinets. It is desirable to have a mockup of the OR so that people can walk through and
actually see where the architect has located the various components. A full- or small-scale
wooden mockup can be done. Alternatively, the room can be laid out with chalk on the floor
and the actual pieces of equipment brought into the area. Cardboard cutouts can be used to
represent various pieces of built-in equipment. It is much easier to visualize the setup in three
dimensions rather than the two dimensions of the blueprints. Using computer software, the
architect may be able to simulate the three-dimensional aspects of the space. This may provide
additional insight into the future function. Potential mistakes and conflicts can be resolved
before construction is actually finished (or even started).
One place where this is particularly important is in a room where there is a fixed piece of
equipment, such as a microscope. Having a microscope mounted and fixed to the ceiling
markedly limits the function of the room. If a microscope is going to be mounted to the ceiling,
it should be on a track so that it can be moved aside when the room is used for other types of
cases. This takes a lot of planning so that the microscope, OR tables, and anesthesia machine
are all in the best position to minimize congestion and interference with other equipment and
to facilitate transporting the patient into and out of the room.
All of these basic principles should be applied to all other areas of the OR. The preoperative
holding area, PACU, locker rooms, lounges, and offices should all be scrutinized for appropriate
size, setup, and flow.
If the facility being built has special needs, such as a labor and delivery suite, a pediatric suite,
or an outpatient surgicenter, then the previous discussion can be applied and tailored to that
specific area. For instance, a pediatric operating suite may require several different
preoperative holding areas so that children of different ages can be segregated. Outpatient
surgicenters have unique requirements, including modifications for recovery in order to ensure
that the patients are able to ambulate before being discharged.
Construction
Once all of the design and construction drawings are finished, the actual work will begin. This is
not a time to sit back and hope everything will go according to plan. It is vitally important that
members of the anesthesiology department and nursing staff make frequent and
comprehensive visits to ensure that the construction is proceeding according to plan. It is also a
time to resolve minor problems and add forgotten items before the suite is finished (Figures 9
and 10).
32

Figure 9
Figure 9 depicts automatic doors leading from the preoperative holding room into the OR
that require a plate to be pressed in order for the doors to open. The plate was originally
located on the wall next to the doors (note the blank cover plate to the right of the doors).
This made it impossible for a person pushing a stretcher to open the doors.
33

Figure 10
Figure 10 depicts how the plate to open the doors has been relocated to approximately 8 feet
in front of the doors. This allows a person pushing a stretcher to operate the door control
without having to leave the patient
It is important that the people who helped during the design phase stay active with the project
during construction. It is almost impossible for someone else to take over at this phase. There
needs to be an agreement between all the parties that any changes will be presented to and
agreed upon by the group. Agreed-upon changes need to be put in writing and distributed to
the group. The meetings need to be scheduled (so that everyone has a reasonable opportunity
to attend) and should be long enough to get the necessary work done. The representative from
the anesthesiology department needs to realize that this will entail being out of the OR for
many hours during the day.
34

No matter the similarity of some rooms, they must be treated as individual projects. One
cannot assume that all of the rooms will be correctly done just because two or three rooms are
correct. For instance, our project involved building three new delivery rooms. All were
supposed to be done the same way. However, we found that one room had no suction for the
surgeons. If such a mistake is identified early, it is easy to fix; if it is discovered on the final
inspection, it is very costly to rectify.
Conclusion
Once the construction is finished, the anesthesiologists should do a final checkout and safety
inspection. The gas lines should have a certified report of testing. Ideally, this is part of the gas
piping installation contract. The contractor must provide a test of both proper installation (i.e.,
brazing and purging of impurities) and proper function (i.e., correct gases in the correct
pipelines). Numerous disasters can occur if this has not been done. The anesthesiology
department should also perform its own check to be sure that oxygen is in the oxygen lines and
nitrous oxide is in the nitrous lines. A complete test of all systems must be done before the
room is used for patient care.
A tremendous amount of work is required in order to have an excellent (functional) finished
product. The difference between an operating suite that is workable and usable and one that is
not frequently depends on how much attention is paid to small details. As always, a vigilant
anesthesiologist (as well as nursing, surgical, and OR staff) is required in order to have a
satisfactory outcome.
35
CHAPTER 3
ERGONOMICS AND WORKFLOW
Lead Author: Robert Loeb, MD; Associate Professor of Anesthesiology; University of Arizona
Tucson, AZ
Contributors: Ramon Berguer, MD; Clinical Professor of Surgery; University of California, Davis;
Davis, CA
Checklist
1. Have end users considered how patients, supplies, and equipment will move through
the planned facility?
2. Have end users considered the workflow of tasks they will repeatedly perform in the
planned facility?
3. Will there be adequate technology and access to technology for communication within
the facility and to the outside (considering telephony, intercoms, information displays
for schedule, laboratories, radiology, etc.)?
4. Will lighting be adequate for the tasks to be performed in the facility?
5. Has the facility been optimized to control noise pollution, provide different temperature
zones, and distribute electrical power and compressed gases?
Introduction
Ergonomics is the field of study of the physical and psychological relationships between
working humans and their tools and environments. The purpose of ergonomics is to promote
efficiency of operation and decrease human error and stress and strain on the user. Ergonomics
should be an early consideration in the design of any new or retrofitted surgical facility so that
the interactions of workers with their coworkers, equipment, and facilities can be studied and
the resulting data can guide the design of better policies, procedures, equipment, and facilities.
Early attention to ergonomics is increasingly applied to the design of medical instrumentation.
In 2001, the American National Standards Institute and the Association for the Advancement of
Medical Instrumentation published the Human Factors Design Process for Medical Devices,
which describes how ergonomics and human factors should be applied to the design of medical
devices. The intention is to help equipment manufacturers develop safe and effective medical
devices. However, no such document describes the application of ergonomics and human
factors to the design of operating suites and other health care environments, even though
these facilities greatly influence the safety and efficiency of the processes within.
The process of facility design has already been covered in Chapter 1, The Design Process, but
the key ergonomic considerations will be highlighted here. Facility design begins with an
analysis of needs and a clearly defined objective. From this, an overall concept for the facility is
formulated. This leads to the development of the functional criteria and requirements for
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specific areas of the facility. Thereafter, a schematic design of the facility is produced. Finally,
construction of the facility begins. But, ergonomic-guided design is an iterative and cyclical
process wherein the steps from overall concept to schematic design are repeated and refined
based on the feedback of owners, end users, consultants, and customers until all the major
design flaws have been fixed. Techniques such as task and workflow analysis, site visits to
similar facilities, building mockups, cognitive or computer-based walkthroughs, and interviews
and surveys are used to obtain feedback on the proposed designs. Such a design approach
requires the early involvement of experienced users who have time allotted to help with the
design process. As stated in Chapter 1, the design team must include people who will actually
work in the facility.
Ergonomics
Factors to consider under the heading of ergonomics include medical teams in the operating
room (OR), lighting, noise, temperature, work-related injuries, and workflow and task analysis.
Medical Teams in the OR
Different needs of surgical, anesthesia, and nursing (including ancillary) teams
Patient safety, communication, and shared data: Universal Protocol, World Health
Organization checklist, time out, and information displays (e.g., x-ray, vitals, etc.)
Communication into and out of the OR and case scheduling
Simulation for OR emergencies
Communication skills: teamwork training
Lighting
Sufficient light is needed for works-specific tasks
Surgeons need the brightest light
Anesthesiologists and nurses need bright light
Hazards of colored lenses (e.g., need for laser safety goggles)
Interference of ceiling-mounted light booms with other equipment (e.g., video
monitors, drop down gas sources, and intravenous poles)
Local-field lighting: headlights
Noise
ORs are noisy

Noise is reflected; thus, the localization of sounds is difficult
High noise levels interfere with communication and alarm perception
American Society of Anesthesiologists standard requires being able to hear the pulse
oximeter variable pitch tone above the background noise
Causes of OR noise (e.g., hard surfaces, suction, room ventilation, conversations, alarms,
pagers, overhead pages, and music)
Room and furniture design to decrease noise levels
38

Temperature
Comfortable temperature increases efficiency and safety
Patient and staff are insulated to various degrees
Patients tend to become hypothermic
Surgeons tend to become uncomfortably warm
Personal cooling and warming devices
Need for rapid changes in room temperatures
Work-Related Injuries
Lifting
Needlesticks and sharps injuries (including exposure to blood-borne pathogens)
Repetitive motion injuries, static posture injuries, and wrist/forearm injuries from the
use of heavy or awkward instruments/devices
Physical fatigue and OR seating
Different user shapes and sizes (e.g., small female vs. large male) and the effect of sizes
and shapes of medical device handles and controls.
Workflow and Task Analysis
Use of simulation in the design phase
Location of supplies, medication, and instruments (e.g., in vs. out of room and free
access to supplies vs. electronic inventory control systems)
Planning for sequential vs. parallel patient flow (e.g., block rooms and induction rooms)
Equipment storage, work surfaces (e.g., setting up and supplies), and writing surfaces
(usually minimal)
The integrated OR concept: Endosuite, integrated room/procedure video, and
telemedicine/telementoring systems
Team-Specific Issues
Anesthesia: The Anesthesia Cockpit

Machine size and orientation:
o Typical anesthesia workstation and medication cart dimensions
o Anesthesia machines are generally configured so the patient attachments (e.g.,
the breathing circuit) are located on the left-hand side of the machine
o The anesthesia machine is best positioned to the right side at the head of the OR
table or in a less desirable location behind the anesthesia provider
o In some surgical procedures, the anesthesia machine may be located at the
patients side or at the patients feet
Suction:
o Suction canister and controls should be located in the anesthesia cockpit within
reach and view of the anesthesia provider
o Height of suction canister should be below the level of the surgical table (to
decrease effect of hydrostatic pressure)
Monitor, computer, and phone:
39

Access to patient data in the Electronic Medical Record (EMR) in real time
Access to help materials (e.g., internet) in real time
Wired and/or wireless access
Portable vs. fixed computers with keyboards and mice; where will the mouse be
located?
o Use of alternate screen-pointing devices (e.g., touch screens, trackballs, and
knobs)
o Glare, spillage, and infection control considerations
o Food and Drug Administration Human Factors Design guidelines
o ECRI Institute resources
Power management:
o Electrical, phone, network, and compressed gas outlets should be located near
the anesthesia cockpit and not across major pathways into and out of the room
o Multiple network ports may be needed because monitors, anesthesia
information systems, hospital EMRs, and general intranet and internet usage
may require separate networks
o Can be located on the ceiling or on ceiling-mounted booms
Hose cord and cable management:
o Hoses, cord, and cables on the floor can be a trip hazard and can interfere with
positioning of wheeled equipment.
o Wheel protectors can be used to push cables away
o
o
o
o
Surgery
Cleaning and sterility
Patient support and positioning systems: adequate table height adjustments during
surgery
Video-endoscopic surgery:
o Integrated equipment towers (e.g., booms vs. carts)
o Display locations and adjustability
o Communication systems (e.g., video, audio, images, picture archiving and
communication system, etc.)
o Surgeon-controlled systems (e.g., computer interface and voice activation)
o Management of multiple cables/tubes from multiple pieces of equipment (e.g.,
OR spaghetti)
Sharps injury prevention: double gloving, blunt suture needles, hands-free zone, and
engineered sharps injury prevention devices
OR documentation: paper vs. computer
Interruptions: personal communication devices (e.g., pagers, cell phones, and cameras),
overhead pages, and in/out room traffic
Workflow aids for best practices (e.g., antibiotics, deep vein thrombosis prophylaxis,
beta blockers, etc.)
Physical safety and comfort: gowns, cooling systems, and eye/face protection
40

Nursing
Preference cards or the electronic equivalent and their use and location
Standardization of supplies
41

CHAPTER 4
ENVIRONMENTAL SUSTAINABILITY: LIMITING IMPACT ON THE ENVIRONMENT
Lead Author: Susan Ryan, MD, PhD; Professor, Department of Anesthesia and Perioperative
Care; University of California at San Francisco
San Francisco, CA
Checklist
1. Sustainable sites: Are the architect/construction teams, materials, and site choice
geared toward low environmental impact?
2. Water: Are fixtures and systems designed for maximal water efficiency?
3. Energy: Is energy efficiency a consideration in lighting, heating, and design choices? Can
green energy be purchased by the facility?
4. Indoor environment: Are interior materials eco-friendly and recyclable? Is
environmental sustainability a factor in operating room (OR) surgical and anesthesia
equipment evaluation?
5. Innovation and design: Can operative and perioperative spaces be proactively designed
to accommodate recycling programs and other features that lower environmental
impact?
Introduction
The imperative to limit environmental impact extends to the health care industry, which is very
high impact and energy consuming. However, this imperative presents many special challenges
given the needs for patient safety, infection control, and cost containment. Fortunately, with
some specific guidance for the industry, green design and green operations in health care
may work in concert with health cares goals and challenges by improving building efficiency
and cost and providing safer, more pleasant surroundings for patients and employees. The
Leadership in Energy and Environmental Design (LEED) program of the US Green Buildings
Council offers guidance and certification for new and remodeled building projects and currently
has over 350 health care construction projects registered. The LEED for Healthcare system, a
more specialized version tailored to the challenges of health care, is under final review and
expected to be available by mid-2011. This more specific guidance, along with the currently
available Green Guide for Health Care (www.gghc.org), will enable implementation of many low
environmental impact solutions.
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A LEED certification involves accumulating points in at least six areas of evaluation: sustainable
sites, water efficiency, energy and atmosphere, materials and resources, indoor environmental
quality, and innovation and design. Based on the degree of compliance in these areas, projects
can be deemed LEED certified, silver, gold, or platinum. Each of the areas of LEED
certification will be briefly addressed, with comments about how they generally pertain to a
health care facility and might more specifically pertain to ORs and perioperative areas.
Sustainable Sites
First, consider what it means to have a sustainable site and whether the other green plans for
the project fit into this location. The ultimate goal is to minimize impact on the surroundings
while choosing a location that best serves the intended patient and employee populations.
Suggestions include:
General considerations: Choose an eco-friendly team of architects, engineers, and
contractors. Discuss plans for possible LEED certification at an early stage. Discuss the
contractors plans for keeping the construction or remodeling site low impact.
New site versus previously developed site: Building on a previously developed site
avoids disturbing undeveloped terrain. However, with a new site, attempt to work with
the terrain and biosystem rather than just replacing it. The Green Guide for Health Care
(GGHC) has very specific recommendations for perimeter footage beyond which the
terrain should remain undisturbed. The GGHC also recommends limiting parking
capacity to the specified minimum; however, this must take into account that patients
and their families will often be driving.
Limited footprint: Can the structure be built up and not out to limit the footprint?
Also, avoid unnecessary replication. Do other nearby facilities or businesses with which
to share parking, energy, water, office, or research facilities exist?
Transportation: Though patients and families will most often be driving to the facility,
health care employees may be encouraged or provided incentives to take advantage of
public transportation. The site should be near mass transit lines or offer shuttles to
them. In addition, bicycle and walking paths should be provided. Adequate lockup space
for bicycles should be included as well.
Regenerative systems: Some hospitals have been built to enhance the area and have positive
impact (e.g., rain collection systems, habitat and pond restoration, etc.). These health care
systems are termed regenerative.
Water Efficiency
Many hospitals and surgicenters are older and have not been built for water efficiency.
Nonetheless, there are several key strategies for conserving water for both new and existing
facilities, including:
Use less water. Low-flow fixtures may be utilized for urinals, toilets, and showers.
Sensing devices may be placed on sinks used for hand washing. As an alternative to
hand washing in some situations, alcohol hand rubs can be made available.
43
Energy- and/or water-saving appliances can be installed. Water used in cleaning or

preparation of surgical/operative items or areas may be difficult to reduce, but
efficiency of water conservation processes should be evaluated.
Use reclaimed water. The GGHC estimates that only 20% of the water in an urban area
actually need be potable, leaving 80% that could be reclaimed water. Given the patient
safety, infection control, and operative sterility needs, 20% potable-quality water may
be a low estimate for a health care facility. However, interior and exterior maintenance
operations could utilize reclaimed water in situations such as closed-loop cooling
systems and landscape maintenance. Consider designing dual-water distribution into
health care structure whenever possible.
Energy and Atmosphere

The LEED certification and the GGHC stress saving energy and limiting the impact on the
atmosphere.
Energy
Energy efficiency can be planned for a new design or remodel with assistance from a system
designed by the Environmental Protection Agency (EPA)the Energy Star rating system, LEED,
and GGHC. Newer facilities are building in methods for monitoring energy use, but some means
of measuring energy consumption should be undertaken. Metering electrical, mechanical, and
air distribution systems will help find weak points and confirm energy saving strategies. Key
strategies include:
Purchase energy-efficient equipment.
Purchase or produce green energy. It may be possible to purchase some percentage of
solar, wind, geothermal, and other green energy. Health care, as an industry, is finding
that smaller energy auctions can add green energy to their portfolios. In addition,
some health care facilities are dedicating some of their own land to installing solar
panels and wind turbines. This allows the facilities to generate their own green energy
and sell surplus to the community.
Utilize natural lighting and energy-efficient artificial lighting. New green-design
hospitals and surgicenters emphasize the use of large windows and weather-resistant
glass walls to allow natural lighting. This is not only more pleasant and healthier for
patients, families, and employees, but can reduce overall energy costs by 30%. The cost
of light energy is reduced by greater than half, and, in some climates, the need for
further energy consumption to modify temperature is reduced as well. In areas
requiring artificial lighting, use the most efficient lighting available. In areas with
variable use, such as bathrooms, offices, and storage areas, consider installing motion
sensors. In ORs, light-emitting diode (LED) surgical lighting is now available from several
companies. Lighting with LED is highly efficient; diodes have a very long life, and LED
lighting produces very little heat, reducing the energy needed to cool ORs.
Consider installing a central monitoring and controlling system for energy use. Older
hospitals and surgicenters may not be monitoring individual rooms or surgical suites.
44

However, this could be very helpful, particularly for individual ORs. Lighting,
temperature, surgical equipment, computers, and anesthesia machines all contribute to
energy use. Because overnight and weekend use can be variable, energy conservation
can be achieved for low- or non-use periods. Placing monitors and controls in a central
OR location (where patient flow and surgery scheduling occurs) and designating staff for
monitoring and operations places priority on energy savings.
Limiting the Impact on the Atmosphere
A number of waste gases have been implicated in ozone depletion and the greenhouse
warming effect. The EPA has recently cited six gases in particular: carbon dioxide,
methane, nitrous oxide, hydrofluorocarbons, perfluorocarbons, and sulfur hexafluoride.
Key strategies to limit their impact include:
Consider monitoring and minimizing any of these waste gases in design or remodel
whenever possible.
Consider replacing older equipment (e.g., refrigeration systems) that may utilize
chlorofluorocarbons.
In the ORs, potent inhaled anesthetics are greenhouse gases, with their own global warming
potentials having been established. In addition, nitrous oxide has both global warming potential
and ozone-depletion capability. Currently, there are no restrictions on expelling these gases
into the atmosphere. However, their atmospheric impact can be lessened. Considerations
include:
Use relatively low fresh gas flows during anesthetic delivery to limit atmospheric impact.
Consider recovery of potent inhaled anesthetics. Several systems to do so are under
development. One recovers anesthetics through a canister placed on the scavenging
system of individual anesthesia machines (Blue Zone Technologies, Canada). Another
pipes anesthetic gases from several ORs into a central location, where recovery occurs
(Vanderbilt University). Neither system is yet available for use in the United States.
Materials and Resources/Indoor Environmental Quality

The LEED guidelines and the GGHC encourage the use of eco-friendly materials from design to
final operations. General suggestions during construction and remodeling include:
Consider use of recycled or salvaged materials, depending on quality.
Show preference for local and rapidly renewable materials. Use of local materials cuts
down on the energy cost of attainment and bolsters local economy. Use of rapidly
renewable materials has a lower impact on the environment.
Consider use of materials that can be recycled into future projects.
Choose wood that is Forest Stewardship Council certified.
Avoid toxic chemical and polyvinylchloride (PVC) use; PVC is very toxic to produce and
toxic on incineration. It cannot be recycled.
Consider carpeting with recycled content and PVC-free backing (which allows the carpet
to be recycled).
45
Use eco-friendly interior woods, furniture, fabrics, and lighting. Avoiding materials that
emit volatile organic chemicals or formaldehyde can be very important to patient
health. Many of these chemicals can trigger asthma attacks or migraine headaches.
Use accepted nontoxic cleaners that meet or exceed Green Seal standards whenever
possible. Green Seal is a nonprofit organization that promotes environmentally
responsible products (taking into account manufacturing, use, and disposal).
All of these suggestions pertain to perioperative areas (e.g., waiting rooms), preoperative areas,
postoperative areas, and ORs. Modifications for infection control may be necessary. Materials
in and practices of the OR encompass many facets of design and operation. General guidelines
for low environmental impact practices within this specialized area include:
Preferential, responsible purchasing: Though many items are purchased through
purchasing cooperatives, some cooperatives are more sensitive to limiting the
environmental impact. For group or individual purchasing, suppliers should be able to
discuss responsible manufacturing practices, use of recycled and recyclable materials,
toxicity-related questions, and use of local manufacturers. Some examples might include
masks, gloves, intravenous bags, and surgical instruments. Companies should also be
able to discuss practices for disposal of old equipment or products.
Reprocessed equipment purchase: Many surgical and anesthesia equipment items are
designated single use by the manufacturer (but not the Food and Drug
Administration). Several companies collect these used items and then reprocess, test,
sterilize, and resell them at a reduced cost. Examples include surgical laparoscopic
trocars, sequential compression devices, and pulse oximeter probes. Several large
health care systems in the United States regularly buy certain reprocessed equipment
items.
Reusable versus disposable equipment: Many items, both surgical and anesthesia
related (airway equipment, in particular), can be purchased as reusable or disposable.
Each surgical/anesthesia practice should interface with material services and
sustainability coordinators to determine the purchase strategy that has the lowest
environmental impact for each item or group of items while safely and efficiently
functioning.
Efficiency system: Each practice should have a system in place to prevent waste of
outdated or overstocked items. Surgical case cart and anesthesia equipment cart
reviews should periodically take place. Removal of rarely used surgical items from a case
cart can prevent the waste of opened, exposed, unused items. Purchase of metal
sterilization pans can avoid blue wrap (a paper/plastic material that is difficult to
recycle) waste. Anesthesia cart reviews can cut down on medication as well as
equipment waste.
Reduce and manage waste: Surgical suites and perioperative areas produce voluminous
waste, with more biohazardous waste than produced by other areas of a health care
facility. Much of the waste in the ORs need not be considered biohazardous. Paper and
plastic may be removed before the patient enters the room, allowing recycling and
regular waste disposal, both being of lower impact on the environment and less costly.
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A recent report from Oregon Health and Science University, a suite of 21 ORs, estimated
that they are currently recycling approximately 300 pounds of uncontaminated paper
and plastic each day. In addition, utilizing closed-fluid waste management systems will
not only protect personnel, but likely decrease secondary biohazardous waste.
Innovation and Design

Innovation and design in green health care projects is currently focused on a two-pronged
approach: (1) innovate and design to reduce or remove negative impact on the environment;
and (2), provide a healthier and more pleasing environment to help the healing process and
retain satisfied and healthy employees. General strategies that bridge both prongs when
considering perioperative design include:
Efficiency: Provide a pleasant and healing environment throughout the perioperative
settings while keeping efficient patient and family flow in mind. Waiting and
preoperative areas should be well lighted (ideally with natural light) and comfortable.
Plan and design private areas for doctor-patient or doctor-family discussions. Plan for
efficient movement from waiting room to preoperative area to OR to postanesthesia
care unit. This efficiency will result in savings in energy and OR time.
Operating and procedure rooms: Good instrument care, waste management, and
recycling require space. The design should incorporate staging areas that facilitate
segregation of different materials and make it easy to sort, recycle, handle sharps,
manage materials, and incorporate closed-fluid waste systems. Currently, low-cost
waste removal and recycling are afterthoughts in the OR; thoughtful design can help
change the culture.
Waste anesthetic gas capture: For both cost and environmental reasons, anesthetic gas
capture may be planned and designed into OR systems. Dual-waste medical gas removal
systems will allow segregation of anesthetic gases from other gases piped out of ORs.
Alternatively, individual machines may be equipped with gas capture capability.
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CHAPTER 5
ADMINISTRATIVE AND PERSONNEL SUPPORT
Lead Author: Autumn Shaffer Hardin, MD; Baptist Health Medical Center
Little Rock, AR
Checklist
Is there sufficient storage space for present and future equipment?

Are there adequate dressing rooms, with appropriate security?
What lounges will be required for what sorts of functions?
Are there appropriate sleeping areas for everyone who will take in-house calls?
Is there adequate office space available for all administrative functions?
Introduction
This chapter discusses operating room (OR) personnel facilities, including OR storage, lounges,
dressing rooms, restrooms and showers, sleeping facilities, and administrative offices. The
number of possible combinations of the physical layout of these areas is limitless, yet a few
general guidelines can be made. Important design considerations include ease of use, flexibility,
flow of traffic between sterile and substerile areas, infection control, air supply and ventilation,
cost, and security. A major consideration in 2009 is that due to the financial crisis, many
renovation or new construction plans have been placed on hold or have been cancelled. Thus,
one must be prepared to justify requests for space and generate a prioritized list of needs
because most budgets will be severely limited. Designing a plan in advance that will allow for
flexibility in the future will be the most cost-effective approach.
Operating Room Storage

The storage issue is critical. One commonly sees equipment in hallways, in front of OR doors, in
front of electrical and gas supply control panels, in front of fire exits, and in every nook and
cranny.
Storage in the OR must meet both current and future needs. Architects generally recommend
at least 150 to 200 square feet of storage space per OR. To estimate total OR storage needs,
one must:
Determine the number and type of ORs in the suite (driven by OR objectives)
Determine the equipment specific to each OR
Include storage needs of all services, such as anesthesia, nursing, hospital monitoring,
biomedical engineering, housekeeping, etc.
Project future storage needs of various services
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Each surgical services storage needs are unique. Dedicated storage areas near or adjacent to
their ORs allow for convenient access of surgical instruments, supplies, and equipment during
an operation. On the other hand, because services often operate in multiple rooms, some
facilities may consider a single storage area for all supplies for all services. A large storage room
could be modestly finished (e.g., it may not need a drop ceiling), but any storage room requires
the ability to clean it, good lighting so that correct equipment and supplies can be identified,
and multiple electrical outlets (perhaps to include ceiling drop cords) so that rechargeable
equipment (e.g., transport monitors, infusion pumps, C-arms, etc.) can be kept plugged in.
Storage of stretchers is particularly problematic. In some hospitals, stretchers are left to block
the entrance to the OR, in obvious violation of fire safety codes! One needs quite a lot of
stretchers: one for each patient in the holding area, the OR, and the postoperative care area.
Additional stretchers are needed to permit cleaning without limiting patient care. A location
with the appropriate cleaning supplies also needs to be planned. If patients to be admitted are
to be directly placed on hospital beds, then the stretcher normally associated with that patient
needs to be stored so the bed can be placed where the patients stretcher would normally
reside. Stretcher and bed storage sites should have electrical outlets to keep motorized beds
(e.g., inflatable beds), transport monitors, and infusion pumps charged.
In regard to storage, the old adage of A place for everything and everything in its place,
seems essential. How much time is wasted in looking for pieces of equipment? The planning
stages should assure a specific storage place (and adequate square footage) for every planned
piece of equipment, and then that space should be greatly expanded to allow for future
equipment (an old piece of equipment is almost never discarded; instead, it is retained as a
spare). A directoryprinted or onlineof all the equipment and its assigned storage place
should be made available.
Advances in minimally invasive surgical technology have provided for smaller surgical incisions
but the need for large equipment. One recent surgical development is the robotic-assisted
system, which requires three components: a computer console operated by the surgeon, a
vision component with a light source and camera, and a surgical component with multiple
instrument arms. The storage space required for this single, specialized operation is
tremendous. Other commonly utilized equipment includes microscopes; specialized frames for
craniotomies or back surgery; cardiac bypass pump systems; laparoscopic, endoscopic, and
arthroscopic video carts; cast carts; C-arms; fluoroscopes; and portable x-ray machines. Even
anesthesiology is culpable when it comes to use of storage space; inventory includes backup
anesthesia machines, bronchoscopy carts, difficult airway carts, latex allergy carts, malignant
hyperthermia carts, and day-to-day supplies needed to perform anesthesia safely.
Objectives in the OR are likely to change with time. For example, an institution not currently
performing kidney, pancreas, heart, or liver transplantations may eventually elect to perform
these specialized operations, which require specialized equipment. If the OR suite or storage
area cannot be enlarged due to physical restraints, storage areas and hallways will become so
cluttered that it will be nearly impossible to transport patients from the holding area to the OR.
50

If complex surgical procedures are infrequently performed, the operation-specific equipment
must be stored until needed. Future storage needs are difficult to project accurately, but it is
likely that technology will continue to advance and additional equipment will be needed and
will need to be stored.
Additionally, space for facilities to repair broken or damaged equipment should be considered
within the OR suite.
Lounges
The lounge is an area of retreat from the demands of the OR. When determining the design of
the lounge area, multiple factors must be considered. First, one must determine the number of
lounges to meet the needs of the OR suite. One approach is the single, consolidated personnel
family lounge. Some health care facilities may prefer several smaller lounges that segregate
groups such as nurses, surgeons, and anesthesia providers. After the number of lounges is
determined, one must plan for the size and function of each lounge. The size depends on the
number of personnel who will use the lounge during both regular and peak hours.
The intended function of the lounge is important. One obvious and essential function is for
snacking and dining. Vending machines and coffee makers can be partial solutions, but shift
lengths require that employees must eat full meals. If the food service solution is that
personnel leave the OR area and go to a public cafeteria, then the pathway and infection
control issues must be considered. Will personnel change clothes or wear cover-ups? Will
personnel eat in the cafeteria, or will they bring food from the cafeteria back to the lounge?
Where will dirty dishes go? Some hospitals send a hot lunch cart to the OR area; others supply a
make-your-own sandwich bar; still others utilize outside vendors who come to the lounge area.
Ideally, there would be hot food available during all hours of operation.
The lounge may also be used for dictation, charting, entering patient orders, checking e-mail,
and so on. During non-peak hours, the lounge could be used as a classroom or conference
room. The equipment needs, such as appliances, computers, plumbing, electrical outlets, and
furniture, of each lounge must be determined. Possible appliances include refrigerators,
vending machines, microwave ovens, televisions with cable or satellite service, DVD players,
CD/MP3 players, dictation machines, and coffee machines. Furniture might include tables,
chairs, and couches. Reclining chairs that could be used for sleeping or napping might be
considered.
Computers with access to the Hospital Information System and the Internet seem essential in
every lounge. A screen display of the current OR schedule is desirable. Overhead paging should
reach all lounge areas. Other amenities include recreational equipment (e.g., weights, treadmill,
pool table, ping pong table, etc.) and perhaps a piano or electronic keyboard.
51

Consideration should be given to building a quiet library area where essential reference
books and Internet access are available, along with carrels for personnel to work quietly and a
separate non-quiet area for making personal or professional telephone calls.
Finally, the location of the lounge within the facility should be considered. Preoperative
patients who cannot eat or drink anything may be offended by the smell of pizza and popcorn
from the lounge!
Dressing Rooms
The location of the dressing rooms within the OR suite is important because they commonly
serve as the transition area between the substerile and sterile environments. The number of
dressing rooms needed depends on the desire to have separate dressing rooms for physicians
or other groups. To determine the size of each dressing room, one must estimate the number
of people who will use it during both peak and regular hours. The ratio of men to women
(within each group, if applicable) is important for determining the size of the mens and
womens dressing rooms.
Security is another major concern because the OR staff will be keeping their valuables in their
designated dressing room. The dressing room entrances should be located away from hightraffic public areas. Advanced security systems, such as keycards and/or biometric
identification, should be considered on the outside doors to the dressing rooms. Conventional
locker design has not changed much in two generations. Conventional key-based lockers may
be problematic because keys may be lost, left at home, or retained by former employees. One
solution is to have personnel bring their own padlocks, either key based or combination.
Lockers with electronic locks or key cards are another option, as is the possibility of installing an
electronic hotel safe in each locker.
Because inadequate locker space is a common problem, both present and future needs should
be considered. To determine the number of lockers, begin with one locker per full-time staff
permanently assigned and add extra shared lockers for part-time staff, students, and visitors.
Add at least 15% for future growth.
Linen control is an important consideration when designing a dressing room. There are two
growing trends in linen control. One is a centralized scrub suit distribution and collection room,
which should be located near the nonsterile entrance of the dressing rooms. The other trend is
the vending machines approach; these machines could be near the nonsterile entrance or
located within each dressing room. Some health care facilities may prefer the older approach of
simply stocking scrubs in each dressing room, but loss of scrubs is a substantial financial
problem. In the latter approach, allow for adequate adjustable shelf space to supply scrubs of
all sizes to OR personnel. Mens scrubs should be supplied in the womens dressing room
because many women prefer these. Additional shelf space will be needed for shoe covers, hats,
and masks. Adequate seating is essential, particularly during peak hours, to minimize the need
for acrobatics.
52
Infection control and traffic control are particularly important. The dressing room must have an
adequate number of sinks for hand washing and plenty of storage space for towels and soap.
Entrance systems via keycard or biometric identifiers are becoming more common in order to
limit access to authorized persons. Finally, the dressing rooms should include a communication
system, such as telephones, an intercom system, overhead paging, and, possibly, access to the
hospital information system.
Restrooms and Showers

The main restrooms are commonly combined with the dressing rooms, but some may be
located in sterile areas for convenience. Restrooms and shower areas are now required to be
handicapped accessible. The minimum number of restrooms should be two mens and two
womens.
The number of showers should be approximately one per 200 lockers. Consideration should be
given to possible emergency need for showers in case of major contamination with blood,
biological agents, etc. What route will personnel take from any particular OR to the showers?
Where will they place contaminated clothes? Where will they obtain clean clothes after they
shower?
Storage for towels, soap, toilet paper, and extra supplies is also necessary.
Sleeping Facilities
Sleeping facilities located near the OR are desirable, and several factors should be considered
when designing them. First, determine exactly who should sleep near the OR. Then, calculate
the number of individuals who will require sleeping facilities at one time and decide which
groups of individuals (e.g., surgeons, anesthesia providers, and nurses) should be segregated.
Beds should be of standard size so that normal hospital sheets will fit, and bunk beds should be
avoided because of the risk of falls. Landline telephones, access to the hospital dictation
system, televisions with cable or satellite service, and internet access are desirable. There
should be at least two means of communication to provide redundancy.
Soundproofing is desirable so that everyone is not awakened when one person watches
television, receives a page, or makes a telephone call. These sleeping facilities should be located
in close proximity to the OR suite for both infection control and traffic control but should be in
an area that is quiet and conducive for resting. If the sleeping facilities are to be segregated on
the basis of sex, project the ratio of males to females. Showers and toilets should be in or
adjacent to the sleeping facility. Clean linens and housekeeping services should be available 24
hours a day.
53

In light of growing concern about fatigue during longer shifts, consideration should also be
given to provision of sleeping facilities for napping, even during the daytime.
Security of the sleeping area is also a concern. Entrances to the sleeping area should not be
located in high-traffic public areas of the building. Easy access from the sleeping area to the
lounge amenities should be planned in advance.
Administrative Offices
There are many administrative functions required by an OR system. Productivity in this system
requires a large team of personnel to perform these functions. The hospital administration, in
concert with the nursing, surgery, and anesthesiology departments, should coordinate its
efforts in determining which department(s) will perform the various administrative functions to
prevent overlap of efforts and facilities. Equipment that is used by multiple departments (e.g.,
computers) should be selected to suit the needs of all parties involved. Administrative offices
need to be located close enough to the OR suites to permit ease of communication but not so
close that they interfere with patient care and workflow. The following list identifies many of
the administrative functions required by an OR suite:
Communication department
Credentialing department
Data collections and management
Disaster preparedness
Documentation
Financial
Forms development
Infection control
Legal responsibilities
Materials management
Pathology
Personnel services
Pharmaceutical control responsibilities
Policy and procedures development
Quality assurance
Safety
Scheduling
A specific area of importance is the scheduling office. Operative procedures require the
synchronization of many entities in addition to the patient, including surgeons, assistants,
anesthesia personnel, nurses, laboratory, radiology, medical records, supplies, and equipment.
The cost to the patient for a 1-hour procedure, including hospital, surgeon, and anesthesia fees,
can easily range from $1000 to $6000. This translates to $20 to $100 per minute spent in the
OR.
54

Obviously, money and effort invested on scheduling to prevent wasted OR time has a high yield.
Computerization of scheduling potentially allows more accurate time allocations based upon
historical data by surgeon and case, as well as prevention of conflicts in surgeons schedules
and equipment. Scheduling clerks should have dedicated telephone lines with headsets at their
terminals to improve efficiency in entering data via the telephone. All data entry personnel,
particularly those entering the OR record information, should have high-quality adjustable
furniture. Adjustments should include keyboard height and angle, display height and angle, and
chair height and back position. Foot rests and wrist rests are also useful. Additionally, data
entry personnel should be given other duties that periodically take them away from their
computer terminals. Tension headaches, carpal tunnel syndrome, back problems, and other
work-related health problems associated with data terminal work result in lost work days,
workers compensation claims, and a decrease in efficiency.
Conclusion
An OR is only as productive as its personnel. Intelligent planning and foresight from all parties
involved in the daily activities of the OR will allow for easier adaptation to future growth and
technological advances. Providing personnel with a few comforts of home while at their place
of employment will only serve to increase morale and job satisfaction.
Bibliography
Andrews JJ. Operating room personnel facilities. ASA Committee on Equipment and Facilities.
Bang C. Optimal Operating Room Design III. Jul-Aug 2004.
Haselby KA. Nursing and administrative needs in the operating room suite. ASA Committee on
Equipment and Facilities.
Patkin M. A users checklist for operating room suites. Michael Patkins website [Web site].
Available at: http://mpatkin.org/op_room_planning/or_checklist.htm.
55

CHAPTER 6
SUPPLY CHAIN
Lead Author: Tangwan Azefor, MD; Clinical Associate, Department of Anesthesiology & Critical
Care Medicine; Johns Hopkins Bayview Medical Center
Baltimore, MD
Checklist
1.
2.
3.
4.
How many anesthesia workrooms and how much space will be required?
Where will gas cylinders be stored?
How will medications be stored and distributed?
Where will bioengineering support be located?
It is not possible to devise a single plan for anesthesia support facilities appropriate for all
health care facilities. Important considerations include available space, location, present needs,
and future expansion. In larger facilities, more than one workroom may be required.
The Anesthesia Workroom

The precise location of the workroom should facilitate prompt serving of each operating room
(OR)/anesthetizing location and will, as such, depend on the design of the operating suite and
the location of the pharmacy and reprocessing areas. Proximity to recovery rooms and
preoperative holding areas should also be taken into account. The size of the room will be
determined by its function: whether primarily a storage facility or also the site of drug
preparation, cleaning of equipment, etc.
Storage
The anesthesia workroom should remain the main repository for anesthesia equipment and
supplies. These should be stored in such a way that they can be easily found, not only by
technicians but by all anesthesia personnel. This point is particularly crucial for out-of-hours use
and in facilities with relatively sparse technician support. As such, grouping of equipment and
supplies and use of cabinets with transparent doors is recommended. A printed or computerbased location list, which lists items by various names that they might be called, is very helpful.
Removing items from shipping containers prior to arrival in the workroom will not only
minimize crowding but also avoid introduction of dust, contaminants, and pests to the area.
Several small insects thrive in the corrugations of cardboard boxes.
56

Disposable items
The quantity of disposable items in the workroom will depend upon the capacity and efficiency
of other storage areas. If peripheral areas can hold and supply a large inventory of items on
short notice, the quantity of such supplies in the workroom may be limited to that required for
a few days. Procedure-based delivery systems, in which supplies are packaged together for an
entire case, increase efficiency.
Reusable items
Storage space for depositing reusable items prior to cleaning and sterilizing may be provided in
the workroom or in an adjacent area.
Other equipment
Equipment that may be urgently needed, even if infrequently needed, should be kept in the
workroom. There should be sufficient space and electrical outlets to allow for charging of
transport monitors, infusion pumps, etc. Specific anesthesia carts (e.g., difficult airway, latex
allergy, malignant hyperthermia, those destined for off-site anesthesia, etc.) should be located
in the workroom or in a designated nearby area.
Reprocessing
Decontamination of reusable equipment should not occur in places where clean equipment is
stored. A separate area nearby should be provided so that either the entire process of
decontamination, cleaning, and resterilization can take place or, alternatively, the initial
decontamination and cleaning can occur before the items are transported to a central area for
resterilization. Depending upon the size of the facility and other factors, the anesthesia
reprocessing area may or may not be combined with the surgical reprocessing area.
The volume of work will obviously also depend on how much of the equipment in each facility is
disposable, single-use equipment versus how much is reusable (e.g., laryngoscope blades,
laryngeal mask airways, bougies, etc.).
Other Functions
In some facilities, the workroom also provides space for paperwork (e.g., blank and completed
anesthetic records, protocols, etc.); equipment manuals and logs; bulletin boards; mailboxes;
and computers for e-mail, internet, and hospital information access.
57

Gas Storage
Cylinders
Cylinders of compressed oxygen, medical-grade air, and nitrous oxide need to be stored in close
proximity to the OR suite for use on anesthetic machines and for patient transport. Upright
storage in a rack with wheels facilitates transfer to central supply for restocking. The area in
which these are stored should be well ventilated and organized in such a way to easily
distinguish the full cylinders from the empty ones. Nonmedical gases (e.g., acetylene) used in
the facility should not be stored in the same location. The number of cylinders stored should at
least be sufficient in the event of pipeline oxygen failure. Many facilities store additional
cylinders in case of natural or manmade disasters. A system for ensuring adequate supply of
cylinders should be in place.
Liquid Oxygen
In some facilities, small portable liquid oxygen containers are used during patient transport. A
large stationary container from which these may be filled may be housed in the main workroom
or cylinder storage area.
Drugs
Several systems of drug storage exist for operating suites. One that provides not only efficiency
in procurement of medications for patient care but also cost containment and control of
abused drugs is essential. The model in which the anesthesia provider obtains controlled
substances from the nursing staff is a common one, but it requires a considerably large stock of
drugs to be stored in the OR suite. This model also risks inventory loss from expired
medications and causes inefficient use of time and personnel in attempts to witness wastage.
Automated machines with password or biometric access can be used to dispense controlled
drugs, other drugs, and needed anesthesia equipment. These machines may be located in each
individual OR and/or a central area, such as the anesthesia workroom. Charges to the patient
can be recorded by the machine. The drawbacks include the expense and possible malfunction
of the machine. Waste drugs may be returned to the machine, or witnessed wastage may still
be required.
The use of controlled drug kits that contain a predetermined selection of
opioids/benzodiazepines may also be used. In this case, the anesthesia personnel would check
out a kit at the beginning of the day and record drugs and amounts received by each patient as
well as witnessed wastage before returning the kit to a dispensing machine/pharmacy/drop
box/locked cupboard under the control of an operating suite staff (e.g., OR charge/recovery
room nurse) at the end of their working day.
58

The above systems will require considerable input from the main pharmacy in terms of
restocking, monitoring of expiration dates, user ID and password management, and supply of
nonstandard drugs (e.g., epidural infusions, vasoactive infusions, etc.). This arrangement may
require special licensing of personnel as dispensary pharmacies and may be legally complex.
A satellite pharmacy strategically located in the operating suite can help bypass some of the
problems of drug handling in the OR suite. Accounting for controlled substances may occur
between the anesthesia provider and pharmacist and, thereby, remove the need to involve
others, usually a nurse or a physician. Medication requirements that arise during the case may
be transmitted to the satellite pharmacist. In some cases, the medications may need to be
ordered from the main pharmacy, but the satellite may often represent a quicker, easier way to
obtain them.
A satellite pharmacy will also be able to provide drugs required for the surgical procedure and,
depending upon the facility, may also be responsible for supply to the labor-and-delivery suite
and for provision of off-site anesthesia. Accounting of medication (controlled and otherwise),
matching use to patient for billing purposes, and surveying agents that are rarely used will be
facilitated by centralizing this activity to one location. The arrangement for non-controlled
substances (e.g., inhalational anesthetics, muscle relaxants, emergency drugs, etc.) can widely
vary. In one model, a used anesthesia drug tray is exchanged for a fresh one. The pharmacist
inventories the used tray to determine what drugs were used and to generate patient charges.
Different kinds of cases may require different anesthesia drug trays. Additional drugs may be
supplied in automated machines or in the workroom. There should be a system in place for
restocking trays and machines. There would need to be trays/kits prepared for off-hours use if
the satellite pharmacy is not available at all times.
One can imagine a combined satellite pharmacy-anesthesia supply facility. Anesthesia providers
would retrieve not only medications but also expensive disposables and expensive durable
equipment from the same person in the same place.
Biomedical Engineering Facilities

Biomedical engineering facilities may be at a site remote from or allocated in a space within the
OR suite. If located in close proximity to the ORs, the engineering staff would be easily
accessible to the OR personnel and would be able to promptly respond to concerns regarding
equipment. This arrangement would also allow increased contact between engineers and
anesthesia technicians, promoting greater efficiency in maintenance of equipment. While some
simple malfunctions may be handled by anesthesia technicians, there needs to be a clear
delineation of which problems they may address and which should be referred to the
engineering department.
59

The drawbacks of having an engineering facility in the OR suite include isolation of the
engineers from the rest of the biomedical staff and deciding how much space is required. If
equipment will be stored while awaiting repair or while awaiting shipment for repair, and if
repair parts will be stored in the engineering area, a relatively large area will be required.
These facilities may also provide storage space for spare equipment that can be exchanged for
malfunctioning equipment (e.g., monitors, anesthesia machines, etc.).
Bibliography
Dorsch JA, Dorsch SE. Anesthesia Support Facilities. ASA Committee on Equipment & Facilities.
Keicher PA, McAllister JC 3rd. Comprehensive pharmaceutical services in the surgical suite and
recovery room. Am J Hosp Pharm. 1985;42(11):2454-2462.
Maltby JR, Levy DA, Eagle CJ. Simple narcotic kits for controlled-substance dispensing and
accountability. Can J Anaesth. 1994;41(4):301-305.
Sabir N, Ramachandra V. Decontamination of anaesthetic equipment. Contin Educ Anaesth Crit
Care Pain. 2004; 4(4):103-106.
60

CHAPTER 7
GAS AND VACUUM SUPPLIES
Lead Author: Steven Helfman, MD; Assistant Professor of Anesthesiology; Emory University;
Atlanta, GA
Checklist
1. What should be the location and number of outlets for oxygen, air, nitrous oxide, vacuum, and
scavenging?
2. Is there need for a second set of gas outlets at an additional location?
3. How will hoses be kept neat and off the floor?
Key Considerations
At an absolute minimum, there should be at least two oxygen outlets, one medical air,
one nitrous oxide, two vacuum outlets, and one evacuation (i.e., scavenging) outlet
available at the head of the table. Additional outlets, particularly for oxygen, are
strongly suggested.
If perfusionists will be required, they will need additional gases, including oxygen, air,
vacuum, and, possibly, carbon dioxide.
Consider a second set of hose drops for different room set ups (reversed patient
orientations) or future needs.
Determine the desired connection option: simple hose drops from the ceiling, wall
outlets, fixed columns, retractable hoses or columns, or multiservice articulated arms.
Every location routinely used for administration of inhaled anesthetics should have a
waste anesthetic gas disposal (WAGD) system that directly exhausts to the outside. This
exhaust port must not be near any fresh air intake ports.
The Centers for Disease Control (CDC) and National Institute for Occupational Safety and
Health (NIOSH) recommend that the ventilation systems circulate and replenish the air
in operating rooms (ORs) (at least 15 air changes per hour, with a minimum of three
fresh air changes per hour) and in recovery rooms (at least six air changes per hour, with
a minimum of two fresh air changes per hour).
Ideally, WAGD is handled by a dedicated system just for scavenged anesthetic gases that is
independent of both the vacuum and ventilation systems. Due to concerns of environmental
toxicity (e.g., smog/global warming), it is likely that emerging systems will allow for filtering and
reclaiming the waste gases.
61

Piped Gases
The anesthesia representatives on the design team must determine the number and location of
outlets for gases that will be piped into the OR. At an absolute minimum, there should be at
least two oxygen outlets, one medical air, one nitrous oxide, two vacuum outlets, and one
evacuation (i.e., scavenging) outlet available at the head of the table. If wall-supplied nitrogen
will be used to power equipment, then a pressure-regulated nitrogen outlet should also be
included, not necessarily at the head of the table. Several vacuum outlets need to be located
around the room for the surgeons. In addition, if the OR will be used for open-heart
procedures, then the perfusionists will need additional gases, including oxygen, air, vacuum,
and, possibly, carbon dioxide.
Providing only the minimum number of gas outlets may make it difficult to reconfigure the
room layout if the function of the room changes, however. Once the gas outlets are installed,
relocating or adding outlets will be a major expense that most hospitals will want to avoid. Long
gas hoses draped around the room to accommodate a new configuration create a hazard of
tripping and issues of contamination and cleaning.
In some roomers, there is a need to have the patients head 180 from the normal position. In
this case, the anesthesia machine will have to be moved to the opposite end of the room.
Therefore, a second set of hose drops should be installed. Some facilities may prefer to install a
second set of hose drops just for future contingencies. At an absolute minimum, it would be
quite prudent to add one additional air outlet and one additional oxygen outlet, especially if
there is ever the possibility to bring an intensive care unit ventilator or extracorporeal
membrane oxygenation machine to the room.
Trying to determine gas line drops during the construction period is problematic. Room air
handling and ventilation will have been designed by the mechanical engineers during the design
phase. The gas line drops need to be incorporated into this design process because it is unlikely
that the ventilation system can be changed once it is designed and accepted. Creating a
mockup may be the best way to determine the drop placements. This also allows a variety of
users to comment on the room setup. Graphical computer software is available to create
models of a room design. However, being able to move in a space to test it out is nice.
The method by which the gas connections will be brought into the room must also be
determined. The options include simple hose drops from the ceiling, wall outlets, fixed
columns, retractable hoses or columns, and multiservice articulated arms.
There are advantages and disadvantages to each of these. Hose drops from the ceiling are very
popular. They are cheap, easy to install, and flexible and require minimal maintenance.
Pigtails with any of a variety of quick-connects can be easily provided so that the hoses can be
quickly disconnected and the anesthesia machine moved to a different location.
62

Figure 1.
Hose connections from the wall have similar characteristics but frequently result in hoses that
are lying on the floor. If wall-mounted outlets are used, then the hoses should be suspended in
some manner that keeps them off the floor (or at least 3 feet away from foot and equipment
travel paths).
Fixed columns were once very popular, but they tend to reduce flexibility and can be a hazard
for tall individuals. Also, they must be opened or disassembled in order to inspect the condition
of the piping or hoses. Future standards requirements may require routine inspection of hoses
and other utilities housed in these columns. There are various methods that enable retraction
of the hoses. Although this would appear to be a good idea, it is usually of little value. Also, the
rolling and unrolling of the hoses can cause premature wear and possible rupture.
Figure 2
63
The multiservice articulated arm looks very impressive and has the potential to organize gas
supplies, electrical outlets, and telephone and data links into one area that can be repositioned
at will. These devices are very expensive, with a cost between $10,000 and $20,000 per room.
The potential advantages of these multiservice arms are frequently overlooked once they have
been installed. It is a good idea to include them in the initial budget request, however. In this
way, they can be omitted later if they are found to be unnecessary; if the department is asked
to reduce its equipment budget, they can provide a relatively painless, high-cost, give back.
Again, future standards requirements may require routine inspection of hoses and other
utilities in these articulated arms. In some designs, it is very difficult to add a new hose or cable
or to replace an old one. The location of the columns will be limited not only by the room air
handling equipment but also by the location of steel beams in the ceiling.
The multiservice articulated arm can also be designed for use by the surgeons and nursing staff.
These arms can hold pieces of equipment that are normally placed on the floor, such as
electrosurgical units, video monitors, light sources, and suction canisters. This eliminates many
of the electrical cords from the floor and increases the usable floor space. Also, because the
arms rotate through a nearly 360 arc, they can be located where needed for a given case. This
use of the multiservice articulated arm seems to make more sense than just for the delivery of
anesthesia gases. The movable, articulating column for gas and electric service sounds great,
but, in practice, one may want to analyze whether the anesthesia machine can be easily located
in the desired position. If not, the expense of the articulating, movable column may be saved.
Individuals may want to consider columns that are attached to the anesthesia machines, totally
minimizing the hoses getting in the way. The expense may not be justified, however.
In some European ORs, the anesthesia machine itself is mounted on a ceiling pendant. This
approach is almost unheard of in the United States, however.
64
Figure 3
The exact location of the gas drop is critical. It is important that the hoses are not draped over
the machine, damaging expensive monitors. Instead, the hoses should hang freely behind the
machine and still allow personnel to walk behind it.
Figure 4
It is almost impossible to accurately locate the gas outlets on the blueprints. The best method is
to tell the architect and contractor that the final position of the gas drops will be determined on
site.
65

Then, before the ceiling is finished, the position of the lights and ventilation grates can be
drawn on the floor and the exact position for the gases determined. In general, the hose drops
should be placed at a 45 angle, approximately 6 feet from the top right corner of the OR table.
Actual equipment or cardboard cutouts of the equipments footprint can be brought into the
room to determine how everything fits together. If a light fixture is in the position that the gas
drops should occupy, then that fixture can be reduced in size (i.e., a 4-foot light can be reduced
to a 2-foot light) or simply eliminated. There should be a more than adequate number of light
fixtures, and eliminating one should be of no consequence.
Consideration should also be given to a location for storage of an oxygen tank and a selfinflating bag for emergency use in case of anesthetic machine or pipeline gas delivery problems.
These items are required under the 2008 American Society of Anesthesiologists preanesthesia
checklist. One solution is a cylinder rack mounted on the wall behind the anesthesia machine.
The rack can be positioned at waist height and oriented at a 45 angle for easier insertion and
removal of the cylinder.
Scavenging/Waste Anesthetic Gas Disposal

Every location routinely used for administration of inhaled anesthetics should have a WAGD
system that directly exhausts to the outside. This exhaust port must not be near any fresh air
intake ports. Ideally, WAGD is handled by a dedicated system just for scavenged anesthetic
gases that is independent of both the vacuum and ventilation systems. If the anesthetic gas
scavenging system is combined with the room exhaust system, then the entire room exhaust
must be vented outside and not used for recirculated air so that scavenged gases are not
brought back into the rooms.
To prevent exposure to waste anesthetic gases exhaled by patients, the CDC and NIOSH
recommend that the ventilation systems circulate and replenish the air in ORs (at least 15 air
changes per hour, with a minimum of three fresh air changes per hour) and recovery rooms (at
least six air changes per hour, with a minimum of two fresh air changes per hour). This degree
of room ventilation will also protect against contamination from leaks in the anesthesia gas
delivery or scavenging systems.
An emerging concern is the venting of halogenated anesthetics and nitrous oxide into the
atmosphere and their possible effects as smog-producing agents and greenhouse gases that
contribute to global warming. Anesthetic agents are the second-highest fluorocarbon
pollutant a distant second to the Freon compounds. As more and more Freon-based
refrigeration systems are removed from service, however, we may anticipate that anesthetic
fluorocarbons may become the highest fluorocarbon pollutant. Emerging systems will allow for
filtering and reclaiming the waste gases. These future systems may be located within the OR
suite, but if they operate in a central location, they will be at the termination point of the
scavenging system.
66

CHAPTER 8
ELECTRICAL SERVICE
Lead Author: Steve Helfman, MD; Assistant Professor of Anesthesiology; Emory University
Atlanta, GA
Checklist
1. Should the operating room (OR) be considered a wet location?
2. Will shock protection be provided, and, if so, will it use isolated power or ground fault
circuit interrupters (GFCIs)?
3. What should be the type, location, and number of electrical outlets?
4. Is there a need for uninterruptible power supplies (UPS) and/or standby generators?
Key Considerations
Electrical power to the OR can be: 1) standard, grounded power, as in the home; 2)
isolated power, which was required up until 1984; or 3) GFCIs.
If the OR is considered a wet location, then either isolated power or GFCIs are
required. Most people who work in the OR would agree that the OR is a wet location
because saline solutions and blood are frequently spilled on the floor, but you may need
to convince hospital administrators and architects.
GFCIs might cost hundreds of dollars per OR. They provide safety from faulty
equipment, cutting power to it and anything else connected to same outlet. This may
cause power to be cut to monitors or other devices because of a faulty radio or
headlight.
Isolated power might cost in the tens of thousands of dollars per OR. It provides safety
by alerting to faulty equipment while keeping it, and everything else connected to the
same outlet, powered.
Determine the number of electrical outlets. A future National Fire Protection
Association (NFPA) standard may call for a minimum of 36 outlets in each OR and is
highly suggested.
Determine whether the electrical outlets will be standard three-prong or twist-lock type
connectors.
Determine the need for equipment (e.g., lasers and some x-ray equipment) that may
require 240-volt power with special electrical outlets.
Consider additional electrical outlets in anesthesia workrooms if you will need to charge
transport monitors, portable ultrasound machines, intravenous (IV) pumps, or other
equipment.
69

Electrical Power
There are three ways to provide electrical power to the OR: 1) standard, grounded power, as in
the home; 2) isolated power, which was required up until 1984; and 3) GFCIs.
With the common type of grounded power that is supplied to the home, it is relatively easy for
an individual to become part of an electrical circuit and receive a potentially harmful electric
shock. GFCIs are commonly installed in wet locations (e.g., bathrooms and kitchens) in the
home in order to provide protection against electric shock. The GFCI will interrupt the power in
the event that a hazardous current is flowing. All electrical devices on that branch circuit will
have the power supply interrupted.
The standards, codes, and Joint Commission requirements revolve around two issues. If the OR
is considered a wet location, then either isolated power or GFCIs are required. Most people
who work in the OR would agree that the OR is a wet location because saline solutions and
blood are frequently spilled on the floor.
Discussions are underway within the NFPA to declare that all ORs are wet locations or to
declare that they are wet locations by default, with local risk management able to determine
that they are not wet locations. Members of the American Society of Anesthesiologists
Committee on Equipment and Facilities have been unanimous in their opinion that all ORs are
wet locations.
The design team must decide whether to provide isolated power supply or GFCIs.
Administrators may look upon this issue as a way to save money. There is a large cost
differential between GFCI and isolated power. GFCIs might cost hundreds of dollars per OR,
while isolated power might cost between $5000 and $9000 per isolation panel, with one or
more panels used per OR.
If isolated power is selected, malfunctioning equipment will generate an alarm but will not
automatically shut off. Many anesthesiologists prefer this approach. The drawback of isolated
power, however, is that in many cases, it is difficult to identify which piece of equipment has
malfunctioned and is causing the alarm. Furthermore, isolated power systems generate the
alarm based upon the total leakage current, and, with many different pieces of electrical
equipment connected, each individual piece of equipment may be within its leakage
specifications yet the total current is above the leakage limit. Thus, there is no malfunction
and, yet, the alarm is sounding.
70

If GFCIs are selected, then malfunctioning equipment will be automatically shut off. It is
generally simple to identify the equipment that has automatically shut off and plug it into a
different circuit. The automatic shutoff could pose safety issues, however, if monitors or lifesupport equipment suddenly lose power. Life-support devices (e.g., ventilators,
cardiopulmonary bypass machines, etc.) commonly contain internal battery backup. If other
necessary equipment (e.g., fixed patient monitors) lack internal battery backup, freestanding
UPS can be used between the GFCI outlet and the piece of equipment. Adding freestanding UPS
to a GFCI system remains less expensive than an isolated system.
Figure 1
71

Every health care facility must have a source of emergency power. This is usually a generator
that is capable of supplying a significant amount of the facilitys electrical power requirements
in the event that the local electrical utility company experiences a power failure. Emergency
outlets in the OR (and elsewhere in the hospital) are commonly colored red, and if the main
electrical service is lost, only these red outlets will continue to supply electricity. If stored fuel is
used to power on-site generators, there must be enough storage capacity for at least 24 hours
of continuous operation. Although various codes may dictate that a minimum number of
electrical outlets in the OR and postanesthesia care unit be connected to the emergency
generator, it is desirable to have all of them connected.
Electrical Outlets
Standards call for operating and delivery rooms to have at least six receptacles convenient to
the head of the procedure table and for each OR to have at least eight duplex receptacles. In
todays environment, most would consider that woefully inadequate. A future NFPA standard
may call for a minimum of 36 outlets in each OR. It is far better to have too many than too few
electrical outlets. Although it is possible to identify and quantify the electrical requirements for
modern day OR equipment, it is impossible to predict how much electrical equipment will be
used in the ORs of the future. Therefore, electrical outlets should be placed on every wall. Also,
in order to help reduce the hazard of multiple electrical cords on the floor, outlets also should
be placed in the ceiling and gas/electric columns. These can be located at the head of the bed
on both sides of the OR table or both sides of the anesthesia workstation and are useful for
plugging in monitors, infusion pumps and fluid warmers.
Figure 2
72
Figure 3
Ceiling outlets at the foot of the table can be used for many pieces of surgical equipment. Cords
can be plugged into the ceiling outlet, extending to 6.5 to 7 feet from the floor.
Figure 4
The electrical outlets can have either the standard three-prong or twist-lock type connectors.
Virtually all hospital electrical equipment comes with three-prong plugs. Twist-lock plugs were
an older replacement for explosion-proof connectors that were required in the days of
flammable anesthetics. Twist-lock plugs provide some protection against accidental
disconnection.
73

Twist-lock plugs on OR equipment were once very popular in order to prevent the equipment
from wandering to other parts of the hospital because other areas of the hospital lacked the
correct electrical outlets to plug in the equipment. Over time, adapter cables (from standard to
twist-lock and from twist-lock to standard) appeared throughout the hospital. These adapter
cables posed additional expense and hazard, and most hospitals have abandoned the twist-lock
connectors.
GFCI circuits are not readily available with twist-lock outlets.
Figure 5
Certain equipment (e.g., lasers and some x-ray equipment) may require 208- or 240-volt power,
with special electrical outlets. The need for these outlets and their location within each OR
need to be anticipated in the design phase.
If anesthesia workrooms will be used to charge transport monitors, portable ultrasound
machines, IV pumps, or other equipment, appropriate electrical service should be provided for
this purpose.
74
2012 Operating Room Design Manual

CHAPTER 9
ROOM VENTILATION SYSTEMS
Lead Author: Kamal Maheshwari, MD, Staff Anesthesiologist, Cleveland Clinic Foundation
Checklist
1. Does the ventilation system in your operating room (OR) meet the standards given by
NIOSH (National Institute of Occupational Safety and Health), ASHRAE (American Society
of Heating, Refrigerating and Air-Conditioning Engineers), CDC (Centers for Disease
Control and Prevention), and AIA (American Institute of Architects)?
2. Can the temperature be adequately regulated?
3. Can the humidity be adequately regulated?
Many regulatory institutions, such as NIOSH, ASHRAE, CDC, and AIA, have developed standards
and guidelines for OR ventilation systems. As in any other environment, ventilation in the OR is
an important issue. The OR has some special needs, however. The goals of the ventilation
system are:
1. Comfort of the patient in the OR
2. Comfort of surgeons and other personnel in the OR
3. Control of the concentration of pollutants:
Chemical (anesthetic gases/volatile substances)
Physical (particulates/aerosols)
4. Ability to quickly raise or lower the temperature
5. Control of infections (microbiological pollutants)
There are various components of ventilation systems in the OR:
1. Ventilation
2. Heating and cooling
3. Humidity control
4. Waste anesthetic gas scavenging (see Chapter 7)
Ventilation
A ventilation system in the OR can be either a recirculating or non-recirculating system. A
recirculating system is one that recirculates some or all of the inside air back to the OR suites or
some other part of hospital, whereas in a non-recirculating system, all air brought to the room
is conditioned, outside air. When a recirculating system is used, the air return duct should have
a high efficiency particulate air (HEPA) filter built into the system. In an OR where inhalational
anesthetics are used, there should be separate systems for ventilation, vacuum (patient and

surgical suction), and waste anesthetic gas disposal (WAGD). A recirculating ventilation system
in the OR can be a problem if a passive WAGD system is in use. In a passive WAGD system,
waste anesthetic gas from the anesthesia machine is directed to the room ventilation return
duct that removes air from the OR. In a recirculating ventilation system, this waste anesthetic
gas will mix with fresh air inflow and be returned to the same room or other areas of the
facility. Thus, it is recommended not to use a passive WAGD system in new construction, and if
it is used, ventilation should be the non-recirculating type. It is best to have a separate active
WAGD system that is independent of both the ventilation and vacuum systems, and gases from
the WAGD system need to be exhausted directly to the outside.
Infection control is critical in ORs. Studies have demonstrated that most of the causes of wound
contamination in the OR are the result of the patients skin flora and bacteria shed on airborne
particles from the OR personnel.1,2 Room ventilation affects the distribution of these airborne
particles in four ways: total ventilation (dilution), air distribution (directional airflow), room
pressurization (infiltration barrier), and filtration (contaminant removal). As the air flows of the
room increases, the greater the dilutional effect on airborne particles. Balancing this
phenomenon is that while increased flow increases the effectiveness of air exchange, resultant
turbulent flow increases microbial distribution throughout the room. Low-velocity
unidirectional flow minimizes the spread of microbes in the room. Directional flow can be
inward, from the outside into the OR (negative pressure), or outward, from the OR to the
outside (positive pressure). Negative pressure ventilation is used for highly infective rooms in
the hospital (e.g., isolation rooms for tuberculosis patients) and positive pressure ventilation is
used for protective environments (e.g., ORs and rooms with immunocompromised patients).
Positive-pressure ventilation is used with a minimum differential pressure of 2.5 Kpa between
the OR and the corridors. Rarely, if there is highly infective patient in the OR, negative-pressure
ventilation might be used (if available). Most hospital ORs are currently designed with HEPA
filtration systems to maximize removal of contaminants in the air.
Operating room ventilation systems should operate at all times, except during maintenance and
conditions requiring shutdown by the buildings fire alarm system. During unoccupied hours, air
exchange can be reduced as long as positive pressure is maintained in each OR. Complete
shutdown of the ventilation system may permit airflow from areas with less clean air into the
relatively negative pressure area of the ORs.
Air is delivered to each OR from the ceiling, with downward movement toward several exhaust
or return ducts near the floor. This design helps provide steady movement of clean air through
the breathing and working zones. The AIA has specific guidelines for the location of outside
fresh air inlets to minimize contamination from exhaust systems and noxious fumes. Fresh-air
intakes (for instance, on the roof) are to be located at least 25 feet (7.62 meters) from exhaust
systems and areas where noxious fumes may collect. Plumbing vents may end as close as 10
feet (3.05 meters) to the air intake system.

Outdoor-air intakes are to be as high as practical, with their bottoms at least 6 feet (1.83
meters) above ground level or, if on a roof, 3 feet (0.9144 meters) above roof level. Air that
could otherwise be recirculated (relief air) but is discharged to the outside to maintain
building pressure is exempt from this separation requirement.
Using computational fluid dynamics analysis, a mathematical technique to comprehensively
look at room airflow, Chen et al. showed that a higher air inflow rate and a larger air-inlet area
are desirable for contaminant control, but these approaches are detrimental to the thermal
comfort of the staff and patient.3 Similar studies by Memarzadeh and Manning4 as well as
Memarzadeh and Zheng Jiang5 led the AIA to recommend an air-change rate in an OR of 20 to
25 air changes per hour (ACH) for ceiling heights between 9 feet (2.74 meters) and 12 feet (3.66
meters); a ventilation system providing a single-directional flow regime, with both high- and
low-exhaust locations; a face velocity of around 25 to 35 fpm (0.13 to 0.18 m/s) from a nonaspirating diffuser array (i.e., ceiling air inlets), provided that the array size itself is set correctly
such that it covers at least the area footprint of the OR table plus a reasonable margin around
it; and that if additional diffusers are required, they may be located outside this central-diffuser
array. According to the AIA, up to 30% of the central-diffuser array may be allocated to nondiffuser items (e.g., medical gas columns, lights, and equipment booms.)
Some controversy exists between engineers and clinicians over the need for laminar airflow
ventilation in the OR to further minimize airborne infection. Careful mathematical analyses of
airflow suggest laminar airflow is not necessary when the previously noted recommendations
are met. Clinical studies are confirmatory.6,7 Similarly, the use of ultraviolet light to cleanse the
room air is no longer recommended.8
Heating and Air Conditioning

Many studies have shown that keeping patients warm during the perioperative period is highly
beneficial. Additionally, the comfort of the surgical team should be kept in mind.
Recommended temperatures for ORs are between 68F and 73F during surgery and between
62F and 80F otherwise, and recommendations for the post-anesthesia care unit (PACU) are
between 70F and 75F.9
Heating and air conditioning systems must allow the individual room temperature to be raised
or lowered rapidly as needed for patient and surgeon comfort. This temperature change must
be accomplished without a large overshoot in the desired temperature and can be
accomplished with individual reheat coils in each OR. Care in how the room temperature is
measured is important because in a very large room, a thermostat controlling the air
temperature by measuring the air around a distant wall will not reflect the temperature around
the surgical table. Some thought should be given to placing the thermostat in the middle of the
room. A move to LED surgical lights, which produce significantly less heat, may make the
temperature of the immediate surgical environment easier to control since it will more likely
reflect the environment further away from the patient.

The use of devices to directly warm the patient also makes the room temperature less
important, except when patient cooling is desired.
Humidity Control
Humidity control is important because decreased humidity may lead to damage in the
respiratory tract and loss of body heat through evaporation of sweat. Excessive humidity is also
undesirable for patient and staff comfort. Relative humidity should be approximately 30%-60%
in most ORs and in the PACU.
Today, because of long procedures, multiple-layered gowning, and x-ray protection, many
surgeons are requesting lower temperatures in the OR. These lower temperatures affect the
moisture content of the air, as cooler air can hold less water vapor.
Obtaining specified temperature and humidity conditions can be a difficult, but not impossible,
task. If all the factors that affect environmental conditions are taken into consideration, the
goal is certainly achievable. Some key points to remember are:
1. Purchase a conditioning system with a tight single-point control thermostat and
humidistat.
2. Buy a thermostat and humidistat suitable for OR application; be sure that they are
properly positioned and routinely calibrated.
3. Ensure that the system has the capacity to handle the internal heat load and that it has
sufficient air-handling capability to promote uniform air temperature and humidity.
4. Be mindful of the influences of heat loads (i.e., heat-generating OR equipment, including
anesthetic and surgical equipment as well as patient- and fluid-warming devices) and try
to minimize them.
5. Ensure that the system has adequate design capacity for extreme outside temperatures.
As an example, many commercial buildings are designed to provide an interior
temperature of 78F with a maximum outside design temperature of 94F. In other
words, the system will provide a maximum of 16F of cooling. If the outside temperature
rises to 108F, as may happen in some parts of the United States, the inside
temperature will be no lower than 92F.
6. Ensure that the conditioned space and ductwork are well-insulated with an
uninterrupted vapor barrier.
Scavenging of Waste Gases (see Chapter 7)

Chapter 10
COMMUNICATIONS
Lead Author: David Cohen, MD, Anesthesiologist, The Children's Hospital of Philadelphia
Checklist
1.
2.
3.
4.
5.
6.
Decide on primary technology for person-to-person communication.

Project how the flow of patients will be tracked in perioperative complex.
Plan how equipment will be located and tracked.
Determine how emergency situations or calls for assistance will be communicated.
Create backup plans and systems for each primary communication scheme.
Ensure that the electronic medical records and all hospital information systems are
accessible to all who need access.
7. Determine how communication will occur across hospital units (e.g., from the operating
room [OR] to the laboratory or intensive care unit, from the surgical floor or emergency
department to the OR, etc.).
8. Guarantee that communication solutions are Health Insurance Portability and
Accountability Act (HIPAA) compliant.
9. Make sure the noise and interruptions of your communication systems do not interfere
with the work of the OR.
10. Determine whether the communication plan is viable in busy environment (i.e., simple
and user friendly).
Introduction
Increasingly, the ability to easily and effectively communicate is thought to be the basis of a safe
and efficient OR environment. Early in the design process of a perioperative complex, key staff
members need to delineate the flow of information and conversation that will improve
communication and, as a result, enhance patient care and the working environment.1,2 Whether
in a two- or fifty-room OR complex, the ineffectual transfer of information leads to errors in
care.3,4 The inability to accurately and effortlessly convey information among the perioperative
staff leads to decreased efficiency and increased frustration. A communication plan that
facilitates specific person-to-person conversation and access to specialized information is just as
important as the hallway and room layout that promotes patient movement and flow.
As the size of the perioperative environment increases, so may the intricacies of a
communication plan. While a simple, uncomplicated scheme may be all that is necessary for a
small perioperative complex, it is likely to be inadequate for a large, hospital-based complex due
to the number of people involved, the size of the environment, and the complexity of the

patients and their procedures. Even in a large, complex environment, communications must be
kept as simple as possible to minimize disruptions in patient care.5 Interruptions may lead to
diversion of attention, forgetfulness, or errors.1,6 Individuals can be overwhelmed with
information that might have been communicated in a less disruptive way. Charge nurses in the
OR can participate in as many as seventy-four communication events in one hour.7 Deciding
what information should be exchanged with an immediate conversation (synchronous) and what
data can be transmitted as a text message or icon (asynchronous) on a screen may minimize the
disruption and maximize the effectiveness of the transfer.
In all cases, a communication plan needs to address person-to-person, person-to-group, and
across-group communication as well as access to patient information, patient location,
procedural progress, and equipment location. Each team of individuals in the OR needs to be
able to communicate within each group as well as with others outside of their group.
Anesthesiologists need to be able to talk to other anesthesia providers and technical personnel,
both one to one and one to many, especially if there is a need for additional assistance or help
emergently. They also need to be able to contact or be contacted by nurses or surgeons during
the course of a day. Every group of individuals in the operating complex has similar needs. How
this communication is handled is important and needs to be part of the perioperative complex
design planning.
Information must also flow across the preoperative, intraoperative, and postoperative areas to
avoid delays and errors in care. Data from the preoperative area must be readily available in the
OR, just as operative data must be available to postoperative caretakers. Patient data from
outside of the perioperative environment, like pathology reports or radiological images, must
also be easily accessible. Whether data are written, printed, spoken, or electronic depends on
the specific environment, although as the change to the electronic medical record progresses,
most information will be electronically stored. Perioperative information must also flow to areas
outside the OR to ensure continuity of care and patient safety. Care must be taken to assure
HIPAA compliance of information to be transferred, especially with regard to accessibility and
encryption.8 Yet, crucial patient information, like allergies, must be immediately available to all
personnel. The information flow begins with the scheduling of the procedure by the surgeon.
Accurate transmission of scheduling information to the proper areas in the operative complex
ensures that correct equipment, staff, and time are allotted. Last-minute changes because of
initially poor information transfer increase staff frustrations and delays and likely decrease
patient safety.
The transfer of information on patient status and location is also important to the efficient flow
for those both inside and outside of the OR complex. Preparation of the next patient is based on
the progress of a previous patient and the availability of staff and equipment. How and to whom
this information is communicated is vital to perioperative flow. Transmittal of last-minute needs,
if any, to the appropriate individual is equally important to this process. Finding a patient in a
large complex can be easy or difficult, depending on how the patients location is communicated
to the staff. Families of surgical patients are comforted knowing the location of their family
member after they are separated from the patient. Hospital staffs arrange assignments,
8

movement of patients, and bed availability based on patient progress in the perioperative suite.
Knowing a patient is coming off bypass may alert the cardiac intensive care nurses to the
impending arrival of a new patient, just as the knowledge that a patient is finishing first-stage
recovery would alert a regular floor nurse to make a bed ready for an imminent patient arrival.
How this information is to be transferred may be different for each operative suite, but
designing how the information will flow is easier during the planning process rather than after a
suite is renovated or built.
Quickly and easily locating a piece of specialized equipment, like a surgical microscope, a laser,
an ultrasound machine for central line insertion, or a fluoroscopy machine, is based on good
communication. In a small operative complex, the location of equipment may be obvious, but in
a large, complex environment with many ORs and other perioperative locations, finding a piece
of equipment may be laborious and frustrating. The ability to quickly find a device, especially in
an emergency, is again based on communication and information sharing. Preventing the
simultaneous need of a specialized piece of equipment is also based on accurate
communication, usually beginning with the surgical booking, but may involve person-to-person
communication before, during, and after a surgical procedure. During the design process, an
overall plan to access and communicate about specialized equipment needs to be determined.
Guidelines
The American Institute of Architects Guidelines for Design and Construction of Health Care
Facilities, a manual used by most state governments, mandates that each OR has a system for
emergency communications with the surgical suite control station.9 Additionally, these
guidelines require that each preoperative and postoperative bedside at which patients are under
constant visual surveillance have the capability for two-way voice communication capable of
summoning assistance from the nursing staff. There must also be a mechanism to summon
assistance from the code team and, as backup, a mechanism to summon assistance from
another staffed area where assistance can be obtained.10 Bathrooms and changing rooms in
patient-care areas must have pull cords accessible from the floor that trigger the nurse call
system. In a large perioperative area, visual signals, like an emergency light over each bedside
and even directional cues in the hallway directing staff to the correct area, are required. While
each system needs individual consideration, the planning process needs to integrate all of the
systems to achieve the communication goals. Loudspeakers and audible alarms often form the
basis of institutional emergency communications for fires and other catastrophic events. The
location of these speakers and alarms as well as access to the system needs to be determined
primarily based on fire code regulations.11,12 Traditionally, regulation mandated separate public
address (PA) and fire alert systems. New regulations, recognizing the need to be able to give
specific, clearly understandable emergency instructions dependent on the situation, allow these
systems to be integrated as long as fire and other emergency communications take preference
over other system uses.13

Communication Technology
Wired Systems
Historically, wired communication systems have formed the electronic backbone for
communication systems. Over time, wireless systems will likely replace many currently hardwired communication systems. Cost and the ability to easily modify or add functions will be
important factors promoting wireless systems. At this juncture, the dependability of current
wireless systems is often less than many traditional hard-wired installations. In any case, a
communication closet with proper ventilation is often needed to house control equipment for
either system.
Public Address Systems
The ability to make public announcements in the perioperative area is unfortunately a
communication requirement, especially in emergency situations, for all but the smallest OR
complexes. As a communication system, PA systems provide widespread distribution of
information at the expense of the pervasive, unavoidable noise pollution. Ideally, usage
guidelines and alternative communication devices minimize the need for routine overhead
announcements. Although PA systems can be wireless in design, the need for the system to work
in emergency situations mandates a wired system with emergency power capability. Depending
on the design, PA systems can be accessed through a microphone in a central location, like the
OR control desk, or through one or more microphones or telephones acting as voice interfaces
for the system. These telephones can be part of the general telephone system or separate,
functioning simply as microphones for the system. As part of the general system, an access code
is often needed to dial into the PA system, possibly making this scheme cumbersome in an
emergency situation if not routinely used. Yet, integration into the telephone system may allow
access from a variety of locations in the operative suite while not cluttering the wall or desk
space with microphones or specialty telephones. While code access from multiple locations is
often desirable, care in designing this feature is important since unauthorized access from inside
or outside the perioperative area may be extremely disruptive. Paging from outside the
perioperative area may need to be blocked entirely. Depending upon the vision for the systems
use, multiple groupings of speakers may be desirable. Crucial emergency communications need
to be heard throughout the entire perioperative area, while an announcement regarding the
towing of an improperly parked car may need to be directed only to the waiting rooms. Specific
areas, like the ORs, preoperative and postoperative areas, and waiting rooms, can be set up as
individual groups in the system, with the ability to lump them together as necessary. Calling for
Dr. Jones for Room 1 may not be an announcement that needs to be heard in the waiting rooms
but may be appropriate for the OR complex and perianesthesia areas. Similarly, calling for a
family member may be inappropriate for in the ORs but appropriate for the waiting rooms.
Careful planning of how the system will be used will minimize noisy interruptions that serve to
irritate and impede care. Loudspeakers need to be placed so that all areas of the perioperative
area can easily hear and understand any announcements.
10

Likewise, their volume adjustment should be easily accessible so the sound intensity can be
tailored as needed to the noise in the environment. Part of the PA plan should include guidelines
for when intensity of a loudspeaker should be adjusted since a well-intentioned individual may
overlook a not so obvious but crucial function of the system that is voided by decreasing the
sound intensity of a specific loudspeaker.
With increasing technology, PA systems can be more and more complicated and intimately
associated with telephone and nurse call systems to provide more functionality for the hospital
staff. However, with an increasing complexity and dependency on other systems, crucial
emergency functions that were once straightforward and dependable may become more
convoluted and unreliable. During the design process of a PA system, its role in disaster
management can never be forgotten, supporting the need for simplicity and independence.
Telephones
Each perioperative location usually requires a wired telephone. At least at this time, wired
telephone systems are less likely to fail. Part of the design process will entail the placement of
the telephone, the number of telephones needed in each location, and the capability of the
telephone installed. Considering who will need to use a telephone will guide the placement and
number of telephones needed. Adding telephone receptacles during the design process is far
easier than after the construction is completed. The capabilities of the telephone installed are
often based on the telephone system installed in the institution but should be configured based
on where the telephones are located and how they will be used. Multiple-line telephones,
direct-dial buttons to key areas (e.g., the control area of the suite or STAT laboratory), easy
access to an overhead paging system, speakerphone capabilities (e.g., for telephone translation
services and pathology reports), and the ability to hold calls are a few of the capabilities that
should be considered in the planning stage.
Care should be taken in designing the telephone numbering system. As an example, the
circulating nurse telephones for ORs 1 through 10 might be 1001 through 1010, while the
anesthesia telephones for those rooms might be 1501 through 1510.
Local Area Networks
Access to wired local area computer networks also needs consideration during the planning
stages. Even the smallest surgery center will soon, if not already, need access to computerized
electronic records, e-mail, and electronic knowledge resources. Medical monitors may require a
dedicated (separate) local area network (LAN), as may anesthesia recordkeeping systems,
radiology imaging systems, surgical navigation systems, and others. A key decision that needs to
be made early in the design process is whether computers are going to be connected through a
wired system, wireless network, or combination system. Likewise, if multiple systems are to
coexist on a single LAN , careful attention to normal and peak bandwidth requirements is
essential.
11
If a wired LAN is contemplated, then access points need to be installed. Like wired telephones,
the number of access points and placement of these terminals should be determined by who
needs access to the computer systems. Consideration should be given to families in the waiting
room. Limiting access to electronic information may impede or hinder care. Having one
computer shared by circulating nurse, surgeon, and anesthesiologist may be inefficient and
frustrating if all need to access the computer at the same time, a phenomenon that often
happens at the end of a procedure when there is the need to write patient orders and complete
electronic nursing documentation. Installation of an electronic anesthesia information system
requires computer access on anesthesia machines and in the preoperative or consultative area
where preoperative evaluations are preformed or accessed. The use of electronic blackboards to
display the surgical schedule and patient location requires additional computer access as well as
specialized display screens in each OR, control office, and preoperative and postoperative areas.
Special consideration for wired access may need to be given to radiological data. As radiology
departments move to electronic images, large computer display screens are replacing the classic
x-ray light box. If large, heavy screens are installed, structural support issues, in addition to the
intranet connection placement, will need to be examined by the architects. The move to digital
radiographs will also require access points in either the OR or radiology equipment storage areas
to permit the transfer of images to central electronic storage systems. Transferring images in
reverse from a central electronic storage system to surgical navigation equipment may
necessitate special intranet connections near where the navigation equipment is to be used. As
we increase the use of electronic information, more and more access will be desired, so careful
consideration to both current and possible future needs need examination during the design
process.
Wireless Systems
Wireless communication systems depend upon either signal transmission to and from an
external network, like cellular telephones, or an internally configured communications network.
With continued advances in technology, information exchange capability will increasingly be
seamlessly incorporated into the OR environment. From the handheld device used for voice and
text communication, to information retrieval systems, to patient monitors and surgical
equipment, integration of information from all sources will be the norm. To accomplish this,
devices will communicate with each other and with one or several networks. How these
interchanges will occur is an evolving process. The Food and Drug Administrations Center for
Devices and Radiological Health has recently issued an initial draft of a guidance document that
discusses the used of radio-frequency wireless technology in medical devices.14
Some medical device companies have adopted wireless LANs using The Institute of Electrical and
Electronics Engineers (IEEE) 802.11 standards to exchange data using the larger unlicensed
Industrial, Scientific, Medical (ISM) frequency band.15 Other firms have created personal area
networks to enable data exchange using Bluetooth and ZigBee communication protocols or
ultra-wide band technology.
12

Wireless LANs use an exchange protocol that permits higher overall exchange rates, while these
other protocols use technology that is designed to use lower energy, minimize interference, and
permit multiple links in the same area. While initial evaluations of Bluetooth have demonstrated
minimal interference with medical devices, multiple devices may create signal degradation and
interference.16,17 Careful planning, risk assessment, and thorough testing is still needed in each
perioperative environment, especially as new devices are added. Eventually, these technologies
may minimize the electrical connections necessary for safe patient care while enhancing wireless
transmission of critical medical alarms, physiological waveform data, and real-time control of
medical devices.
Handheld walkie-talkies are small radio transmitters and receivers, operating usually with less
than 5 watts of power, which provide almost instantaneous communication between one person
and a group. Person-to-person communication is also possible, although the number of
individual conversations that can be held is limited to the number of channels on the specific
model used. To contact a different individual, one has to change to the appropriate personspecific channel. However, a one-to-many call, in an emergency situation, is easily accomplished
by pressing a button to talk. Because of the low power of the device, successful use in an indoor
environment with many walls and doors, such as an OR complex, requires the use of multiple
repeaters to boost the signal. During the design process, placement of these repeaters needs
consideration. Adequate signal coverage needs confirmation after construction is completed.
Higher power devices are not portable and may interfere with medical devices.18 Walkie-talkies
provide immediate access, although with little privacy, and may be seen by many as noise
intrusive. To minimize the number and duration of conversations, rules of use need careful
consideration.
Beepers
While slowly falling into obsolescence, beepers or pagers are still widely used in hospitals since
newer communication networks often have poor or spotty coverage. Unlike cellular telephone
networks, pagers often have better receptive coverage because of the way their signal is
transmitted, although local antennas may still be necessary to have complete coverage of a
perioperative area. A careful survey is needed to ensure appropriate signal coverage. Pagers
permit both one-to-one and one-to-many communication. Modern pagers can be accessed by
computer networks, telephones, and other pagers. Pagers can be assigned to an individual
person or an individual function, such as anesthesia on-call or anesthesiologist-in-charge. When
a pager number is assigned to a function, either the pager can be physically transferred to the
responsible individual or the page can be electronically forwarded to the device held by the
appropriate individual.
Classically, pagers have been a one-way communication system with many inherent problems.
First, the sender does not know if the recipient has received the message and, thus, whether one
has to resend the message or try an alternative recipient or communication system to transfer
the desired information.
13

Unpredictable message transmission speed also obscures whether a message has been received
since the transmission of a page may be delayed a variable length of time as the paging system
deals with multiple, simultaneous pages from several paging sources. As cellular networks
improve and less attention and resources are applied to paging networks, the unreliability of the
paging network may also increase. Even if the message is expediently received, a delay can arise
in response if the recipient has to find a telephone to respond. Delays also occur during the
callback process because the number paged may be busy or the person who placed the page
may have left the area. Newer two-way text systems resolve some of these issues. Two-way
systems have the capability to automatically notify the sender that the recipient of a message
has received the message and permit direct responses with short text messages, decreasing
patient care interruptions.19 Additionally, new systems can escalate messages to other systems,
like e-mail or cellular telephones, if a page is not opened in a specified time, essentially providing
an automatic backup system for message transmission.
Cellular Telephones
As cellular telephones become more and more ubiquitous, the desire to replace all
communication devices with one cellular telephone device will increase as long as the device can
fulfill the necessary communication needs. Initially forbidden in hospitals, especially in
environments where telemetry and sensitive medical devices were in use, current data suggest
that minimal restrictions, approximately 1 meter between cell phone and medical device, are
necessary to minimize the possible ill effects of cellular telephone use.20-22 Cellular telephones
send and receive radio transmissions to the nearest relay station, or cell tower. Proportional to
the distance to the relay station is the energy produced by the cellular telephone. The cellular
telephone will emit energy or radio waves even when no conversation is occurring. This
radiation can affect certain medical devices, although a 1-meter separation from the device will
usually minimize deleterious effects. Historically, certain locations, especially ORs, had poor
reception because of the shielding from the construction and distance from the cellular towers.
Hospitals can enhance reception by using wall-mounted relays, or distributed antenna systems,
in areas with little cellular signal. In addition to improving reception, less energy is emitted by
the cellular telephone to communicate with the closer antenna. Less energy emission decreases
the chance of the cellular telephone interfering with medical equipment.
Even the most basic cellular telephone allows person-to-person communication while protecting
patient privacy. Some telephones have a broadcast mode, or push-to-talk mode, allowing
communication from an individual to a group of individuals. Initially limited by group size and
number of groups, individuals with this function can have many specific groups with up to fifty
individuals per group, depending on the cellular telephone plan. In either mode, cellular or
broadcast, communication is simplified by contact lists that can be maintained, usually on each
telephone or through an internet website. By using the list to select a contact or a group with
the push-to-talk mode, the caller does not need to know the cellular telephone number of the
person to be called.
14

A system for updating lists needs to be considered since inevitable staff changes and telephone
number changes will decrease the effectiveness of the cellular device if no telephone list
maintenance plan is in place. Some devices can use voice recognition to even further simplify the
call and make the telephone call almost hands free. Text messaging allows certain types of
information to be conveyed without the need for a conversation to take place immediately or at
all. Information that needs no discussion is ideal for text messaging. Alerting the anesthesiologist
about changes in schedule or where the next patient is as well as results of laboratory tests
could be communicated by text messaging. At least one OR patient-tracking software has the
ability to automatically send text messages at points determined by the user.
The extent of cellular coverage is the key factor limiting the effectiveness of cellular telephones
in the perioperative environment. Since each cellular company uses different systems to send
and receive signals, all individuals must have a cellular device on a system with reception that is
acceptable both in the hospital and also outside of the hospital if one telephone is going to serve
as the primary communication device. Some cellular systems have the ability to seamlessly
transfer to a local wireless intranet network, or voice over internet protocol (VOIP), when in
range of the local network and then transfer to the cellular network when out of range of the
VOIP network. This technology may permit the use of cellular telephones where there is poor
cellular coverage. Careful consideration of cellular telephone coverage is important, and a
distributed antenna system, if necessary, should be part of the design plan. Negotiations and
contracts with one or more cellular carriers may be needed to establish and maintain an internal
network. Prior to opening a new or renovated facility, the cellular reception needs to be
surveyed and tuned since cellular coverage may not be totally predictable, even with the best
planning. Cellular telephone devices provide immediate communication between two
individuals, but instant communication can increase or decrease efficiency and safety.23,24
Frequent interruptions can be distracting and divert attention from a critical task. Yet, improved
communication of critical information may enhance safety in the OR. A protocol for cellular
telephone use in the perioperative environment is crucial for the device to enhance care as well
as allow families to use their cellular telephones in a safe manner.
Dedicated Telephone Systems
Several companies now manufacture proprietary wireless telephone systems that can be used in
the OR. These systems may or may not allow incoming and outgoing external calls. Coverage
areas, compatibility of equipment, and ease of use of the equipment are critical in evaluating
such systems.
Backup and Emergency Systems
Regardless of the nature of the telephone system installed, careful consideration needs to be
given to what will happen if the system is down or main power is lost for a short or extended
period of time. Some hospitals have installed a redundant emergency telephone system, with
separate numbers, to be used in case the primary system is inoperable.
15

Wireless Networks
Initially devised to promote computer-to-computer communication, wireless networks are
increasingly being used to promote the interchange of all types of data and voice communication
with devices that avoid the traditional tethering to walls and telephone lines. Commonly known
as Wi-Fi (wireless fidelity) or WLAN (wireless LAN), wireless networks require access points,
antennas, controllers, and connection to a local computer intranet. Devices to be linked to the
wireless network must have the ability to permit connection wireless interface cards.
Information technologists, architects, and end-users need to plan what types of data are to be
exchanged, estimate the volume of data interchange, and decide on the extent of the wireless
signal. Based upon these discussions, the configuration of the wireless network can be
developed, although prior to final implementation, a careful survey and tuning of the network
may be necessary because of the unpredictable interference from other devices and peculiar
structures, such as lead-lined walls.25 One advantage of a well-designed wireless network is the
ability to add new devices as they are developed without additional construction since wireless
networks and wireless devices conform to international standards.15 As newer devices are
developed, they can be added to the network since manufacturers add backward compatibility
to older versions of these network standards.
Wireless networks can be extensions of existing hardwired computer networks or independent,
new networks. Computers with wireless connections can be placed in the initial design phase
and then later easily moved as functions of new or renovated areas are better understood. New
computers or devices can be added to the network without significant construction simply by
configuring the wireless interface between device and network. Similarly, individuals can carry
portable connected handheld devices that allow access to results data or other medical
information and communication. The number of devices and type of information transferred is
limited only by the capacity of the wireless network. Voice communication, for instance, requires
significant bandwidth and will perform poorly, as well as disrupt other data transfer, if not
properly integrated into an appropriate network design.
Wireless telephones functioning locally over a wireless network, or VOIP system, can be used to
enhance person-to-person or person-to-group communication. Unlike traditional cellular
telephones, wireless telephones can be directly linked to the hospital communication system,
essentially functioning as extensions on the hospital system. Services such as local telephone
directories, extension forwarding, and attachment to nurse call systems are possible through
internal wireless systems. Just as with a cellular telephone system, continued upkeep of
directories and maintenance of coverage is needed. At least one company has developed a
wireless intranet telephone based on voice recognition.26 One contacts another or a group by
pushing a large button and saying the name of a person or group. Most other functions of
wireless telephones, like call forwarding and messaging, can be accomplished with voice
commands to the device. Limitations appear to be based on failure of voice recognition, privacy
concerns, and the adequacy of the wireless network.
16

Privacy can be maintained with an earphone with an attached microphone, although in the OR,
this may get in the way of the rapid use of a stethoscope. Noise in the perioperative
environment also interferes with the devices effectiveness.
With a local wireless system, communication ceases once out of range of the wireless network.
To decrease the number of devices that need to be carried, telephones that allow one to
communicate on a local wireless network and traditional cellular networks when outside of the
local network are being developed. Within the hospital, only one telephone network would need
to be maintained, and the hospital could avoid the commercial cellular telephone fees for inhospital use.
Radio Frequency Identification Systems
As the perioperative environment increases in complexity, electronic positioning devices may
facilitate additional communication, especially concerning the whereabouts of equipment, staff,
and patients. Radio frequency identification (RFID) has been used in manufacturing and sales
settings for a number of years and is slowly moving into the medical environment. The basis of
the system is a tag on the device or person to be tracked. Depending on the system
configuration, a specific tag either actively reports its position to a computer network or is
passively recognized as it moves into a zone with a sensor. Specialized software then interprets
the signals and shows the location of the tag. Historically, the passive system can use smaller
tags, which are less expensive since they do not have an internal power supply and are powered
by the radio signal from the sensor antenna. Passive systems can easily provide information that
a device has been removed from a specific area as long as it moves under or through a sensors
emissions. Specific RFID readers need to be positioned to create the zones in which the entry
and exit of a device is to be tracked. Active devices can function on their own network or on a
preexisting wireless network. Both network systems may need fine-tuning of relays or nodes to
enable the desired accuracy in the triangulation of the RFID sensor position.27,28
Enormous amounts of time and energy are spent looking for equipment and supplies in
perioperative complexes. Being able to see the location of specific devices on a computer screen
would likely save time and prevent the usual frustration that accompanies the search for a lost
or misplaced device. Eventually, RFID systems will integrate into supply systems to decrease
errors in supply, billing, inventory control, and medication management. This integration is not
yet widely available.
RFID networks may help in the automatic tracking of staff and patients in a complex
perioperative environment.29 In the OR complex, locating a patient or staff member is often
difficult. Depending on the accuracy of the system, RFID can track a patient through the
preoperative processcheck-in, radiology, and laboratoryand into the OR and then recovery.
Similarly, the location of a radiology technician or specialized nurse could be easily ascertained if
staff was tagged with RFID devices, minimizing the need for paging, telephoning, or looking
around for them.
17

With the appropriate interfaces, specific time points, like arrival, presence in preoperative area,
and arrival in recovery, could be automatically entered into an operative information system,
unlike conventional systems that require someone to enter data, making the accuracy of the
manually entered data only as good as the effort of those required to enter data.30 Automated
entry into management software, then, would likely enhance the accuracy of reports used to
make management decisions.
From a safety perspective, if computer software was correctly configured and available, an alert
could go off if a patient wearing an RFID device entered the wrong OR. Likewise, surgical sponges
tagged with RFID devices may enhance patient safety by making it more difficult to leave a
sponge in a patient.31,32 Matching blood products and medications to the correct patient may
also be possible as software interfaces mature.
Unfortunately, RFID and cellular telephones have similar risks in interference with existing
medical equipment and with communication devices sharing like frequencies. Both passive and
active RFID devices can significantly interfere with a wide range of medical equipment at
distances up to 6 meters.33 Before implementing a RFID system, careful planning and
examination of the proposed use, the environment, the software, and the hardware is necessary
to minimize unwanted effects.34
Other technology can also be used to perform similar functions. Low-energy, battery-powered
disposable identification tags have been used, as have bar codes that can be read at a distance.
Patient Tracking Software

Efficient patient flow is important to a safe and profitable perioperative environment. As the
complexity of the OR complex increases, knowing the patients location and progress decreases
the frustration of staff and enhances the safety and efficiency of the system. Computerized
tracking displays allow staff to avoid making telephone calls or walking to another location to
find a patient, determine if a patient is ready for surgery, decide if a room needs to be cleaned,
or determine if a patient is soon to be transferred outside the OR complex. Several of these
systems are integrated with scheduling and documentation systems, eliminating the need for
dual data entry. Electronic visual alerts can be incorporated into the tracking system used. By
tapping specific keys or key combinations, names can flash and/or change colors and icons can
appear or disappear, signaling a desired action to be initiated. These alerts may be used to
indicate a variety of actions, including the need to premedicate a patient, transport a patient,
clean a room, or make a patient bed ready at another location. These visual signals may
eliminate the need for one or multiple telephone calls since the data can be made available on a
computer display to all individuals who may need the information. Tracking information can be
accessed from each computer in the perioperative complex as well as from other specified
locations connected to the information system and software.
18

Some systems can be configured to send e-mails, text messages, or pages to specific individuals
when an alert or time point is entered. A surgeon can be alerted that his/her patient has been
called to the OR or that the previous patient has left the OR. Most current systems require some
manual entry of time points, although RFID input or bar code scanning may eventually simplify
the data input. Large display screens, like those seen at an airport showing departures and
arrivals, can be mounted in various locations to provide easy and ready access to the
information contained in the tracking system. Displayed information can be configured to be
HIPAA compliant, if necessary. Waiting areas can have screens to allow families to monitor the
progress of their family member, with a code used to represent the patient name. For instance,
patient names can be coded as initials or handles (e.g., Bubba, Coach, Dancer, etc.). For each
large display, network access and mounting issues need to be considered to ensure that both the
wall structure will support the heavy screen and access to power and a network server is
available. Additional space in the OR complex may need to be allocated to computers or servers
to enable a patient tracking system. Considerable effort is needed to plan for the necessary
hardware as well as in selecting and configuring the software so that it provides the information
needed by each specific OR setting.
Real-Time Display of OR Activity

Patient flow and procedure progression in an OR can also be followed with the use of real-time
video of the OR.35 An observer with OR experience may have enough visual cues to avoid the
need to visit or call for certain information. Displayed in area or areas frequented by OR staff,
real-time OR video can show whether staff, specialized equipment, and patients are in an OR as
well as whether the patient is positioned, draped, or undergoing surgery. In addition to a video
camera in the OR, a video network, image processor, and display unit or units are necessary.
Several of the new OR image systems have the capability to provide these room images.
Protecting privacy, maintaining patient confidentiality, and restricting access to images are
paramount concerns with the use of these video systems.36
Conclusion
As the complexity of medical care increases, information takes on increasing importance. How
and when information is transferred or exchanged affects safety and efficiency. Communication
system design, thus, needs to be an integral part of a perioperative plan. Retrofitting
communication systems is expensive, time consuming, and disruptive. Since technology has the
capacity to be both informative and disruptive, careful consideration of needs is paramount.
Future considerations also need to be addressed in the communication design. Adding empty
communication conduits to ORs ceilings and hallways during initial construction may save
significant money and disruption in the future as new technology is implemented. Just as
important, the communication plan must also deal with technology failure and how critical and
noncritical information will continue to be communicated in the perioperative environment in
the event of a disaster or catastrophic event.
19

Input into the planning process from representatives of all of the different perioperative groups
is necessary to ensure a workable plan that addresses all communication issues. Once a plan is
designed, the technology to facilitate that plan can be incorporated into the OR construction
project.
20

CHAPTER 11
MONITORING AND ANESTHESIA INFORMATION MANAGEMENT

SYSTEMS
Lead Authors: Shermeen Vakharia, MD, Clinical Professor, University of California Irvine, and
Robert Loeb, MD, Associate Professor of Anesthesiology, University of Arizona
Checklist
1. Are the number and capabilities of the anesthesia workstations (i.e., anesthesia gas
delivery system, ventilator, intravenous (IV) delivery system, patient monitor, and drug
cart) adequate for the procedures that will be performed in the facility? Have backup
and emergency needs been considered?
2. Do all anesthesia workstations meet the standard of care (i.e., American Society of
Anesthesiologists [ASA] monitoring standards, ongoing service plan, not obsolete, etc.)?
3. Is special equipment organized and available for managing cardiac arrest, difficult
airway, or malignant hyperthermia and for performing regional anesthesia?
4. Does the facility provide the infrastructure for perioperative data management,
including anesthesia information management systems (AIMS)?
5. Is there a well-organized team approach to choosing, installing, and maintaining the
perioperative data management system?
Introduction
This chapter will focus on equipment to be considered for a new operating room (OR) suite, as
well as an addition or alteration to an existing one. Personal preferences, cost considerations,
mandated requirements, and type of practice will all influence the specific devices chosen.1
Many of the details that a user might wish to consider in selecting equipment are discussed in
three recently published textbooks:
Ehrenwerth J, Eisenkraft JB, eds. Anesthesia Equipment: Principles and Applications. St.
Louis, MO: Mosby; 1993.
Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment, Construction, Care and
Complications. 3rd ed. Baltimore, MD: Williams & Wilkins; 1994.
Saidman LJ, Smith NT, eds. Monitoring in Anesthesia. 3rd ed. Boston, MA: ButterworthHeinemann; 1993.
Other excellent sources of information are Medical Instrumentation (the journal of the
Association for the Advancement of Medical Instrumentation) and Health Devices (a publication
of the Emergency Care Research Institute).
23

Anesthesia Machines2,3
While there are currently only a small number of companies producing anesthesia machines for
sale in the United States, there are some options available. United States standards for
anesthesia machines were published in 1979 and 1988.4,5 When purchasing a machine, be sure
to choose one that meets the 1988 standard. Used machines are sold by a few companies, and
it is important to make certain that such a machine can be serviced. Some models are no longer
serviced by the manufacturer, or the original manufacturer is no longer in business. In these
cases, parts may no longer be available. Considerations in evaluating a new machine include
service, cost, size, and desired features. The need for good service should be obvious, as all
equipment fails at some time and under some conditions. It is a good idea to discuss the quality
and promptness of a manufacturers service with other anesthesiology departments in your
area. Depending on the size of the department, having one or two spare machines is useful.
Spare machines will permit routine preventive maintenance to occur without affecting patient
care.
Many departments prefer to have machines from only one company or even only one model, as
there may be less chance for errors or misuse if all machines are the same. However, this may
place unacceptable limits on the practice. For small rooms, such as cystoscopy, endoscopy, and
minor procedure rooms, a smaller machine may be preferable. Machines that have only two
gases and two vaporizers can be made smaller than can those with three or four gases and
three vaporizers, but this may be unacceptable in certain practices. A small machine may also
be more suitable if it is to be moved from room to room or taken out of the OR suite to a
remote anesthetizing location.
Anesthesia machines come with a variety of features. Most have basic monitors, such as airway
pressure and respiratory volumes, and may also have gas and physiological monitors. Which
model is best for a particular practice depends on the needs of the practice and the monitors
already present in the department. Magnetic resonance imaging (MRI)compatible machines
are now available with ventilators, oxygen analyzers, and airway pressure monitors. Where
these machines can be placed in the MRI suite to avoid artifact on scans is dependent on the
machine and magnetic shielding. Prior to patient use, test scans should be performed to
determine the best position for the machine. Special gas cylinders made of aluminum must be
used. Many newer anesthesia machines are equipped with ventilators that are capable of
ventilating small neonates and infants unless lung pathology is significant. In departments
where premature and neonatal patients are frequently anesthetized, consideration should be
given to purchasing a ventilator specifically designed for these patients. However, it may be
difficult for anesthesia personnel who do not use this equipment on a regular basis to maintain
familiarity with it. When faced with a neonate with significant lung pathology, hand ventilation
and using a standard neonatal ventilator with a neonatologist or respiratory therapist present
to assist are options.
24

Monitors
Instruments that measure blood pressure (invasive and noninvasive), electrocardiogram (ECG),
oxygen saturation, central venous pressure, pulmonary artery pressure, temperature,
electroencephalogram, cardiac output, and respiratory and anesthetic gas concentrations
should be considered. These should be capable of interfacing with the electronic record, if one
is planned. The choice of appropriate monitoring instruments depends on the type of cases to
be performed in a particular room. If cardiac surgery is to be performed, a monitor that
includes most of the above parameters is desirable. If patients are relatively healthy and/or
procedures of low intensity are to be performed, ECG, noninvasive blood pressure, pulse
oximetry, inspired oxygen, and capnometry will probably be adequate. It may be desirable to
have monitors in the OR that are compatible with those in other areas of the facility, such as
the critical care unit or the postanesthesia care unit (PACU). This will facilitate transfer of
information between monitors, and sensors applied in the OR can follow the patient to other
areas. Having all monitors from the same manufacturer may lead to economy in parts and
better servicing. Modular monitors may be advantageous. With this type of device, a set of
modules, such as blood pressure, ECG, and pulse oximetry, is available for each room. Other
modules (e.g., invasive pressure and cardiac output) can be added as the situation warrants.
Modular equipment may have significant financial advantages, despite higher initial cost,
because upgrading can be performed without retiring the entire unit, and modules can be
swapped without taking the whole unit out of service. Some monitoring instruments are now
being built into anesthesia machines. This usually results in economy of space and integration
of machine and monitor information and alarms. A disadvantage is that the built-in monitors
may not meet all the needs of the user and may be different from monitors in other ORs. Also,
the entire anesthesia machine may need to be removed if the monitoring instrument needs
repair.
Electrocardiogram6,7
The ASA Standards for Basic Anesthetic Monitoring require that every patient receiving
anesthesia have the ECG continuously displayed from the beginning of anesthesia until
preparing to leave the anesthetizing location.8 If a strip chart recorder is not available, it should
be possible to freeze the display. Use of monitors that can detect ST-T segment changes may
result in increased detection of ischemia. Some of the newer monitors can automatically
recognize deviations from sinus rhythm and display them on the screen to be reviewed.
Noninvasive Blood Pressure Monitors7,9
The ASA Standards for Basic Anesthetic Monitoring require that every patient receiving
anesthesia shall have arterial blood pressure and heart rate determined at least every 5
minutes.8 A noninvasive blood pressure monitor may be part of a multivariable monitor, an
anesthesia machine, or a separate console.
25

Invasive Pressure Monitors9
Invasive (e.g., arterial, central venous, and pulmonary artery) pressure monitoring is frequently
employed in patients who are very ill and those in whom tight control of pressures is necessary.
Most invasive pressure monitors are part of a multivariable monitor.
Pulse Oximetry10,11
The ASA Standards for Basic Anesthetic Monitoring require that a quantitative method of
assessing oxygenation, such as pulse oximetry, be employed during all anesthetics.8 Pulse
oximetry may be incorporated into a multivariable monitor or the anesthesia machine, or a
dedicated pulse oximeter may be used.
Temperature Monitors12,13
The ASA Standards for Basic Anesthetic Monitoring require that a means to measure the
patients temperature be readily available. The temperature should be measured when changes
in body temperature are intended, anticipated, or suspected.8 A temperature monitor may be
part of a multivariable monitor or a small, inexpensive, stand-alone device.
Neuromuscular Transmission Monitors
A variety of neuromuscular transmission monitors are available,14,15 and it is recommended that
there be one in every OR. Patterns of stimulation should include twitch, tetanus, train-of-four,
and double-burst, and there should be a variable output in milliamperes. As yet, these devices
are not part of anesthesia machines or multivariable monitors but may be in the future. More
complex neuromuscular transmission monitors include the accelerometer and the
electromyogram, which are more expensive but have desirable features, including the ability to
accurately determine the train-of-four ratio. They can be used in cases in which the arm is
tucked beside the patient.
Airway Pressure Monitors16
Most anesthesia machines and some multivariable monitors have airway pressure monitoring.
Dedicated airway pressure monitors are also available. The pressure may be displayed as a
numerical and/or wave form. One of the newer developments is pressure-volume loops.
Respirometers17
Respirometers may be analog or electronic. Electronic versions may have associated alarms.
Some display flow-volume loops that relate the flow of gas to tidal volume. Respirometers are
incorporated into all new anesthesia machines but may also be part of a multivariable monitor
or a separate dedicated monitor.
26

Anesthetic and Respiratory Gas Monitors18,19
The ASA Standards for Basic Anesthetic Monitoring require that during administration of
general anesthesia, the concentration of oxygen in the patient system be measured by an
oxygen analyzer with a low oxygen concentration alarm.8 The standards also require that every
patient receiving general anesthesia have the adequacy of ventilation continually evaluated.
Quantitative monitoring of the CO2 content is encouraged. When a tracheal tube or laryngeal
mask is inserted, end-tidal CO2 to verify correct positioning in the trachea is required, as is
continual monitoring during the anesthetic when a tracheal tube or laryngeal mask airway is in
use. Gas monitors may measure carbon dioxide, oxygen, helium, nitrogen, and/or anesthetic
agents. A gas monitor may be a separate monitor or incorporated into an anesthesia machine
or a multivariable monitor. All anesthesia machines are equipped with oxygen monitors.
Other Monitors
Other monitors include cardiac output, transesophageal echocardiography, and the
electroencephalograph. The need for these will depend on the type of surgery to be performed
in a particular facility.
Breathing Systems20,21
The circle breathing system is the most popular in the United States for adult patients.
Completely disposable circle systems (including CO2 absorbent) are available. These may be
especially useful for patients with malignant hyperthermia or a highly infectious disease, such
as active pulmonary tuberculosis. Disposable breathing circuit tubes come in a variety of
lengths, with and without bacterial filters, and as stretchable or coaxial. There are a variety of Ypiece configurations. Most disposable breathing tubes are clean but not sterile. If tubes are to
be added to the surgical field, sterile ones should be available.
Systems other than the circle, such as one of the Mapleson systems, may be used. They may be useful
for transport, resuscitation, application of continuous positive airway pressure, and pediatric patients.
These are not commonly used for general anesthesia for adults because the gas flow required for
adequate ventilation makes them uneconomical.
Humidification Devices22,23
Disposable heat and moisture exchangers, especially those that also filter viral and bacterial
particles, have become popular. Use of heated humidifiers has decreased with the increased
use of heat and moisture exchangers, low fresh-gas flows, and forced-air warming machines.
27

Warming Devices
Forced-air warming machines maintain intraoperative normothermia better than do circulatingwater mattresses24 and are often used during prolonged cases. However, it is recommended
that some circulating-water mattresses be kept for cases in which a forced-air machine cannot
be used. For pediatric cases, radiant heat warmers may be desirable. Devices for warming fluids
usually surround the IV tubing with a water bath or a heating element. These devices are useful
if large volumes of cold blood or IV fluid are to be administered.
Airway Management Equipment25,26
Tracheal Tubes
Tracheal tubes need to be stocked in sizes commensurate with the particular anesthesia
practice. Laser tubes, molded tubes for head and neck surgery, double-lumen tubes, wire-spiral
tubes, and tubes for bronchoscopy or laryngoscopy may be needed for special situations.
Double-Lumen Tubes and Blockers
Both right and left double-lumen bronchial tubes with appropriate suction catheters and stylets
need to be available if thoracic surgery is to be performed. A means to apply continuous
positive airway pressure should be available when a double-lumen tube is used. An alternative
to a double-lumen tube is the Univent tube, which has a bronchial blocker.
Airways
Oral and nasal airways should be available in a variety of sizes. Special airways for fiberoptic
intubation should be available (see Fiberoptic and Difficult Intubation Equipment below).
Airway Accessories
Airway accessories, such as forceps, stylets, and adaptors, need to be available. The specific
items depend on the users preferences and needs.
Laryngoscopes
The laryngoscopes that are needed will depend on the preferences of the user. Both straight
and curved blades in a variety of sizes and at least two handles should be kept in each
anesthesia cart.
28

Fiberoptic and Difficult Intubation Equipment
The following equipment may be useful when a difficult intubation is anticipated or when
fiberoptic intubation is planned: fiberoptic light source and fiberscope; defogging solution;
swivel fiberoptic adaptors; local anesthetic spray; Patil-Syracuse endoscopic mask; fiberoptic
intubating airways (e.g., Ovassapian, Patil-Syracuse, Williams, and Berman); fiberoptic stylet
laryngoscope; lighted intubation stylet; Bullard laryngoscope; Wu scope; bougies; tracheal tube
changers; laryngeal mask airways; cricothyrotomy device; jetting device or other transtracheal
jet ventilation equipment; and combitubes. Arrangements of equipment for fiberoptic
intubation are given in several publications.27
Automatic Infusion Devices28-32
Automatic infusion pumps are used in the OR to administer IV fluids, anesthetics, analgesics,
vasopressors, and epidural solutions. It is best to have the same type of IV fluid pump
throughout the facility. Electronic syringe pumps have become increasingly popular. Often,
standard disposable syringes already stocked by the facility can be used. A drawback to these
devices is that the size of the reservoir is limited. The selection of a pump depends on several
factors, including available features, cost of the pump, cost of the infusion sets, safety, ease of
use, and required maintenance. The device should have a battery backup so that it will function
during transport. If the infusion devices have data port outlets, infusions can be recorded on an
automated anesthesia record.
Equipment for Regional Anesthesia
It may be convenient to keep equipment and supplies used for regional anesthesia on a
separate cart. A variety of disposable trays are commercially available. It is good practice to
keep extra needles on hand to replace ones that become contaminated or damaged rather than
open another tray. A supply of extra-long needles should also be available. The following
equipment should be considered for a regional anesthesia cart: B-bevel needles; marking pen;
insulin syringe; tourniquet; prep pads, sticks, and solution; bactericidal ointment; double
tourniquet for Bier block; spray adhesive; various types of tape; scissors; nerve finder and
special insulated needles; sterile gloves; clear adhesive bandage; control syringes; temperature
monitor; and intubation equipment. An ultrasound machine to assist with needle placement is
a useful adjunct.
Resuscitation Equipment33
Each OR suite should have at least one cart that contains the items needed to deal with a
cardiac arrest. It is expected that laryngoscopes, stylets, forceps, airways, tracheal tubes, and
other equipment commonly stocked on an anesthesia cart will be available in each OR and
would not be needed on the resuscitation cart. This may not be the case for the holding area or
the PACU, so a complete supply of drugs and equipment needed for emergencies should be
29

present. The following equipment should be considered for a resuscitation cart: spinal needles
(18G, 19G, and 20G); labels; IV catheters; prep solutions, tourniquets, tape, and gloves; ECG
pads and paper; defibrillator pads; blood pressure cuff; urinary catheterization kit; nasogastric
tubes; wall suction setup, tubing, and suction catheters; monitor and defibrillator; external
pacemaker; self-inflating resuscitation bag; and face masks.
Pediatric Equipment34
While pediatric equipment may be readily available in a health care facility where pediatric
surgery is routinely performed, it may be preferable to have pediatric equipment carts available
in facilities where pediatric anesthetics are less often performed. A pediatric cart might contain
the following: tracheal tubes in 0.5 mm sizes from 2.5 to 6.0 mm, both uncuffed and cuffed;
laryngoscope handles and blades in pediatric sizes; pediatric suction catheters; pediatric
breathing systems (e.g., Mapleson A, D, and F); pediatric ventilator bellows (if required by
anesthesia machine); pediatric airways; precordial stethoscopes; pediatric masks; pediatric
blood pressure cuffs in assorted sizes; Doppler ultrasound for blood pressure determinations;
pediatric temperature probes; pediatric laryngeal mask airways; pediatric nasogastric tubes;
pediatric urinary catheters; and a pediatric self-refilling bag-valve-mask unit.
Malignant Hyperthermia Cart
The following equipment should be considered for a malignant hyperthermia cart: malignant
hyperthermia protocol and hot line number; chart for recording drugs, temperatures, and
various interventions; syringes and needles; arterial blood gas (ABG) kits; arterial catheters;
pressure transducers; Vacutainers for laboratory tests; central venous and pulmonary artery
catheters; pressure bags for IV infusions; temperature probes (e.g., esophageal, rectal, etc.),
including pediatric sizes; nasogastric tubes, including pediatric sizes; urinary catheters, including
pediatric sizes; cold packs; cold IV solutions; and 1,000-mL bags of sterile water for mixing
dantrolene.
Trauma Cart
Many departments find it useful to keep a cart stocked and ready for handling major trauma
cases. The following should be considered for inclusion on such a cart: drugs (e.g., albumin and
hetastarch, Hep-Lock solution, heparin, etc.); central venous and pulmonary artery catheters;
central venous pressure manometer; pressure transducers; arterial catheters; ABG kits;
Vacutainers for laboratory tests; blood filters and administration sets; IV solutions; fluid
warmers; pressure bags for infusions; flexible oximeter sensors; and urinary catheters and
urometers.
30

Anesthesia Information Management System
Product Selection and Evaluation
Departmental and institutional goals will largely determine AIMS product selection. Obviously,
a system comprising a full array of perioperative modules (i.e., surgery scheduling,
preoperative, anesthesia, PACU, Nursing, and postoperative) is most desirable. The following
should be considerations for goals: Electronic Medical Record [EMR]
Business and efficiency enhancement tools
Patient safety and quality improvement
Areas of use (e.g., preoperative, intraoperative, postoperative, ORs, ICU, obstetrics [OB],
etc.)
Clinical work flow: Patient care protocols
Drug tracking: Regulatory compliance
Billing, coding, and charge capture
Outcomes research: Return on investment considerations
Data exchange: Links to an enterprise-wide clinical information system
Senior departmental and Information Systems IS leadership steer the selection and
implementation of AIMS by setting performance standards and expectations. Issues to be
considered before product evaluation include:
Who is paying for the system? Rather than the best system, there may be institutional
pressure to implement an AIMS by the same vendor used elsewhere in the hospital.
Locations where AIMS will be used (OR, OB, MRI, Cardiac Catheterization labs, ICU)
Information technology (IT) support needs to be addressed early:
o Adequate support and staffing during implementation
o Ongoing maintenance, including 24 hours/day-7 days/week coverage during the
go-live phase
o Plan for ongoing IT support, server structure, and software products
o Wireless coverage
o Interfaces with existing applications (e.g., admission, discharge, and transfer [ADT];
pharmacy; materials management; laboratory; billing; etc.)
o Security considerations
Functionality requirements should be considered. These include data capture from
physiologic monitors and anesthesia machines, graphic anesthesia record display at
each work station, automatic report generation for pharmacy, billing, materials
management, hard copy printout, automatic data backup, electronic signatures for
anesthesia providers, and special access privileges.
The leadership, along with an implementation team (see below), generates a detailed request
for proposals (RFP). The vendors then provide information on costs for purchasing and
licensing, upgrades, support, maintenance, and other requirements, like network specifications,
work stations, servers, applications, interfaces needed, and hardware estimates. Adequate
account should be made for hardware and other essentials. These include keyboards, computer
31

mice, cables, brackets, mounting arms and devices, network switches, uninterruptible power
supplies, and mobile adjustable carts for workstations on wheels (WOWs). Computers with six
data ports are usually well suited for connecting to physiologic monitors and anesthesia
delivery systems. Monitor configuration and display is vendor dependent.
Important considerations in selecting a vendor include track record on AIMS implementation
and performance at other sites; average time from contract signing to go-live date; company
size and stability; business and service plans, including costs of software upgrades; system
interfaces; compatibility of systems with standard commercial software and hardware;
technical support; and minimal acceptable functional requirements. Other factors that
determine the robustness of a vendors AIMS include work station response to temporary
power or network failure, system availability during software security patches and application
updates, daylight savings time transitions, detection of real-time provider concurrency, visual
and electronic alerts and prompts, and accommodation of unusual clinical scenarios (e.g.,
emergency case, death in the OR, discontinuous anesthesia times, patient identification errors,
etc.).
The total cost of an AIMS is $4,000.00-$9,000.00 for each anesthetizing location. The WOWs
cost approximately $6,000.00-$8,000.00. The timeline and target dates should be set in
conjunction with vendors, depending on the departmental requirements and available
resources. The implementation can take anywhere from 6 months to 2 years before a go-live
date is achieved. The ongoing IT support cost and model needs to be incorporated into the
proposals and accepted in the initial approval phases.
Implementation Team
The implementation team typically consists of a core group of members from anesthesiology,
perioperative services, biomedical engineering, and IS. Individuals from materials management,
billing, compliance, pharmacy, and perioperative nursing may also play a role on the
implementation team. The lead personnel on the implementation team include:
Project manager, preferably a senior anesthesiologist familiar with IT, who oversees the
project, including interface design, hardware purchase and installation, and daily
progress of the project; escalates issues beyond the authority of the implementation
team to appropriate levels; and determines go-live readiness
Anesthesia clinical lead, who configures the software, confirms the completeness and
accuracy of all the lists and verifies documentation, coordinates with Compliance and
other committees to obtain approval of electronically generated medical records, and
updates end users on new developments
System administrator, who oversees day-to-day management after the go-live date,
triages problems as they arise with a good working knowledge of the software, and
generates reports for various departments and quality assurance
32

Configuration Setup
Software customization has to be balanced with end-user adaptation and work flow. Creating a
standardized format for documentation can minimize free-text entries. These formats include
action buttons, lists (for medication, drips, fluids, blood products, quality indicators, etc.),
subspecialty templates (e.g., cardiac, pediatric, obstetrics, ambulatory, etc.), and drop-down
menus (for procedures and other documentation). However, this software build has to be done
cautiously so as not to compromise reliability, ease of upgrades, and user training.
Patient safety, compliance, and process improvement
Essential documentation of patient safety protocols, for example, preoperative anesthesia
safety check, World Health Organization and The Joint Commission (formerly JCAHO)
recommended preprocedure verification, Universal Protocol- National Patient Safety Goals,
patient reassessment, and presurgical time out, can be formatted for ease of documentation
and auditing. Macros or templates can prompt the user to follow and document established
patient care protocols and increase adherence with Physician Quality Reporting System
(formerly PQRI). Visual alerts can further aid documentation, and decision support has the
potential to improve medical care. The Anesthesia information database can also be used as a
quality assurance tool. A comprehensive perioperative AIMS that interacts with the PACU
nursing module can be used to identify patients at risk for postoperative complications (e.g.,
postoperative nausea and vomiting, pain control, respiratory depression, etc.) and close the
loop on quality improvement. AIMS that interface with the OR scheduling software enable
tracking of times to improve efficiency (standards defined in the Procedural Times Glossary by
the Association of the Anesthesia Clinical Directors). Physician-specific reports produced from
an AIMS database can also be used for education and improvement of quality of care and
efficiency. Electronic signatures and special privileges for attending anesthesiologists must be
delineated to fulfill attestations of medical direction and supervision in compliance with
regulatory agencies. Electronic signatures must also be suitable for billing.
Interfacing
Proper configuration of the software can help minimize redundancy in data entry. AIMSs
essentially interface with OR scheduling and ADT databases. Most will also interface with
materials management, enabling charge capture, and with pharmacy, allowing charges for
drugs and tracking of controlled substances. Real-time integration with perioperative nursing
enables sharing of common data fields, for example, surgery start and stop times. Most AIMSs
also communicate with the laboratory information system. Accuracy of data transfer must be
verified before the go-live date. Most of the interfaces between clinical databases are on the
HL7 Clinical data architecture format.
33

Training and Go Live
Thorough testing of network and server problems is essential before going live. Going live in a
multiuser environment is never totally smooth. Education must be planned in close proximity to
the go-live date so that the training is not forgotten. Classroom-style sessions with hands-on
training of each trainee at a work station are most effective. Essential elements of training
should include selecting the correct patient, filling a complete record, accurately entering drugs
and controlled substances, closing the anesthesia record, and troubleshooting basic issues (e.g.,
making sure observations are turned on, checking connections, rebooting, etc.). The attending
anesthesiologists training should also include attestations for medical direction and supervision
as required by regulatory agencies. Drop-in sessions, in which AIMS stations manned by a
superuser are set up in close proximity to the OR suite, have also been described.
Go live can be done in a big-bang approach, in which all the work stations go live in a matter of
few days to a week. Laminated cards or cheat sheets with essential instructions can be helpful.
A call center should be established to receive calls regarding concerns or questions and to
expeditiously deploy appropriate help. The number for the call center should be posted at
every work station. Both the vendor and the institution must commit enough resources,
including personnel support 24 hours a day for the first couple of weeks. All electronic records
must be reviewed for errors before they become a permanent part of the patient record.
Adequate resources are key to the success of go live; lack of adequate support may lead to staff
frustration, poor documentation, and delays in patient care. An alternative approach to the bigbang rollout is the graded approach, which may be preferable in large institutions with few
superusers and multiple clinical environments with different anesthesia machines and
monitors, each of which require different interfaces. Sometimes, concurrent charting on paper
records and electronic records for the first few days of going live allows checks for consistency
and accuracy of electronically produced records.
Systems33,35,36
An AIMS is more than just a record-keeping mechanism. If such a system is contemplated, each
piece of equipment must have an interface port. It is important to have adequate wiring to
interconnect the various components.
34

CHAPTER 12
PATIENT INTAKE AND AMENITIES
Lead Author: Uday Jain, MD, PhD, Staff Anesthesiologist, Highland Hospital, Oakland, CA
Checklist
1. Are there adequate waiting areas for patients and families?
2. Are there adequate facilities in the preoperative holding area?
3. Where will invasive monitoring lines and regional blocks be placed, and what facilities
and equipment will be needed for these?
Patient-intake areas of the operating room (OR) suite receive incoming surgical patients and
their companions. Patients discharged after surgery may also utilize these areas. These areas
include the preoperative waiting room, usually staffed by a clerk, and the preanesthetic holding
area staffed by nurses and other personnel. A separate toilet facility should be available for
each of these two areas, as the patients in the latter area are usually in hospital gowns. An
anesthesia preoperative clinic and pain clinic may be adjoining and may use these areas as well
as require examination rooms. Procedure rooms for nerve blocks, placement of invasive
monitors, and other procedures may also be parts of these areas. The same rooms may serve as
examination rooms as well as procedure rooms. In the absence of separate rooms, procedures
may be performed in the preanesthetic holding area. Inpatients may not be brought to this area
but instead briefly wait in the corridors during their trip to the OR from their bed in the ward.
Some hospitals, especially the older ones, may not have patient-intake areas near the OR. In
those hospitals, even the outpatients may briefly wait in the corridors during their trip to the
OR from the intake area.
After their discharge from the postanesthesia care unit (PACU) or directly from the OR, day
surgery patients may be brought back to the preanesthetic holding area, which now serves as
the phase II recovery area, from where the patients are discharged home. Alternatively, the
phase II recovery area may be separate from the preanesthetic holding area.
Time in the OR is substantially more expensive than in the preanesthetic holding area, which is
substantially more expensive than in the preoperative waiting room. The patients are brought
to the preanesthetic holding area so there is sufficient time to complete preparation for
anesthesia and surgery before they are transferred to the OR.
Surgical patients are generally grouped into three categories: 1) inpatients, who are in the
hospital the day prior to surgery; 2) day surgery outpatients, who come to the hospital and
return home in less than 24 hours; and 3) morning-admit patients, who come to the hospital on
the morning of surgery and stay at least 24 hours.
37

The facilities required for each group vary. For example, inpatients arrive in the OR suite in
hospital gowns. Outpatients and postoperative admission patients arrive in street clothes and
need dressing rooms and storage facilities for their clothing and belongings. Currently, a
majority of patients in most health care facilities are day surgery outpatients.
The preanesthetic holding area is utilized by nurses and physicians to perform preparatory
activities for anesthesia and surgery. Examples include intravenous (IV) catheter placement,
medication administration (e.g., antibiotics, sedatives, etc.), charting (e.g., verifying patient
identification, permits, vital signs, nursing assessments, etc.), and monitoring. The
preanesthetic holding area usually contains beds or stretchers screened by curtains on
suspended tracks. This is preferable to isolated rooms, which increase nursing staff needs,
decrease nurse supervision of patients, and require a nurse-call communication system.
Individual bays offer increased privacy without compromising nursing supervision, especially
if the nursing station is located to optimize patient observation. Facilities suggested for each
bed space (station or bay) include lights, electrical outlets, emergency call button, privacy
curtains, and a bedside chair. Each station usually has monitoring comparable to that in the OR.
Piped-in oxygen and suction are also provided. The preanesthetic holding area also requires a
clean utility room for supplies, such as drugs, syringes, needles, IV catheters, sets, and fluids. A
soiled utility room is needed for items such as soiled linen and urine samples, and clean storage
for linen and nonmedical supplies is also needed. Appropriate resuscitation equipment (e.g.,
crash cart) must be readily available.
Invasive procedures, including placement of radial artery, central venous, and pulmonary artery
catheters, may be performed in the preanesthetic holding area or an adjoining procedure
room. Induction of regional anesthesia (e.g., epidural and upper extremity blocks) may take
place in this area, as may induction of general anesthesia in pediatric and developmentally
delayed adults. This may involve the administration of intramuscular, intranasal, oral, or rectal
anesthetics. Specific patient populations may require special facilities in the preanesthetic
holding area. For example, the hospital environment often causes apprehension in children. A
colorfully decorated designated pediatric area with toys and the availability of television or
video games may alleviate some of the fears and anxieties. Parents are often allowed to remain
with their children in the preanesthetic holding area, as it usually decreases anxiety, but will
increase the number of persons that must be accommodated in the area. Patients with
contagious infections may need to be isolated from other patients, and an isolation room
should be a part of this area. Prisoners and their guards may also be segregated from other
patients.
According to Bolognesi, when building or renovating a health care facility, the use of
appropriate consultants is recommended. These include: 1) a health care facility consultant
(i.e., a strategic planner who understands and assesses the political atmosphere, addresses
Certificate of Need issues, and organizes the building/renovation project); 2) a financial
consultant; 3) an architect/engineering team; and 4) a construction contractor.
38

Planning for the patient-intake areas begins with a description of the functional activities
required. Because of the potential for dual use of the facilities and personnel, the patient-intake
area is often planned with the preanesthesia evaluation clinic and the PACU. A pain clinic may
also be a part of this area. Close physical proximity of these facilities is required to achieve dual
use.
The design of ambulatory surgery centers in England is reviewed by Burns. In these facilities,
the preanesthetic holding areas and phase II postoperative recovery area are both situated in
the ward.
The following paragraphs describe the facilities at the various University of Florida Medical
Centerassociated locations. When the University Hospital renovated its preanesthetic holding
area and PACU in 1995, health care consultants closely worked with health care providers and
personnel from hospital facilities and planning. The five-step process included: 1) description of
functional activities (i.e., what the facility would provide); 2) workload and staffing
requirements; 3) work environments within the facility and the methodology for determining
the space necessary for each; 4) proposed space allocation; and 5) criteria for translating space
allocations into floor plans. The functional activities of the preoperative/postoperative facility
are: 1) providing for preoperative screening of surgical outpatients and postoperative
admission patients, including pediatric patients; 2) providing a preoperative holding area for
inpatients; and 3) delivering postoperative care to postanesthesia patients, except those
recovered in critical care areas. The workload and staffing requirements measured the surgical
workload in terms of surgical hours and the number of ORs. The same was done for nursing,
clerical, and technical personnel. The activity of the preoperative/postoperative facility was
directly coupled to the number of ORs. For example, the number of beds needed in the
preoperative holding area was set equal to the number of ORs. The surgical case load was
categorized by patient type (e.g., inpatient, day surgery, and outpatient admission) to better
define the needs of the facility. Outpatients require clothes-changing facilities and clothing
lockers or other storage, as well as phase II recovery facilities. Based on these calculations, the
preoperative holding area was felt to require a nurses station (150 square feet), two charting
workstations (30 square feet each), 24 adult holding beds (60 net square feet each), a patient
toilet with handicapped access (40 square feet), and a storage area (100 net square feet), for a
total of 1,790 net square feet. Finally, in the design criteria/affinities section, it was noted that
the preoperative holding areas should be proximate to the OR and phase I recovery, phase I
recovery should be adjacent to the OR suite, and phase II recovery should be proximate to the
phase I recovery.
The Veterans Affairs Medical Center at the University of Florida, built in 1968, had 347 inpatient
beds and eight ORs. All surgical patients used to be inpatients. Preanesthetic holding activities
took place in the corridor just outside of the OR. Patient stretchers were positioned along the
corridor walls in view of the main OR desk.
39

In these corridors, IV lines and, occasionally, radial artery catheters were placed, and IV fluid
bags were hung from wall hooks above each stretcher position. This implementation cluttered
the OR corridor, obstructed traffic flow, and reduced patient privacy. To accommodate
outpatients, additional facilities (e.g., dressing rooms, toilets, and phase II recovery) would be
needed. In many other hospitals, the inpatients stop in the corridor on the way to the OR rather
than in the preanesthetic holding area.
Shands Hospital at the University of Florida is a 534-bed tertiary care medical center. There are
23 ORs in the main suite and two remote cystoscopy rooms. The preanesthesia holding area
includes 12 preoperative bays (i.e., large open room with divider curtains) and eight bays that
serve both preoperative and postoperative (phase II) patients. A separate nursing station is
positioned at the end of each of these two areas. For first-start cases, pediatric patients are
gathered in the PACU (which is empty at this time), where toys and videotapes are available.
Parents are allowed to remain with their children. For subsequent cases, a section of the
preanesthetic holding area is designated for pediatric patients, and the toys and videos are
moved to this area. Each bay in the preoperative and combined preoperative/postoperative
patient areas is equipped with piped gases (i.e., oxygen, air, and vacuum), electrical outlets, and
a shelf for noninvasive monitors. The piped-gas supply system, specifically the vacuum line, is
positioned lower than normal so that a connected suction canister would not be at the
patients eye level.
The 423-bed county general hospital at the University of Florida has eight ORs and one
cystoscopy room in the main surgical suite. There are four beds in the preoperative holding
area just inside the OR suite. Additional patients are placed along the OR corridors. This facility
uses a day room approach for outpatients and postoperative admissions, similar to the
outpatient ward described by Burns. Outpatients are admitted to a room on the ambulatory
surgery ward. This ward provides clothes changing facilities, storage, toilet, television, and a
comfortable and private environment for patients and their families to wait for surgery. Before
surgery, the patient is moved from the ambulatory surgery ward to the preanesthetic holding
area. Postoperatively, the patient returns to the ambulatory surgery ward for phase II recovery.
Patients seem highly satisfied with this system because they have their own room.
A freestanding surgery center that has seven bays in the preanesthetic holding area and four
ORs performs approximately 250 anesthetics per month. The bays are situated in a semicircle
around the nursing station. This arrangement facilitates close observation of the patients by the
nursing staff. One drawback, however, is that it is difficult for nurses and physicians to privately
discuss an individual patients condition or management plan because other patients can hear
the conversation. The patient bays do not include piped compressed gas supplies, so oxygen
cylinders, portable suction units, and appropriate resuscitation equipment must be brought
into the area.
40

At a private community hospital with 298 inpatient beds, there are eight ORs in the major
surgery suite. The preanesthetic holding area consists of seven dressing rooms and two
restrooms. When called to the OR area, the patient waits in one of two bays to the side of the
OR corridor, with space for additional patients along the OR corridors. An attached surgery
center has four ORs and seven bays in its preanesthetic holding area. Each patient bay contains
a television set. Patients complete their preanesthetic holding activities as well as phase II of
postanesthesia recovery in this area. Diagnostic and therapeutic pain blocks may be conducted
here. Thus, the basic components of the patient-intake areas of the OR suite are similar in most
of the hospitals.
41

CHAPTER 13
SPECIALIZED OPERATING ROOMS
Authors: Timothy S. J. Shine, MD, Department of Anesthesiology, Mayo Clinic, Jacksonville, FL;
Bruce J. Leone, MD, Department of Anesthesiology, Mayo Clinic, Jacksonville, FL; David L.
Martin, PE, Campus Planning and Projects. Mayo Clinic, Jacksonville, FL
Orthopedic Operating Rooms Authors: Sital Bhavsar, MD, Hospital for Joint Disease, New York,
NY, and David Albert, MD, Hospital for Joint Disease, New York, NY
Pediatric Operating Rooms Author: Gordana Stjepanovic, MD, New York University School of
Medicine, New York, NY
Introduction
The increasing complexity of procedures and patients has resulted in an increase in the
monitoring and support systems required in specialized operating rooms (ORs). Considerations
should include: 1) the size of the room; 2) the room orientation (the long axis is the orientation
of the operating table, and the short axis is 90 to the long axis); 3) medical gases needed; 4)
number and locations of electrical and medical gas outlets; 5) access to the room; and 6)
location of the room. The planning process can be divided into four steps: programming,
schematics, design development, and construction documents. The goal of programming is to
determine the requirements of all users of the room, how much space will be required, and the
optimal orientation of the room. Schematics are diagrams that define the relationship of the
different spaces to each other and are usually prepared from the programming by the architect.
Frequently, the diagram must be revised to accommodate flow. If scheduling dictates,
schematics and programming may concurrently take place, but this is not suggested. The design
development stage needs to be very specific, addressing the location of doors, lights, clocks,
ventilation diffusers, electrical and medical gas outlets, millwork, scrub sinks, etc. Finally,
technical diagrams and construction documents are created by an architectural design team
and reviewed by the end user for completeness. Once all comments have been noted in the
document set, the drawings are assembled, sent out for pricing, and then constructed.
Space Requirements
A standard OR occupies 400 sq ft. A room for cardiac procedures may require 600 sq ft, and a
specialized OR for transplants may require 750-800 sq ft. Where possible, the room needs to
have a clear area around the periphery. This may be achieved by using utility booms. The
number of items placed against the wall should be limited to provide safety for staff and
patients, with less risk of a plug being inadvertently disconnected. It is important that access is
possible without crossing sterile areas.
44

Different needs for equipment require additional space, so having some idea of the space
required is useful in the programming and design development phase. In addition to machines,
standard monitors, and intravenous infusion pumps, space allotment for additional monitors
and supportive devices needs to be considered. Many liver transplant patients require some
form of intraoperative renal replacement therapy (e.g., continuous venovenous hemofiltration
[CVVH]), usually a continuation of therapy that was started in the intensive care unit (ICU). This
requires a minimum of 16 sq ft for the machine and operator on the right-hand side of the head
of the bed. Nitric oxide administration requires a 4 4 ft space at the right side at the head of
the table. The anesthesia machine requires a minimum of 10 sq ft. A standard anesthesia cart
with storage space requires a 2 5 ft space, while a double cart requires a 2 7ft space. A
transesophageal echocardiography (TEE) machine requires a 4 2 ft space. Rapid infusion
machines require a 2 2 ft space. An airway cart requires a 3 2 ft space.
Access to the room needs to consider the size of the patient bed and any support equipment
that may be brought into the room with the patient, such as a ventricular-assist device, balloon
pump, etc. Having the entrance door at the head of the bed gives immediate access to the
anesthesia workplace. A dual-leaf opening with an active 4-ft leaf and passive 2-ft leaf has
proven adequate. Having appropriate support beams in the ceiling to bear the load of ceilingmounted equipment (e.g., fluoroscopy screens; ceiling-mounted supports for microscopes;
fluoroscopy lights on articulated arms; booms with medical gases, electrical outlets, suction,
and data jacks; etc.) needs to be considered in the programming stage. Trying to install these
supports after the fact may result in the support being too low and the ceiling-mounted devices
being potential obstructions.
Cardiac and Specialized Transplant Operating Rooms

Having the transplant rooms close to the cardiac rooms provides easier access for support
services and services provided by specialized nursing. Ease of access to the cardiac
catheterization laboratory, invasive radiology suites, blood bank, laboratories, and ICUs should
be considered. Wide-access corridors will make transporting patients needing life-preserving
technologies (e.g., balloon pump, ventricular-assist devices, etc.) to these rooms and the ICU
easier and safer. Entrance doors should be at least 6-ft wide. Ceiling-mounted monitors and
video screens allow easier access, create less floor clutter, reduce the number of wires running
across the floor, lessen the risk of blowing fuses, and increase safety for OR personnel. An
induction/line placement room adjacent to the OR allows the patient to be brought to the OR
with lines in place, the patient being prepared while the OR is being prepared for the surgery
(i.e., parallel processing). For complex pediatric and adult cardiac surgery (when deep
hypothermic cardiopulmonary bypass is required), a system for rapid heat exchange needs an
ice supply for transplant organ preservation, cooling devices, etc.
45

Liver transplant patients may require some form of intraoperative renal replacement therapy.
Usually a continuation of therapy that was started in the ICU, CVVH requires a minimum of 16
sq ft for the machine and operator on the right-hand side of the patient at the head end of the
bed. Space for bench surgery on the donated organ space for operating area and storage of the
donated organ in ice will add 6 to 8 ft to the long axis of the OR table.
Requirements for Perfusionists

Listing the needs for electrical supply, medical gases, and vacuum gives an estimate of the
minimum electrical and medical gas outlets and vacuum inlets needed. Such a list should
include, but is not limited to, the following:
The heart-lung machine needs an electrical plug, preferably on a dedicated circuit so the
machine does not impact another device.
The cardioplegic pump requires its own electrical plug.
The heater-cooler system needs its own electrical plug.
The cell saver needs its own electrical plug.
A TEE machine draws a large electrical load and should not be plugged into the same circuit
as the life-preserving pumps, ventricular-assist devices, and intra-aortic pumps.
An intra-aortic pump or ventricular-assist device may require a dedicated electrical circuit to
avoid disrupting power to other devices.
The perfusionist may need to check the accelerated clotting time or other measure of the
adequacy of heparinization, which may require an electrical plug.
A space of at least 8 8 ft will be required for the perfusionist and his/her equipment. The
perfusionist space is in the short axis of the operating table and, thus, adds to the short axis
width by a minimum of 9 ft.
At least three vacuum outlets (two vacuum and one waste anesthetic gas outlet) will be
required for scavenging anesthetic gases and the cell saver.
Neurosurgical Operating Rooms

In addition to the usual space requirements for a standard OR, additional space around the
operating table may be needed for new technologies (e.g., a Stealth navigation system) used by
neurosurgeons. The Stealth system requires a 3 3 ft space, and the detection system, which is
on a stand close to the patients foot, needs minimum of 8 sq ft so that the system is not moved
or bumped. Motor-evoked potentials and somatosensory-evoked potential (SSEP) monitoring
systems require space for the monitor, the operator, and an electrical outlet. Fortunately,
electroencephalography and SSEP machines are becoming smaller. A data jack port will be
necessary for information storage. Spinal surgery requires a large nursing back table for the
array of screws and other hardware that the surgeon needs to choose from during the case.
The specialized Jackson table that sandwiches the patient between supports will require space.
46

Other Specialized Operating Rooms
Laparoscopic and Robotic Surgery Rooms

An OR designed for laparoscopy and thoracoscopy improves productivity and convenience.
Laparoscopic rooms ideally have piped carbon dioxide (CO2) to inflate the abdomen so that
personnel do not need to handle a CO2 tank. Lasers often have special electrical requirements
and may need special electrical circuits. Robotic surgery requires a 5 5 ft space at the foot of
the table where the robot is placed. The console where the surgeon controls the robot is set off
to the periphery of the room, either on one side or behind the anesthesia equipment, and
requires a 6 6 ft space. Ceiling- or wall-mounted screens allow easy visualization of the
laparoscopic or robotic images and decrease the need to move rolling carts with screens in and
out of the room. Care must be taken to ensure that booms for the surgical lights and screens
can be moved into the appropriate positions required by the procedures to be performed in the
specific room and will not interfere with other equipment in the room. Using computer
software or mocking up a demonstration room should be encouraged since visualization of
actual sight lines and competition for space by both equipment and staff is difficult to visualize
on architectural plans.
If multiple screens are being mounted from equipment booms, serious consideration should be
given to designating one screen as a slave for the anesthesia monitor, enhancing the
anesthesiologists ability to face the surgical procedure and patient and still easily see the
anesthesia data without turning. With ceiling-mounted equipment, additional supports will be
needed in the ceiling. Lighting systems with the ability to switch from a normal room-lighting
pattern to specially colored fluorescent lights may enhance visualization of images projected on
room monitors and should be considered in the design phase. New room installations now have
a variety of integrated equipment available, from lights and monitors to voice-activated audio
control of equipment and integration with distant locations, like pathology or a conference
room for distant education. Besides the surgical images, computer feeds from the rest of the
hospital can interface with these systems, allowing patient information, like x-ray images, to be
displayed at the OR table. As the complexity of these systems increases, so does their cost and
complexity of use. During the design, all of the participants using the room need to be involved
in order to maximize the room capabilities yet prevent unnecessary expense.
Orthopedic Surgery Rooms

With the increasing advances in orthopedic surgery and the increasing requirements of the
aging population, there is undoubtedly a need for ORs that can accommodate the wide range of
needs for orthopedic surgery, from simple arthroscopic procedures to complex surgeries on the
spine with neurophysiologic monitoring and large radiological equipment. Orthopedic surgery is
one of the surgical subspecialties demanding the most varying type of equipment and surgical
instruments. Many orthopedic procedures also necessitate the use of both general and regional
anesthesia. An OR that is designed to facilitate both the choice of anesthetic(s) and the surgical
procedure can greatly increase ease of patient care and the productivity and efficiency of OR
personnel.
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Preoperative Block Rooms
Preoperative block rooms have a definite role in the efficiency of OR turnover. A well-designed
block room would have to be in proximity of the ORs for immediate transport and must have
adequate resuscitation equipment available. This includes an ability to monitor patients and
treat any emergencies that might occur. The doorway must be the appropriate size to allow
easy entry and exit, and in addition, the ideal stretcher must be adjustable in both height and
position. Furthermore, appropriate personnel must be available to remain with the patient
after block placement and transport to the OR. Since many regional blocks are now being
performed with ultrasound guidance, the block room should be designed to accommodate this
imaging equipment.
Intraoperative
Surgical equipment. Interestingly enough, as the surgical incisions become smaller and less
invasive, it seems as though the surgical equipment required gets larger and more
cumbersome. Many of the computer-assisted devices, robotic and arthroscopic instruments,
and video screens necessary to perform orthopedic procedures are large and require many
wires, cables, and electrical outlets in order for them to be functional. A design plan for the OR
would ideally involve rooms sufficiently large enough to accommodate this equipment and
dedicated electrical outlets for surgical instruments. One option is to suspend equipment, such
as cameras and video monitors, from ceiling booms that also provide anesthetic gases, suction,
and electrical outlets.
Operating table. Obtaining proper surgical access to the patients for orthopedic procedures
entails multiple position options, such as supine, sitting, lateral decubitus, and prone. These
positions many times require special beds, such as a captains chair, Jackson flat, fracture table,
Andrews frame, Mayfield head frame, etc. A thorough understanding of the limitations and
advantages of each of these tables will improve patient safety and minimize morbidity. Moving
and storage of these beds can become a process in and of itself, and beds that are
interchangeable may be the wave of the future.
Electrical needs. Due to the large volume of irrigation fluid used in arthroscopic procedures,
ORs must be appropriately wired. Line isolation monitors and alarms that warn/prevent the risk
of microshock and macroshock are vital. Sixty-cycle (60 MHz) interference from various
electrical equipment can lead to an inability to interpret electrocardiogram readings.
Orthopedic ORs can become dangerously slippery as water accumulates during arthroscopic
procedures. This, obviously, can pose a threat to all OR personnel, both from a physical (e.g.,
falling and slipping as a result of the water) and an electrical standpoint. These rooms may have
to be considered wet ground and may need specialized electrical wiring to prevent short
circuits and the possibility of electrical shock for anyone in the OR. Careful attention must be
paid to any electrical cord that lies on the ground and may come in contact with water that
puddles on the OR floor.
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The increasing use of neurophysiologic monitoring for spine operations can impose further
electrical demands on the OR and may also need to be taken into consideration. There are
companies that manufacture monitoring equipment with the ability to reduce electrical
interference from other OR sources (e.g., electrocautery, anesthesia monitors, etc.)
Furthermore, the presence of the water that may accumulate would call for rooms with
drainage systems that would more effectively remove the water from the procedures. It may be
wise to use designated rooms that are electrically wired and have specialized drainage systems
exclusively for arthroscopic procedures.
Radiography and microscopic requirements. Many orthopedic procedures require radiographic
imaging in the form of plain film x-rays, computed tomography images, or real-time fluoroscopy
during the procedure. Again, these needs call for the ability to move sometimes large and bulky
x-ray equipment in and out of the OR many times during the course of one operation. This can
be facilitated with advances and investments in smaller, more efficient x-ray machines and with
fluoroscopy machines that work with mountable c-arms in the designated ORs. Ceiling- or wallmounted fluoroscopic equipment is an option that can save valuable OR space but limits
portability and options. Strict adherence to code is vital. Walls must be lead lined when
necessary to prevent unintended exposure to radiation to all personnel within the OR suite and
in adjoining rooms and facilities. Providing and storing the lead aprons used by OR personnel
are other issues to consider when using radiographic techniques. Having a closet type of
space or rack in the substerile area would allow for people to quickly protect themselves
without having to spend time finding the lead aprons for each and every case. Along with
radiographic needs, there are many procedures that call for the use of a microscope, which is
yet another consumer of precious OR real estate.
Anesthetic requirements. Surprisingly, as the equipment that orthopedic procedures require
increases, the need of the anesthesia for these cases has undergone only minimal changes. In
addition to the basic setup of any OR, including the anesthesia machine, monitors, anesthesia
cart, and scavenging system, an ultrasound machine for performing regional nerve blocks is
probably the one piece of additional equipment that is most used in this subspecialty.
Ultrasound machines can be rather bulky, but newer machines provide more efficient and
compact designs that make their use easier. Another design aspect that would benefit the
administration of anesthesia would be the presence of two wall sources for anesthetic gases,
which would allow the anesthesia machine to be moved if the patient were to have complex
positioning requirements.
Patient warming devices, such as forced-air warming, fluid warmers, and heating blankets, are
essential for orthopedic procedures, as surgeries can be long and incisions extensive, and the
possibility of rapid patient heat loss exists.
49

Air flow and temperature regulation. Air flow is another important operative issue, especially
for joint replacement surgeries. The normal flow of air in most types of buildings entrains room
air into the supply air stream. This allows the two types of air to quickly mix and develop a
comfortable air supply and temperature. This, however, is not desirable for a hospital due to
the fact that this would spread airborne contaminants throughout the building. Airflow systems
are designed to use laminar flow in order to minimize the spread of the airborne germs. This is
necessary in order to prevent perioperative infections in patients. The OR design must take into
account airflow direction and exchange rates so as to ensure proper movement of air and, thus,
minimize infection risk.
It would be advantageous to allow each OR to control both room temperature and humidity.
Pediatric surgeries require quickly and efficiently warming rooms, and then these rooms need
to be quickly cooled down for ensuing adult procedures.
Pediatric surgery rooms

Since the only constant is change, many health care facilities that were state of the art a
decade or two ago are rapidly becoming functionally obsolete due to exponential progress in
new technologies, clinical services, and operational trends. Changes are dramatic not only in
clinical fields but also in fields integral to the delivery of health care, such as communication,
new materials and technologies, demographic changes, and the state of the economy.
When building new or renovating existing facilities, one should follow the concepts of:
Lean: Lean is an approach to reduce waste and streamline operations. Lean is based on
the concept of continually increasing the proportion of value added activity to a business
through ongoing waste elimination. A Lean approach provides companies with the tools to
survive the demand for higher quality, faster production time and lower prices in a global
market. Lean implementation is therefore focused on getting the right things to the right place
at the right time in the right quantity to achieve perfect work flow, while minimizing waste and
being flexible and able to change.
Green: A sustainable building, or green building is an outcome of a design which

focuses on increasing the efficiency of resource use -energy, water, and materials - while
reducing building impacts on human health and the environment during the buildings lifecycle,
through better siting, design, construction, operation, maintenance, and removal. Green
buildings are designed to reduce the overall impact of the built environment on human health
and the natural environment by:
o Efficiently using energy, water, and other resources
o Protecting occupant health and improving employee productivity
o Reducing waste, pollution and environmental degradation
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Flexible: Due to accelerated advances in science and technology, it is very difficult to

have a long-term vision of the future OR, which means when building a new or renovating an
old OR, emphasis should be placed on flexibility and adaptability. The OR design must
incorporate the necessary space and infrastructure that will adjust to future trends. This
includes interstitial spaces for structural, mechanical, electrical, and information systems, which
need special layouts to allow for system modifications and upgrades. Flexible designs include
accessible ceiling systems, grouping of similar modalities, and sharing of equipment spaces.
The challenge to all involved in planning, construction and management of healthcare
facilities, is to anticipate, to the greatest degree, where changes are most likely to occur and to
consider flexibility throughout all stages of the planning, design, construction and postoccupancy phases to ensure that the ultimate goals of client satisfaction, desirable clinical
outcomes, efficient work environment, and effective use of limited capital dollars, are all
achieved.
All said, whether within a childrens or general hospital, pediatric ORs should be seen as part of
a pediatric OR complex that consists of:
Pediatric operative suites
Preoperative area with activity room (i.e., playroom) with age-specific activities
Premedication room or area
Postanesthesia care unit (PACU) or area
Family resource center with preoperative learning programs
Support facilities (e.g., bathrooms with infant changing tables, pump room, waiting
room, etc.)
Blood bank
Laboratory
Three major components of this complex are personnel, equipment, and patient care facility.
Personnel
Required personnel include anesthesiologists, surgeons, nurses, OR technicians, and all other
health professionals with expertise and experience, such as pediatricians, radiologists,
respiratory therapists, electrophysiology therapists, pharmacists, child life specialists, and
administrative staff.
Whenever possible, care of pediatric patients should be consolidated into a separate facility
staffed by specialty-trained anesthesiologists. Studies demonstrate that this improves efficiency
and patient and staff satisfaction.
Equipment
Preoperative area equipment is required to be age and size appropriate for preoperative
preparation and evaluation of pediatric patients. It should be situated in a comforting
environment that provides privacy to the patients and their families.
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In order to maximize safety and efficiency, OR equipment should be strategically situated.
There is an increasing trend in the use of booms, which are ceiling-mounted articulating arms
that support equipment, gas and electrical outlets, and communication and video displays. This
promotes decluttering, better space utilization, and sterility and reduces maintenance and
equipment damage. Booms must be coordinated with the ceiling lighting, ventilation, heating,
and electrical systems.
The American Society of Anesthesiologists Closed Claim study has found a greater incidence of
equipment-related problems in pediatric patients in comparison to adults, with almost 50% in
children aged less than 2 years.
The American Academy of Pediatrics states: There should be a full selection of equipment
available for application to the pediatric patient. This equipment should be easily accessible and
well maintained.
Airway equipment includes positive-pressure ventilation systems, ventilation masks,
endotracheal tubes, laryngeal mask airways, oral and nasal airways, and laryngoscopes, with a
wide range of pediatric blades.
Standards in pediatric and adult breathing circuits were established in 1963 by the American
Society of Anesthesiologists and in 1967 by the International Anesthesia Standards Committee.
There is no anesthesia machine specifically developed for pediatric patients; all anesthesia
machines should deliver precise volumes and concentration of anesthetic gases. However, use
of anesthesia machines with a pressure-control ventilation option is preferable in the pediatric
population.
Equipment for intravenous administration of fluids includes intravascular catheters, pediatric
volumetric fluid administration systems, and kits for intraosseous access. Space must be
available to store a wide variety of sizes of disposable equipment within easy reach of
providers.
Maintaining temperature is critical, particularly for neonates and infants. Therefore, a variety of
equipment (for age and size) must be available to maintain normothermia, including warming
lamps, circulating warm air devices, air humidifiers, and fluid warmers. Again, storage space for
this equipment must be readily accessible.
Storage must also be available for other specialized equipment, including:
Equipment for invasive monitoring of arterial and central venous pressures
Infusion pumps
Regional anesthesia equipment for performance of neuraxial and peripheral nerve

Blocks
52
Resuscitation cart with equipment and medications appropriate for pediatric patients of
all ages, including pediatric defibrillator paddles; written pediatric dose schedule for the
resuscitation medications should be immediately available
Readily available, fully stocked, difficult airway cart with specialized equipment for
management of the difficult pediatric airway; content should include, but not be limited
to, fiberoptic bronchoscope and emergency tracheostomy and cricothyrotomy
equipment
Readily available, fully stocked, and regularly maintained malignant hyperthermia cart;
contents are the same for patients of all ages
Transport equipment, such as transport monitors and portable equipment for

oxygenation
Specialized equipment and sizes of equipment must also be readily accessible in the PACU area.
Each bedside location should have sufficient room for storage of a wide variety of airway and
resuscitative equipment.
Facility
Studies have shown that the establishment of dedicated pediatric ORs results in decreased
variability of anesthesia-controlled time (significantly shorter times of induction and
emergence), allowing for better case scheduling as well as surgeon and patient satisfaction.
When designing and planning for the construction of a new or renovation of an old OR suite,
early engagement of the infection control (IC) team is crucial. Issues to be addressed include
space constraints, storage and equipment cleaning areas, hand-washing facilities, air-handling
units, ventilation and environment control, barrier systems, medical waste containers,
appropriate finishes, specific products with infectious implications, traffic flow, specifications
on temperature and humidity ranges, applicable regulations, and necessary budgets. The IC
team should ensure that major design components are addressed as appropriate and justified
by relevant guidelines, codes, standards, and regulations.
The operating suite needs to be adaptable, with the capacity to maximize the use of space,
time, equipment, communication devices, and personnel in an affordable manner. It needs to
be structured for controlled access and traffic flow. The OR suite cannot be a passageway to
other rooms. It should be located in close proximity to support facilities/services (e.g., neonatal
ICU, pediatric ICU, blood bank, laboratory, etc.). The patient and staff entry points into the OR
are crucial in design, since they will dictate the sterile field location and, in turn, flow of sterile
materials. In order to ensure that clean areas will remain clean, pathways of clean supplies
must not intersect pathways of contaminated supplies.
The Facilities Guidelines Institute and the American Institute of Architects 2006 Guidelines for
Design and Construction of Healthcare Facilities sets a minimum of 400 sq ft for a new general
inpatient OR and 600 sq ft for specialized ORs. For an ambulatory surgery/Class A minor surgery
room, the requirement is 150 sq ft. Requirements for OR storage space is 50 sq ft per OR, with a
minimum of 150 sq ft total.
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Room floors, walls, and finishes should meet standard requirements for OR cleaning,
maintenance, and durability and be aesthetically pleasing. Floors must be able to support the
weight of the permanent furnishings and equipment while considering future installation of
imaging systems. For that reason, ferrous reinforcement needs to be minimal in order to allow
for proper function of those systems. Use of reinforced concrete, rather than steel beams, will
eliminate vibrations. Different levels of lighting should be available through a control
workstation, with consideration of additional occupancy sensors and voice control capabilities.
Ceiling-mounted equipment requires access to above-ceiling services. Walls, ceilings, and floors
must be sealed. All booms must be gasket sealed. Heating, ventilating, and air conditioning
must have a velocity of 25-35 ft/min. Temperature control and maintenance is one of the
crucial elements of care for the pediatric patient population. Temperature and humidity control
panels for the pediatric ORs must be easily accessible to OR personnel and should not placed in
a remote area in order to allow for prompt adjustments.
Preoperative and waiting areas should provide quiet environments with ergonomic furniture,
television and computer stations, a play room, and lockers. Evaluation and consultation rooms
should have double entries to allow for separate entry of medical staff and patients and their
family members. Ideally, these rooms should be equipped with computers to allow medical
staff to communicate preoperative and postoperative findings and images to the family.
When planning for space, increased recognition of family members and caregivers
contribution to the healing process and gradual acceptance of the benefits of nontraditional
modes of therapy (e.g., massage therapy, music therapy, and acupuncture) should be
considered as well. Perioperative areas need to address the needs of patients of varying ages.
Healthy toddlers waiting for day surgery procedures should have age-appropriate play areas
decorated to appeal to young children. Adolescents, on the other hand, will be uncomfortable
in a setting for young children and should have a more private area for waiting and recovery, as
well as private areas for changing. Families of young infants often appreciate a more quiet and
private setting. Preprocedure anxiety in children often has a profound effect on postoperative
psychological problems (e.g., night terrors, enuresis, etc.), so it is worth the extra investment in
specialized perioperative areas that appeal to patients and families.
Many pediatric procedures take place in an ambulatory setting. Access to nourishment prior to
discharge is another important issue. Typically, juices or ice pops are offered to determine that
the child is well enough for discharge (and to help signal this time-for-discharge) to patients and
parents. This area needs to be separated from the waiting area, where children are fasting prior
to procedures. Distinct areas for different ages are postoperatively important as well. Young
children need to be with parents in a familiar environment, perhaps an area with available ageappropriate videos. Adolescents often prefer a more quiet area and feel particularly
uncomfortable in a large open room that precludes privacy. Optimizing flexibility in
perioperative spaces is key to meeting the needs of all ages.
54

CHAPTER 14
POSTANESTHESIA CARE UNITS
Lead Authors: Denisa Haret, MD, Clinical Assistant Professor of Anesthesiology, University of
Iowa; Misty Kneeland, Resident, University of Arkansas for Medical Sciences; Edmund Ho, MD,
Resident, University of Arkansas for Medical Sciences
Checklist
Location with respect to the operating room (OR)?
Number of postanesthesia care unit (PACU) beds required?
Patient, family, and staff traffic patterns?
Equipment needed at each bedside?

Attention has been increasingly focused on the PACUs since the 1990s, in part because of the dramatic
improvement in patient safety in the OR. In the past, when unrecognized esophageal intubations and
ventilator disconnects were more common than they are today, most of the problems that occurred in
the PACU seemed small by comparison (with the exception of inadequate ventilation caused by residual
muscle relaxant medication). Now that major intraoperative catastrophes directly attributable to
anesthesia care are extraordinarily rare, events in the immediate postanesthesia period receive more
attention than they have in the past. Accordingly, attention to the basic issues involving the PACU raised
here, as well as the warnings about common PACU critical incidents (i.e., developments in a patients
course that, if not treated, will result in patient injury) is warranted.
Status of the PACU

The first dedicated recovery room for postsurgical patients was opened in 1942 at the Mayo
Clinic. Previously, patients were simply taken directly from the OR to the regular hospital room
from which they came. Today, a PACU associated with an OR is considered standard in US
facilities where surgery involving general or regional anesthesia is performed. Interestingly, as
recently as the mid-1980s, the lack of a standard PACU-type facility was reported to be
associated with an increased incidence of anesthesia-related complications in France.1 These
data were used as a strong justification for the French surgery/anesthesia community to work
toward the universal availability of such units. Today, in other first-world countries, there are
still a few examples of facilities lacking PACU-type units. However, the real issue is the so-called
second- and third-world countries where surgery and anesthesia do not yet consistently meet
the most basic standards. This is compounded by the lack of PACU facilities matching the level
of sophistication of their associated OR suites.
Purpose of the PACU

In contrast to the older practice of returning patients directly from the operating table to their
ward beds, the PACU allows centralization of care by a group of specially trained nurses who
are expert in interpreting and responding to the events of the brief but intense period
immediately following a procedure requiring anesthesia. The PACU has highly specialized
facilities and essentially functions as an intensive care unit (ICU). This is appropriate since all
57

patients who enter a PACU face some type of threat or danger to their lives. Furthermore, the
immediate proximity of the PACU to the OR is critical because it provides instant access to
essential resources, including supplies and equipment, but even more importantly, the surgical
and anesthesia personnel who recently cared for the patient. This immediate availability allows
timely intervention and treatment of any significant problems during the immediate
postsurgical period. Finally, the nursing care required by immediate postsurgical patients has
become increasingly specialized and is now a recognized subspecialty of nursing. Availability of
this specialized nursing expertise is one of the main reasons that PACUs exist.
PACU Location
Ideally, the PACU should be directly contiguous to the OR area from which the greatest number
of patients come. While this is certainly preferable, it may not always be possible due to
constraints of preexisting architecture or construction imperatives in a new facility. Then the
question arises: How far away is too far? There are no published standards on this, leaving the
issue to the so-called rule of reason. One key point is to avoid elevator trips as a routine part
of a transfer from the OR to the PACU if at all possible. Elevator transport simply introduces
both a delay and a potential for great vulnerability if the patient were to experience an
untoward development while in the elevator. Assuming that the PACU is relatively nearby and
on the same floor as the OR, the ease of negotiating the hallways (e.g., straight path versus
multiple turns) is just as important as the actual distance. The time it would take to travel from
the most distant OR to the PACU door while pushing a stretcher and several intravenous (IV)
poles with infusion pumps should be estimated through actual time trials before construction
plans are finalized. The responsible anesthesiologists should determine if this time is
reasonable, or alternatively, should strongly lobby for a closer PACU location.
Independent of its location, it is very important that the orientation of the PACU facilitate the
flow of patients. There should be a direct entrance to the PACU from an OR corridor and a
separate exit, preferably to a main hospital corridor. This places the PACU between the OR and
the ultimate destination of the routine patient, whether that is a hospital bed or a Stage II
recovery area for outpatients. Constructing the PACU so that the same door is used for both
entrance and exit will inevitably lead to traffic jams and potentially dangerous situations. For
example, a patient leaving the PACU may prevent the rapid entrance of a new patient who is
having a problem (e.g., airway obstruction) during transport. Both the entrance and exit doors
must be extra wide to guarantee the smooth and safe passage of the widest equipment. A fullsized hospital bed with an intra-aortic balloon pump console and people pushing IV poles on
both sides should serve as the standard. It is remarkable to witness the irritation and expense
associated with knocking out parts of walls to replace doors that were installed with only a
standard-sized hospital stretcher in mind. Automatic opening of the doors operated by a push
button on the wall or by motion sensors is a modern convenience added in newer facilities.
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Number of PACU Bed Slots
The appropriate number of PACU bed slots will vary with the surgical case mix, the length of the
cases (e.g., will first cases likely be discharged from the PACU before second cases are
finished?) and the usual turnover time of both the OR and PACU beds. A high turnover of
outpatients or a significant number of long-stay ICU patients will create a need for more PACU
bed slots. In the past, the suggested guideline was that the number of PACU bed slots should
equal the number of rooms in the OR suite. This idea has been replaced by a newer algorithm
that recommends there should be one and a half to two PACU slots for each room in the OR
suite. The factors described above and any other unusual issues for that particular PACU could
impact such calculations. The important point is to involve all relevant personnel and
departments (including support services, such as respiratory therapy and housekeeping) very
early in the decision-making process. Their input can impact the decision as to how many bed
slots to build.
PACU Floor Plan

Obviously, the realities of either the existing building or the construction-related imperatives in
a new facility must be accommodated in determining the PACU design. However, when
possible, it is critical to maximize effectiveness of care in a thoughtfully planned PACU. For
example, a traditional design is a square floor plan with one wall accommodating the nurses
desk and support areas (e.g., medication carts or cabinets, seating area for order writing or
dictation, equipment and supply storage, linen carts, etc.) and the other three walls having
patient bed slots. This design offers direct sight lines to the patients and the shortest distance
between points in the PACU. An open-ward design facilitates simultaneous observation of all
patients. While traditional, in part because of the utilities coming from the wall by the patients
head, there is no requirement that all patient bed slots be lined up along a wall. Many
alternative innovative designs are possible. One involves pods of four beds at 90 angles
located in the middle of a large space. Utilities drop from the ceiling or come up into a towerlike structure (a utility tree) at the center of the four patients heads. The rationale is that one
or two nurses can stand in or near the small area defined by the heads of the four patients and
have immediate access to deliver care with little time or energy lost walking from bed to bed up
and down a traditional row of stretchers along a wall. Supplies that normally are stored on
shelves or in baskets on the head wall in the traditional design are usually placed on rolling
carts in the pod configuration, and sometimes the carts are exchanged after each patient
discharge so that the turnover of a bed space can be accomplished in as short a time as
possible.
As a routine guideline, it is wise to budget a total of about 150-200 sq ft for each patient slot
(this includes the bed space, open space, nurses station, etc.). This total does not include
allocation of central storage space for equipment and supplies, which will significantly vary
based on the type of patients served.
59

Dividing a PACU into subsections for administrative and clinical purposes and including these
subsections in the floor plan is certainly reasonable and should be considered at the earliest
possible planning stages. Lines of sight are critical. Corners that block the line of sight of
someone working at the desk or attending another patient invite untoward clinical events or
demand increased nursing staff.
The design of the PACU must accommodate certain necessities. If an anesthesia machine is to
be kept in the PACU for emergencies (at one time, a relatively common practice), it needs an
out-of-the-way storage area where it is unlikely to attract attention to its supply of nitrous
oxide. Permanent and prominent places for emergency carts (resuscitation, airway, and
surgical, if indicated for that patient population) need to be incorporated into the original
design. Significant storage space is necessary and must be included in the plans; the amount
truly required is usually significantly greater than what is generally allocated by architects and
hospital designers. Failure to allow sufficient storage at the outset will result in a cluttered and
eventually dysfunctional PACU in the long run.
At least one enclosed patient space is desirable for patients needing isolation for infection
control. The issue of patient isolation is one that will always be debated. Ideally, there should
be at least one isolation or side room that has a wide door connecting with the PACU main
area and another door in a border wall opening out to a hospital corridor. This will allow
patients with resistant infections, for example, to receive PACU care but also remain segregated
from the other PACU patients. Likewise, severely immunocompromised patients should be
separated from the general PACU population for their own protection. Thus, the isolation room
could serve two important functions. If it is likely that both purposes will be served in one
room, it can be constructed (at some additional expense) with an air-handling system that can
be changed literally with the push of a button from the usual negative pressure flow of an
isolation room (protect the other patients) to a positive pressure flow (protect the patient in
the room from outside infectious threats).
PACU Traffic
The PACU should be constructed so that patients directly enter from the OR and then exit from
the other end into a corridor on the way to their next destination. All of the patient portals
should be standard automatic double doors that are activated by push buttons on the wall,
pressure-sensitive floor mats, or electric eyes above the door. Very important and often
overlooked is the need for enough open space and wide aisles to allow movement of stretchers
and beds without disruption of care to the other patients in bed slots. Optimally, there should
be enough room around to each bed slot for a regular hospital bed with a full set of suspension
traction to make a 360 turn.
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Another often overlooked issue is the desirability of having a separate pedestrian entrance
distinct from the doors used for patient entrance and exit. This facilitates movement of staff
and visitors and minimizes traffic jams and whooshing of the large automatic doors that could
be distracting as well as conducive to the introduction of contaminated air from other parts of
the facility. Associated with this is the need to consider whether patients family members will
be visiting them in the PACU; this is now very common with children and increasingly so with
adult patients. If this will be the case, then the design should allow foot traffic in and out of
each bed space with minimal exposure to patients in other spaces.
PACU Bed Spaces

All of the bed slots should be identical. This facilitates the delivery of care, especially in difficult
or emergency circumstances, since equipment, supplies, and functions will always be in the
same place. Patient privacy is an important concern. The Joint Commission on Accreditation of
Healthcare Organizations has increasingly emphasized this point in recent years. It is possible to
place hard partitions between bed spaces in a PACU, but its practicality has been questioned.
Ceiling-to-floor privacy curtains (with mesh netting above eye level to facilitate hearing and
verbal communication from behind a closed curtain) are more practical. There should be at
least 100-120 sq ft of floor space to the actual bed slot itself. This means the nurses should be
able to work around all four sides of a full-sized hospital bed with at least 3 ft of clearance. On
the head wall, or possibly on a rolling cart, there should be at least 12 sq ft of shelf space for
supplies and equipment, and there should be writing surfaces nearby (many PACUs use the
rolling tray tables found in most hospitals). While IV poles are acceptable, ceiling-track
mounted IV poles are extremely versatile and convenient. Finally, each bed slot needs a pullchain emergency nurse call buzzer. This can be given to a patient when his or her nurse must
step away from the side of the stretcher for a moment, or it can be used by the PACU personnel
to call attention in an emergency without yelling and alarming other patients in the room.
General Features of the PACU

A number of important, seemingly self-evident points can easily be overlooked. Two fire exits at
opposite ends of the room are recommended, and, naturally, compliance with all applicable fire
and building codes is mandatory. There should be a nonslip tile floor in one neutral color
(patterns make finding dropped objects, such as a needle, difficult). Light, neutral, warm
colors are best for the walls. There should be multiple clocks (all synchronized to the same
time) readily visible from all locations in the room. A handwashing sink for each six or so bed
slots is strongly recommended. A medication room or area (whether for a cabinet or carts) will
be required.
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The Joint Commission requires that clean and dirty storage be separated. Therefore, two
separate utility rooms with storage areas should be incorporated into the plan. A very large
blanket warmer should be available in the clean area. The dirty utility area should be on a
border wall if at all possible, with a separate door to an outside corridor, allowing trash,
contaminated waste, and dirty linen to be removed without carrying it past patients in the
PACU. Also, the dirty area needs three separate sinks for regular use, instrument washing, and
flushing.
Staff support space is important. There needs to be adequate space for staff possessions. The
number of staff lavatories will be determined by the size of the staff, but these need to be
separate from any patient facilities. A break area for staff in the PACU is a necessity and will be
especially valuable if patients can be observed and alarms heard while staff members are on
break. There must be adequate desk space for physicians and support staff, such as secretaries,
to write notes or dictate. Also, if there is a computerized information system, then an adequate
number of terminals must be allotted for physicians and nursing staff. Office space for the head
nurse is another highly desirable addition that will facilitate both function and communication.
Staff
The PACU is a division of the anesthesiology department, and there is always an
anesthesiologist assigned to be responsible for final medical decisions in the PACU. Usually,
however, a charge nurse, who also acts as a backup care nurse when the PACU gets busy,
supervises the minute-to-minute operation. In at least one hospital with a large PACU, an
advanced practice nurse with advanced cardiac life-support expertise has been specifically
trained to direct the PACU, under the supervision of the anesthesiology department.2 Each
patients postoperative care remains under the direction of the operating anesthesiologist, who
makes decisions related to the patients vital functions (i.e., respiration, circulation, fluid, and
metabolic balance) and analgesia. The operating surgeon is responsible for decisions about the
results of the operation.
PACU Nurses
Skilled nurses provide the direct postoperative patient care in a PACU. PACU nurses should be
trained in airway management, basic life support, and the special needs of postoperative
patients emerging from anesthesia. They should also be adept at caring for acute surgical
wounds and a variety of drainage catheters. For each PACU, a health care professional trained
in advanced cardiac life support should always be available.
Patients are more likely to have medical difficulties as they begin to emerge from anesthesia
than later in their recovery; therefore, for the initial 15 minutes in the PACU, it is necessary to
have one nurse caring exclusively for that patient. After about 15 minutes, patients who are
conscious and stable can usually be monitored by a nurse who is simultaneously watching one
or even two other similar patients.
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Patients who are stable, conscious, and uncomplicated and who have been in the PACU for
more than 30 minutes can be watched even less closely. On the other hand, patients who are
unstable or who have airway complications (e.g., artificial airways or mechanical ventilation)
require constant close monitoring, no matter how long they have been in the PACU.3 PACU
nurses estimate that it takes at least 60 minutes to admit a patient, manage the patients
recovery, get the patient ready for discharge from the PACU, and complete all the paperwork.
Special Considerations for Pediatric PACUs
Anesthesiologists and Physician Staff

In order to apply specific expertise in the provision of pediatric anesthesia services, an
anesthesiologist or other physician trained and experienced in pediatric perioperative care,
including the management of postoperative complications and the provision of pediatric
cardiopulmonary resuscitation, may be made immediately available to evaluate and treat any
child in distress. Pediatric advanced life support or advanced pediatric life support certification
is recommended.
Pediatric Anesthesia Equipment and Drugs
In order to provide immediate availability of specialized pediatric equipment and drugs, these
supplies should be stored and available in the PACU. Every child admitted to the PACU should
have his or her vital signs monitored. Suction equipment and oxygen should be available at
each bedside. A respiratory oxygen delivery system should be available for use in the transport
of infants and children from the OR to the PACU and/or ICU.
PACU Lighting
It is desirable to have some daylight visible to patients in the PACU. Beyond that, the standard
bright fluorescent lights will be used in ceiling fixtures in the general common areas. Each bed
space needs three levels of lighting that can be individually controlled within the bed space.
There needs to be a low-level nightlight for observation of a sleeping patient when the unit is
otherwise quiet, particularly for overnighters. There must be a standard fluorescent fixture
centered in the ceiling. Also, each bed space needs at least one procedure light or bright
spotlight in the ceiling over the bed space in the event of a development requiring maximum
light for diagnosis or treatment. In addition, the PACU should have at least one portable light
that can be moved to any bed slot to facilitate procedures.
PACU Environment
The average temperature in a PACU should be about 75F. While cooler temperatures might be
favored by some of the staff, patients would then have difficulty recovering from the ORinduced hypothermia that is so common. The relative humidity should be maintained at 40%60%. In general, it is recommended that the heating, ventilation, and air conditioning system of
the PACU be set so that there is a slight positive air pressure in the room, discouraging outside
bacteria from entering the room and potentially infecting PACU patients. There should be a
minimum of six air changes per hour, two of which are fresh outside air.
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In addition to verification of this air-handling system by heating, ventilation, and air
conditioning system engineers, there should be testing for compliance with all OR standards on
waste and trace gases.
Electrical Power
There should be at least six to eight regular outlets on the head wall or on the utility center
(hanging or ascending) for each bed space. At least two (preferably all) of the outlets should be
connected to an emergency power system that has a kick-in time of less than 10 seconds
following a power failure. These outlets should be clearly marked with red face plates.
Ventilators and infusion pumps for vasoactive drugs should always be plugged into emergency
outlets. If the OR has electric plugs and outlets of a different design (e.g., Hubble no-spark
electric plugs), then each bed space needs one or two of these so that OR electrical equipment
can function in the PACU. Lastly, there should be several 240-volt plugs to allow the use of
portable x-ray machines.
Medical Gases
Extensive regulations for all medical gas installations must be observed for any medical gas
system and outlet installations (see Resources). For the PACU, there should be at least two and
preferably three oxygen outlets (one having a flow meter installed at all times) on the head wall
or utility tree for each bed slot. Most importantly, there should be three to five suction outlets
at the head of each bed slot. One should have a tracheal suction regulator and bottle installed
at all times, and another should have a gastrointestinal suction regulator and bottle, likewise at
all times. The other outlets are for chest tubes, drains, and emergencies (airway or surgical).
Finally, there should be one compressed air outlet at each bed space to allow the use of a
blender for certain respiratory therapy procedures or a ventilator.
PACU Communications
A common problem of many PACUs is an inadequate number of telephones. The best
suggestion is to seek advice from a consultant as to how many telephones would be
appropriate and then install double that number. Cordless telephones can be quite useful, since
they allow the nurse to talk on the telephone without leaving the bedside. Obviously, the main
telephone at the unit secretary or coordinators desk needs to be as free as possible for
incoming calls. It is advisable to have a telephone number that is different from the main
number and used only by OR circulating nurses (and posted on the wall in each OR as its only
listing) to call the PACU to advise of impending patient transfers from the OR to the PACU. A
potential redundancy for this function arises when the utility of an intercom system is
considered. Some PACU staff find that, no matter how good the intentions, the regular facility
telephone system is not reliable enough for necessary incoming information and, more
importantly, outgoing calls for help. Therefore, a dedicated intercom system exclusive to the
surgical suite area is a viable alternative.
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Terminals should be placed in each OR, at the OR front desk and any inside central scheduling
location, in the anesthesiology departmental office and break room, and in the PACU. This will
allow instant two-way voice communication that will not be busy and also a broadcast
capability to send out a general call for help in the event of a severe untoward patient
development. This may or may not tie into the overhead paging system that is found in most
OR suites. If the PACU is large enough, it may need its own paging system with loudspeakers in
the ceiling that can be used to call the attention of staff working at some distance from the
central desk.
Increasingly, there has been a proliferation of wireless networks in the hospital, and this has
started to change the way people have interacted with each other. There are devices now on
the market that allow instant two-way voice communication utilizing the wireless network,
voice recognition, and wearable equipment. This may allow the nurse to continue to take care
of the patient at the bedside without a cordless phone. It may allow PACU personal to find and
communicate with each other instantly, or during an emergency/disaster situation, mobilize the
necessary personnel no matter where they are in the hospital.
Finally, even with elaborate and sophisticated communication systems, it seems wise to still
recommend that there be yet another dedicated alarm system that would summon help in a
crisis (e.g., code situation). This involves a large (often red) button under a clear plastic cover at
the desk or on the wall in a central location in the PACU connected to a light and bell alarm on
the wall in the OR and, often, in the place most likely to be populated by anesthesia personnel
who can respond immediately.
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Central Equipment in the PACU
Several sets of basic equipment are required in each PACU. A full resuscitation or code cart is
an obvious necessity. Whether more than one is needed will depend on the size of the unit and
the type of patients served. Associated with this should be complete pacing setups, including
both external and transvenous pacing electrodes and generators. Respiratory equipment is
important. How many spirometers and negative inspiratory force meters are required will again
depend on local factors, but there must be enough so that they are readily available when
needed. This type of equipment is distinct from the difficult airway cart that should be in every
PACU and duplicate the cart in the OR that contains a complete array of airway equipment,
including a fiberoptic scope and light source. When this equipment is needed in the PACU, the
time frame will be too short to allow obtaining one from the OR. Consultation with respiratory
therapy personnel will be necessary to determine if a mechanical ventilator should be
permanently kept in the PACU, ready for rapid deployment when needed.
The number of surgical trays and supplies to keep in the PACU will depend on patient factors.
However, it seems prudent to have, at a minimum, a thoracostomy tray, tracheostomy tray,
and cut-down set at all times. In a crisis, there is usually not enough time to have them brought
in from the OR. Warming devices above and beyond the traditional heated blankets are gaining
acceptance in the PACU. These frequently have rolling consoles for the heat source and would
need to be stored in the PACU. Another useful addition is a tube system. This is a series of
vacuum tubes that can be used to send paperwork around the hospital or specimens to the
laboratory. If this system is installed in the hospital, then space must be allocated for it in the
PACU. Whatever disinfection apparatus, if any, will be used should be added to the list of
equipment for the PACU. Lastly, there needs to be a supply of flashlights and battery-powered
lanterns, because there is always the remote possibility of a power failure in which the
emergency power also fails, resulting in total darkness.
Essential Equipment for Each Bed Space

How the supply and storage of stretchers is organized will vary among facilities, but it is very
important that all stretchers used for patients coming to and residing in the PACU be capable of
a head-down position. Usually, having one stretcher per bed space is not enough, because once
the stretcher leaves with the discharged patient, it is unlikely to be returned in time to be
cleaned and prepared for the next patient to be transferred from the OR to that bed space.
On the head wall or utility tree (or adjacent cart dedicated to the respective bed space), many
key pieces of equipment must be stored for immediate availability. There must be oxygen
tubing and associated oxygen delivery devices, such as nasal cannulae, regular face masks, and
rebreathing masks. A flashlight is required for both routine use and help in a power failure.
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Nasal and oral airways as well as tracheal suction catheters go here. If the bed space does not
have a capnograph as part of the electronic monitoring system, it is reasonable for one of the
colorimetric filter paper indicators of expired carbon dioxide to be placed with the routine
PACU equipment in the bed space. There must be a self-inflating resuscitator bag near the head
of each bed space at all times; this will allow ventilation by mask or tube, even in the event of a
loss of piped oxygen. Other items that should be immediately at hand include a pressure bag
for rapid IV infusion, blood tubes, blood gas kits, basic nursing equipment (e.g., emesis basin,
gauze, gloves, eye protectors, pads, tape, IV equipment, etc.), tools (e.g., scissors, a clamp set,
possibly a suture set, etc.), and a variety of other related items that will vary according to the
specific circumstances of that unit.
Patient Monitoring
Beyond the requirement that a quantitative method of assessing oxygenation, such as pulse
oximetry, be employed in the initial phase of recovery4 , there are no specific promulgated
standards for patient monitoring in the PACU that would be analogous to American Society of
Anesthesiologists Standards for Basic Anesthetic Monitoring. A pulse oximeter must be
available for all newly admitted PACU patients. Many units have simply installed a pulse
oximeter at each bed slot, and it is often left on and functioning throughout the patients stay.
Alternatively, if the plan is to have pulse oximeters on rolling stands that are moved from
patient to patient, there must be enough of them so that one is not removed and shifted to a
new patient when it is still needed on the original patient.
It has become a de facto standard of care that there be a physiologic monitor for each PACU
patient. At a minimum, this includes an electrocardiogram monitor. Most of these monitors will
also have noninvasive blood pressure modules. Whether some or all of these monitors should
have invasive pressure channels will depend on the patients and procedures in that facility.
Most acute care hospitals in which major surgery is done will have pressure measurement
capabilities at most, if not all, PACU bed spaces. These devices can be freestanding so that they
can be moved to the patients who need them most. The availability and use of noninvasive
blood pressure devices does not eliminate the need for a standard, classic sphygmomanometer
and stethoscope in each bed space. There needs to be a way to accurately measure
temperature. There are a variety of rapid-acting electronic thermometers, but old-style
mercury thermometers should be available, too. The question of capnography as a patient
monitor has been repeatedly raised with regard to the PACU. It certainly seems wise to have at
least one capnograph immediately available to monitor ventilation in a seriously ill patient or
verify correct intubation and adequacy of ventilation. If there is the likelihood of many
ventilated or severely ill patients, it may be reasonable to have a capnograph in the physiologic
monitor at many or even all bed spaces.
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There has been an increase in the number of malpractice lawsuits against anesthesiologists
involving PACU reintubations. It has been suggested that the same standard for verification of
correct tracheal tube placement by identification of expired carbon dioxide as applies in the OR
should be applied to any intubation in the PACU. This seems a prudent course. Individual
circumstances will vary, of course, but these concepts must be appreciated by the staff
personnel involved in dealing with PACU problems. If pulmonary artery catheters are used in
the unit, a dedicated cardiac output computer must be available. There should be at least one
peripheral nerve stimulator with train-of-four and double-burst capability in the PACU at all
times in order to evaluate patients for residual muscle relaxation.
Computerized patient data management systems have been widely touted. Many have a PACU
component into which data can be entered by either direct capture of monitor signals or entry
by PACU personnel or physicians. If such a system is contemplated, all those involved must
carefully plan to be certain that appropriate hardware and software is purchased and then
thoroughly tested after installation but before its use.
PACU Patient Safety Concerns

There is a new emphasis, particularly by plaintiffs lawyers, on adverse events occurring in the
PACU. Airway obstruction appears to be the most common untoward event reported in
immediate postsurgical patients. Aspiration of vomitus is much discussed but comparatively
rare in actuality. Inadequate ventilation from residual medication, either muscle relaxants
specifically or anesthetics in general, is a significant concern, but there are not good data
indicating its incidence.
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A corollary is oversedation from pain medication administered in the PACU once the patient has
emerged enough to complain. This can contribute to airway obstruction, aspiration, or
hypoventilation as well as the adverse consequences of each.
Step-Down Recovery
The step-down recovery area or predischarge area (synonyms are phase II recovery, short-stay
recovery unit, and secondary recovery area) may share a space with the preoperative area for
ambulatory surgical patients or may be a separate area. Here, patients are physiologically
stable, awake, and oriented, with a postoperative pain control plan already implemented. They
are tolerating oral intake yet still have the IV catheter in place upon arrival. Nurse-to-patient
ratio is much lower in this area, and family is often allowed to participate in the recovery
process. The patient may be in a semirecumbent position or sitting position in a lounge-type
chair, and activities such as nutrition, voiding, ambulation, dressing, and predischarge
instruction are carried out at this time. Staff must be prepared to treat pain, nausea, and
emesis and continue to evaluate patients for late development of postoperative complications.5
Cross-Training of Staff
Efforts are being made to better utilize recovery room staff and appropriately match staffing to
actual patient care needs. These include frequently updated staffing analyses based on patient
numbers and acuity, as well as cross-training staff to handle other groups of patients, such as
patients recovering from radiology, catheterization laboratory, or gastrointestinal procedures.
Criteria-Based Recovery
The concept of criteria-based recovery has emerged along with the availability of short-acting
anesthetic drugs. As compared to arbitrary time-based recovery, in which patients stay in each
phase of the recovery process a minimum amount of time, criteria-based recovery allows
patients to move through the recovery process at their own speed, determined by their
meeting specified criteria for each transition. Patients who have received short-acting
anesthetics; are awake, alert and responsive; have stable vital signs; are able to ambulate with
minimal assistance; and have manageable pain and nausea may pass to step-down recovery
after a very short stay in the phase I recovery area or move directly from the OR to phase II
recovery (fast tracking).5
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Summary
Outlined above are both general issues and specific points to be considered regarding the
needs and designs of an optimal PACU. Careful planning of the precise location and floor plan
before construction or renovation can dramatically improve the work environment for the staff
and improve the care received by the patients. Suggestions for equipment and functional
design are intended to anticipate the needs of the patient in the PACU and help optimize the
care delivered there.
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CHAPTER 15
FREE-STANDING AND OUTPATIENT SURGERY FACILITIES
Lead Authors: Michael Wajda, MD, Medical Director of Ambulatory Anesthesia, New York
University Langone Medical Center, NY; Charlotte Bell, MD, Chair, Committee on Equipment
and Facilities, Milford Anesthesia Associates, CT
Checklist
Team organization
Land acquisition
Design process
Administration and organization
General construction
Sterilization and space heating
Heating, ventilation, and air conditioning (HVAC) and humidification
Medical gas and vacuum systems
Essential electrical systems
Capital equipment
Emergency equipment
The Team
Although the surgical procedures and personnel for both hospital-based ambulatory surgery
units (ASUs) and free-standing ambulatory surgery centers (ASCs) are often identical, the design
process is typically very different. Early in the process, the team responsible for design and
construction likely already exists within the existing institutional structure. Free-standing
facilities must organize a team consisting of operational consultants, a health care attorney
with specific knowledge of the legal and political structure for the state and region, an architect
with past experience in designing ambulatory surgery units, a general contractor with positive
references for on-time and on-budget successes in previous ASC structures, and an equipment
planner for procurement and installation of fixed, mobile, capital, and disposable equipment. It
is critical that all members of this team have knowledge and experience of federal, state, and
county codes along with association and societal guidelines. In particular, the team should be
very familiar with requirements of both the American Association for Accreditation of
Ambulatory Surgery Facilities (AAAASF) and Accreditation Association for Ambulatory Health
Care (AAAHC), the regulatory agencies that will provide accreditation. In addition, the building
process is eased if this team has previously worked together and has worked in that geographic
area so that they have positive working relationships with each other and local and state
regulators.
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Land Acquisition
The location of an ambulatory unit must be considered prior to construction and development,
whether it is being built as an addition to an existing structure or a free-standing unit. The
proximity of a free-standing surgery center to the supporting hospital is of upmost importance.
In the case of a medical emergency, the patient should be able to be rapidly transported to the
acute care part of the facility or a separate hospital by emergency medical services.
An environmental study of the land should be considered to ensure no contamination of the
soil exists prior to building. Knowledge of water runoff and flooding should also be determined.
In addition, the team will likely want to consider if the land is located in an area of population
growth and if there are other similar facilities in close proximity. It is important to determine
the patient market and whether these patients will travel to the proposed site. The area should
be large enough to allow for parking adjacent to the facility, with at least some covered area for
pick up and drop off of patients. In urban areas, the availability of convenient public
transportation may be equally important. The owners of the ASU will want to consider if the
land is available for purchase or lease.
Design
The National Association of Architects can provide a list of architects who have had experience
with the design of ORs (ORs) and free-standing facilities. It is recommended to review the
architects previous work to ensure that the needs for your facility can be met. In addition, the
architect, through a contractual agreement, should ensure that the facilitys standards meet all
state and federal regulations, Medicare and Medicaid regulations, and the accrediting bodys
regulations. It is important that the final product be a state-of-the-art facility and comfortable
to the patients that are treated at the facility. In addition, the construction should be attractive
to the surgeons to aid in recruitment. Consideration should also be made for overbuilding to
leave room for future expansion. The ultimate design goal is for a safe facility with high patient
satisfaction and maximum efficiency.
Before facility design begins for either type of ASU, the potential types of surgery that will be
performed must be clearly identified. Surgeons, anesthesiologists, OR nurses, and technologists
with specific knowledge of these procedures are consulted in order to develop a room-by-room
list of fixed and mobile equipment. This process is particularly important as rooms will be used
for multiple purposes and multiple types of surgery. For example, storage and ready access to
portable x-ray equipment may be necessary for a morning case followed by availability of an
operating microscope in the afternoon. Complex electronics and optics do not tolerate
extensive movement, so defining storage areas in proximity to ORs with ample space for
supporting disposables is important to preserve equipment longevity.
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Strategic supply specialists are helpful to direct positions of gas lines, water pipes, and
electricity in consideration that the position of the OR table and anesthesia equipment may be
moved to facilitate certain surgical procedures. Ultimately, the design should facilitate OR
efficiency by allowing for multiplicity of use and ease of conversion of rooms. The ability to
improve throughput of patients (from admission to discharge) should also be incorporated into
the initial phases of design.
Finally, the entire design team should consider management of potential hazards to staff and
patients, including noise, infection control, and standing water (and drainage). In addition, a
philosophy for promoting environmental sustainability should be discussed early in the process
along with an assessment of the impact of the facility on the existing community. The US Green
Building Council has developed Leadership in Energy and Environmental Design Certification,
which defines the nationally accepted benchmark for the design, construction, and operation
of green buildings. In addition, the Green Guide for Healthcare provides specific guidelines
promoting their three core values (economic, environmental, and social). More information on
health care facilities and environmental sustainability is available in Chapter 4.
The operational consultant should be involved in the design process to ensure that completed
facilities will meet standards for accreditation, as retrofitting is always more problematic and
expensive. The three organizations that accredit ambulatory centers are the AAAASF, the
AAAHC, and the Joint Commission (formerly JCAHO).
Administration and Organization

It is required in 43 states that free-standing ambulatory centers are licensed by that state. The
licensee should have the overall authority for organizing the unit. This person must designate
an administrator, medical director, and director of nursing of this ambulatory unit.
The administrator should verify that the unit is in compliance with all applicable federal, state,
and local laws. The administrator should develop facility policies and annually evaluate their
implementation. This person should also maintain staffing to meet the needs of the patients
served.
The medical directors responsibilities include responsibility for all operations and anesthetics
delivered at the unit. This physician should maintain a quality improvement mechanism to
identify problems at the institution and various ways of managing these issues. The director will
coordinate and evaluate all procedures done at the facility. The physician will determine the
type and amount of equipment needed at the facility to deliver the optimum care to the
patients.
The director of nursing will maintain qualified health care givers that are under the supervision
of nursing. This director will update nursing care policies and ensure documentation during
perioperative care. The nursing director will ensure patient care policies during admission and
discharge are followed.
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Certification of an ambulatory unit by Centers for Medicare and Medicaid Services (CMS) is
essential for any facility that wants to be reimbursed by Medicare and Medicaid for patient
services. Accreditation of the facility is recommended to verify that the center meets the
specific criteria that are indicative of high quality care.
Construction
Operating Rooms
The number and size of the ORs in the unit must be determined first. Each OR should have a
substerile room adjacent for entry and scrub sinks in the immediate area. There should be one
scrub sink per two ORs. In the OR, there should be sufficient space for sterile supplies and
equipment as well as an anesthesia machine (if desired) and anesthesia supplies. In general,
approximately 3000 sq ft of surgery center space is needed for each OR, with each OR providing
1000-1500 cases per year. In addition, three preoperative and three postoperative bays per OR
should be included in the design for maximum efficiency. The OR size should range from 14 16
to 14 20 sq ft. Remaining open floor space is the most important factor after considering all
equipment, plumbing, air conditioning, cabinets, etc. Selection of floor and wall coverings may
impact costs of maintenance and cleaning. Iodine-based prepping solutions and various dyes
may stain certain floors. Tile walls will facilitate terminal cleaning of ORs.
Preoperative Holding Areas
Two or three preoperative holding areas per OR are generally needed to keep adequate
processing and flow of patients into the OR. There should be a planned restroom for the
patients in this area for voiding prior to OR. There should be lockers available for the patients to
secure their clothes and personal possessions.
Recovery Rooms
Two or three recovery room beds per OR are needed to achieve optimum efficiency of the
facility. This area must be staffed by nursing for postoperative monitoring. It is acceptable to
use the preoperative admitting rooms for second-phase recovery. Handwashing stations in the
recovery room are essential. Support areas in the postanesthesia care unit for medication
preparation, supply storage, soiled linen, and equipment storage must also be considered.
Storage space, along with suction and oxygen, should also be available at each bay. Typically, all
medications for the facility (particularly controlled substances) are kept in one area located
within the recovery room as this area is readily available to staff and under continual
observation. Individual lighting for each bay allows for optimal patient comfort. Some access to
natural light while providing privacy (such as clerestory windows) also promotes a sense of
wellbeing for patients and staff. In addition, recovery areas must have a designated kitchen
area to provide oral intake for patients after surgery. Specific requirements for food
preparation vary from state to state, so these laws should also be considered when designing
the recovery area.
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Operating Room Equipment Storage
An OR equipment storage area must be planned to store supplies and OR equipment (e.g.,
mayo stands, kick buckets, etc.). Obtaining the footprint for large storage items (e.g., cribs,
mobile x-ray equipment, video towers, wheelchairs, lasers, microscopes, etc.) prior to design
will help ensure that storage areas are sufficiently large for anticipated current use and
potential expansion. Moving electronic equipment may cause expensive damage, so locating
storage areas in close proximity to ORs both for efficiency and to minimize breakage is advised.
Additional Areas
Control center. It is advised to designate a central location in the OR suite where all activities in
the ORs are monitored. The area must be situated to allow visualization of all pedestrian traffic
entering the restricted area.
Soiled utility room. An area is required for dirty supplies and linens as well as providing a space
for waste receptacles.
Sterilization center. There should be a separate area for cleaning and decontaminating
instruments for sterilization. Space should be allotted for sterilizing equipment needed for the
procedures.
Laboratory. It is desirable to have a small area located near the preoperative area for
laboratory testing (e.g., blood glucose or pregnancy testing) that might need to be performed
on the morning of surgery. In general, tests that do not require separate inspection and
accreditation by the state should be selected. This list varies from state to state.
Anesthesia workroom. The workroom provides an area where all excess anesthesia supplies
are stored. Extra monitoring equipment should be stored in case of breakage so that a patients
heart rate, blood pressure, cardiogram, and oxygen saturation can always be monitored in the
perioperative period.
Locker rooms. Areas for staff to change into scrubs must be available, with a bathroom and
break or lunch room attached. This area should have direct contact to the surgical suite.
Bathrooms. The bathrooms should be located near the OR and recovery room. Handicap access
to the restrooms is essential. An emergency call bell should be placed in each patient toilet.
Waiting rooms. There should be sufficient space planned for family waiting. This area should
have an information counter and a restroom in the vicinity. A public telephone and accessibility
to drinking water should be considered.
Office space. There should be adequate space for the business office, medical directors office,
and consultation room. There should also be an area for medical record storage.
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Communications. Communication systems must be included in the design process. These
include telephone and fax systems, emergency lights, call lights, paging systems, networking
(both internal and Internet), and systems for electronic information management and billing.
Sterilization and Space Heating

Sterilization requires 60 psi of steam. Sterilizers may be purchased with self-contained electric
heat or separate electric steam generators if an onsite boiler is not available. Most offsite
ambulatory centers do not have an onsite steam boiler system since it requires maintenance
staff, space, and steam-to-hot water converters. There are small, 60-psi natural gas boilers that
are available for sterilization. The essential electrical system must serve the flash sterilizers.
Space heating in most small offsite ambulatory centers is provided by hot water heating
systems or electric duct reheating systems since little space and maintenance personnel are
required for these systems. The essential electrical system must supply the HVAC space heating
in the ORs.
HVAC and Humidification

The HVAC heating and supply, return, and exhaust ventilation in the OR is supplied by the
essential electrical system. The HVAC system chosen for a facility requires special attention to
space requirements, maintenance, installation costs, and temperature control. The HVAC
controller involves locating a thermostat, a humidistat, and a recorder in the OR. Alternatively,
the recorder may be located in a remote location outside of the OR. There should be, at a
minimum, two exhaust air grills. If there are more than two exhaust grills, they should be
centered on the walls of the OR. If there are only two exhaust grills, they should be located
opposite each other. Humidifiers are required in the ORs and can be powered by any fuel
source.
Medical Gas and Vacuum Systems

The National Fire Protection Association (NFPA) has set guidelines for electrical systems as well
as medical gas and vacuum systems in the health care center. Their recommendations are the
basis for a number of joint commission and CMS standards and regulations. Ambulatory ORs
require level one or level two piped gas and vacuum systems. A level one system is one in which
interruption of the piped gases and vacuum system would result in imminent danger of
morbidity and mortality to the patient. A level two system is one in which interruption of the
piped gases and vacuum systems would place patients at a manageable risk of morbidity and
mortality. A level three system is one in which the interruption of the gas and vacuum supply
would have no detrimental effects on the patient. Most free-standing centers would be either
level one or two since the administration of general anesthesia frequently occurs. In addition,
the use of supplemental oxygen usually accompanies regional anesthesia and monitored
anesthesia care.
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Level one systems have multiple pumps to ensure continued flow of the medical gases and
vacuum systems. Another difference between the three systems is the alarm features, which
are more sensitive in the level one system.
There is no code or requirement for the number of medical gas and vacuum outlets per OR.
Guidelines have been set by the American Institute of Architects for the total number of outlets
for medical gases and vacuum systems. The Joint Commission has made recommendations as
well. General recommendations include one oxygen and one vacuum station for minor surgery
ORs, two oxygen and two vacuum stations for intermediate surgery ORs, and two oxygen and
three vacuum stations for major surgery OR stations. Each station must have an adequate flow
rate for proper delivery to the patient and adequate functioning of connected equipment. The
free-air allowance CFM (l ft3/min) at 1 atmosphere for major A OR (e.g., transplant and open
heart) is 3.5 (100) per room, major B OR (all other major cases) is 2.0 (60) per room, and
minor cases is 1.0 (30) per room. All medical piped gases must be identified by a color coding
system. Color coding for piped medical gases in the United States is as follows: oxygen (green),
nitrous oxide (blue), nitrogen (black), air (yellow), and vacuum (white).
Medical gas and vacuum piping can be delivered through surgical ceiling columns. They can be
either rigid in design or retractable. When designing the facility, the ceiling columns should be
placed at opposite ends of the OR table to provide easy access for the anesthesiologist. Extra
electric outlets as well as grounding receptacles can be placed on these columns for
convenience. Medical booms that descend from the ceiling typically include hoses for medical
gases and suction as well as electrical outlets. The placement of these booms may critically
impact patient throughput as well as safety for staff and patients. The anesthesia machine is
routinely placed behind and slightly to the right of the OR bed, so the gas outlet and circuit is to
the right of the anesthesiologist. Therefore, the boom should be located to the right and behind
the anesthesia machine and the door to the OR to the left. With this configuration, neither the
patient nor the staff need to walk through or around the boom to access the OR table or
equipment.
The total oxygen needs and consumption for the facility must be calculated. One must consider
the procedures done at the facility, number of oxygen stations, and the number of procedures
to be performed monthly. In the acute care setting, consider oxygen utilization to be 1000 ft3
(28 m3)/bed/month. Any facility requiring more than 35,000ft3/month must have a bulk
storage system of oxygen. Those requiring less than 35,000 ft3/month can use a cylinder
manifold system for oxygen supply. The common source for nitrous oxide is the cylinder
manifold system. Nitrous oxide should not be stored in a cold environment, as the lack of heat
for vaporization will occur, and it will be unable to maintain the line pressure. Medical
compressed air can be delivered to the facility via a cylinder manifold or a medical air
compressor system.
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Essential Electrical Systems
The NFPA defines the need for a Type 1 essential electrical system as a facility with critical care
areas or electrical life support systems. Any Type 1 essential electrical system must have
emergency electrical power. The NFPA requires a minimum of three automatic transfer
switches for any facility with an essential electrical load of more than 150 kVA. If the load on
the essential electrical system is less than 150 kVA, the NFPA only requires one automatic
transfer switch. Thus, a facility must project their kVA usage to determine the number of
automatic transfer switches needed. The most common system of emergency power has been
the engine-generator configuration. Whatever method of emergency power is used, the need
for a supply of 60-HZ (AC) power to the essential electrical system must be established within
10 seconds of power failure. Battery-operated OR lights are required to prevent danger to a
patient during the potential 10 seconds of darkness. For ambulatory units that do not have
electric life support systems or critical care areas, the NFPA defines the need for a Type 3
essential electrical system. A Type 3 system would require power for life safety and the
termination of the current procedures. Life safety is battery power for lights, fire alarm
systems, and emergency exits. The NFPA requires that the life safety power remain for 1.5
hours after interruption of normal power.
Ground Fault Interrupters
Isolated power systems are essential in ORs that are considered wet areas, where the
interruption of power is not acceptable to patient safety. Even routine procedures in the
ambulatory setting have saline, urine, and a number of other fluids in the OR suite. These wetprocedure locations have the potential to have electrical equipment come in contact with the
fluids and result in electrical shock.
Ground fault interrupters are used to prevent people from an electric shock in wet-procedure
locations. The problem with ground fault interrupters is that once a fault current is detected,
power to all downstream equipment is disrupted. This is of particular concern when that
equipment is a ventilator or other type of patient life support. Isolated power systems contain
the ground fault interrupter while maintaining the downstream power needed in critical care
areas. A line isolation monitor will alarm at the first signs of a potential fault current and allow
the problem to be addressed.
Equipment
Instruments and pieces of equipment for ambulatory ORs may number in the thousands and
may require purchases from hundreds of manufacturers. Many capital purchases, including
defining specifications, manufacturer, shipping, installation, biomedical certification, and
training of personnel in use, require lead times of several months. Furthermore, equipment
specifications should be given to architects, engineers, and contractors prior to beginning the
design process so that appropriate electrical, plumbing, space needs, and building code
requirements are addressed.
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Whether free standing or attached, the initial phase of equipment procurement should be
determination of types of procedures, surgical specialties, and anticipated volume. Staff (i.e.,
surgeons, anesthesiologists, and nurses) should be queried as to preferences and minimum
quality required to meet standards. Cost and availability should also be considered. For ASUs
attached to larger facilities, a survey of existing equipment will help determine how much
additional equipment must be purchased.1
Emergency Equipment
All facilities must meet the standards set by the NFPA in regards to fire safety. Fire
extinguishers and fire alarms should be placed in all facilities, and documented fire drills should
be performed. All ambulatory surgery facilities should be prepared for the management of lifesaving emergencies. All monitoring equipment, such as blood pressure, cardiac monitor,
thermometer, and pulse oximeter, should be present. A stethoscope, Ambu bag, oxygen, oral
airways, laryngoscope, and various sizes of endotracheal tubes should always be present.
Intravenous (IV) fluid and IV catheters should also be on hand. A defibrillator and crash cart
with all emergency drugs, including dantrolene, should be prepared and routinely checked for
expiration dates. All staff should be trained in advanced cardiac life support and pediatric
advanced life support if the facility treats children. The proximity of the facility should be within
minutes of a hospital that can accept any transfers.
Amenities
The single biggest draw for ASC/ASU facilities is the convenience and ease for patients and the
convenience and efficiency for surgeons. To this end, adding certain amenities to the facility as
part of the design process will contribute to the overall satisfaction of both patients and staff
and ultimately optimize center efficiency. Some of these issues are:
A private, pleasant registration area that accommodates the patient and family with
appropriate soundproofing to meet Health Insurance Portability and Accountability Act
compliance
Generalized soundproofing in patient and staff areas to decrease noise pollution
Natural daylight in patient and staff areas to promote wellbeing, mood, and faster
recovery
Parking areas that are flat (i.e., no curbs), well lighted, and at least partially covered for
patient pickup
Hand washing stations that are readily visible to patients and conveniently located for
staff
A separate anesthesia office space that allows for storage of references and resources
as well as some privacy for conferring with staff or colleague
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CHAPTER 16
REMOTE AND HAZARDOUS LOCATIONS
Lead Author: John Rogoski, DO, Assistant Professor of Clinical Anesthesiology, Ohio State
University College of Medicine
Checklist:
Is the room size large enough to accommodate the fixed imaging equipment, the
anesthesia equipment and monitors, the patient, and support staff?
Is there adequate overall space to move anesthesia equipment if patient positioning
changes or imaging equipment moves?
Are suction, scavenging, medical gas lines, and electrical outlets located in more than
one location if patient positioning will change?
What are the energy hazards for this location? How will equipment, patients, and staff
be protected from this hazard? How can observation of and access to the patient be
optimized?
Where will induction and recovery take place? Is transport necessary? What equipment
is needed for transport? What is the most direct way to transport a patient to higher
acuity areas?
Are there adequate spaces for storage of disposable items?
What is needed to summon help or access information?
Introduction
There is an increasing demand for nonoperating room (OR) anesthesia in remote locations.
These remote locations offer challenges to the provider beyond those found in the traditional
OR suite. Data from the American Society of Anesthesiologists (ASA) Closed Claims database
suggests that anesthesia at remote locations poses a significant risk for the patient. Many of
these locations also expose the patient and provider to hazards. Procedural areas are often
designed for their intended purpose (typically, imaging) without considering the needs of a
patient receiving anesthetic care or the practitioners providing that care. In this chapter, we will
discuss the considerations that should be made when designing a suite where anesthesia may
be required.
Remote locations share several design challenges. These areas belong to other departments
that are responsible for the costs of design, building, and maintenance. In considering both
budget and who should be involved in the process, the concept of sedation or anesthesia
needed for the clinical processes once the project is completed may not even be on the
horizon. If it is considered, the knowledge of what is required for pre-procedure, intraprocedure, and post-procedure care may be limited.
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It is critically important that anesthesia care providers be involved early in the design process,
as retrofitting these areas can be prohibitively expensive or impossible, depending on fixed
structures.
These locations are typically located far from the main perioperative areas because they need
to be within the responsible department (e.g., radiology, radiation therapy, nuclear medicine,
etc.) for support personnel and equipment and may need external facility access for ambulatory
patients or other physical support. For example, many facilities share magnetic resonance
imaging (MRI) or positron emission tomography units that exist on large trucks and are
attached to the institution on a regular basis.
Anesthesia support facilities are not usually readily available away from the perioperative area.
This means that replacement parts, anesthesia technicians, carts for rare events (e.g.,
malignant hyperthermia, difficult airway, etc.), laboratory data (e.g., arterial blood gases),
recovery areas, and supportive colleagues are not close at hand. It is typically prohibitively
expensive to keep these items at every non-OR location, so systems for their rapid transfer to
the facility must be in place. In addition, anesthesia and OR information management systems
may not be available or may not be usable (e.g., in high magnetic field areas), so anticipated
patient data may not be easily found.
Some of the reasons why these locations exist so far from the perioperative area are that the
equipment is very large, is fixed, and typically offers some type of energy hazard that is
potentially dangerous to staff and patients and may greatly impact anesthesia equipment and
monitors. Thought must be given to the overall size of the room, footprint of the imaging
equipment, and footprint of the anesthesia equipment. There will likely be a need to move the
anesthesia machines and monitors for different type of procedures, so locating suction,
scavenging, and medical gas lines in more than one location should be considered. Transporting
equipment (e.g., machines, carts, and monitors) from the ORs may decrease the life of this
equipment. Keeping this equipment on site requires a separate storage area nearby if it is not
used every day.
Every anesthetizing location has requirements which include:
An area to conduct the pre-anesthetic assessment with consideration given to the
patients privacy and Health Insurance Portability and Accountability Act requirements
An area in the procedure room for the anesthetic provider and the equipment necessary
to conduct the anesthetic, located so that the provider has:
o Access to the patient for both monitoring and intervention
o The ability to communicate with and summon other qualified personnel should their
assistance be necessary
o A free approach to the patient so that others may assist in his/her care
o The ability to evacuate the patient from the treatment area if necessary to avoid a
hazard or provide more effective resuscitative efforts
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An area where post-anesthesia care can be provided or the ability to safely transport a
patient to a post-anesthetic care unit
Oxygen supply (and other medical gases as needed)
Suction
Scavenging outlet (waste anesthetic gas disposal)
Adequate power outlets and lighting
It is recommended that persons designing facilities for anesthesia care away from the ORs
review the following documents:
Statement on nonoperating room anesthetizing locations. 2003, 2008. Available at:
http://www.asahq.org/publicationsAndServices/standards/14.pdf.
Practice advisory on anesthetic care for magnetic resonance imaging. 2008. Available at:
http://www.asahq.org/publicationsAndServices/9.pdf.
ACR guidance document for safe MR practices. 2007. Available at:
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx.
Magnetic Resonance Imaging
MRI is a technique that utilizes fixed and time-varied magnetic fields along with radio-frequency
pulses to provide computer-generated images.
The hazards in the MRI suite are associated with the magnetic field, high-frequency
electromagnetic waves, and acoustic noise. Ferrous objects can become dangerous projectiles
when acted upon by the magnetic fields. Patients and providers must be screened for the
presence of implanted or imbedded ferrous materials and cardiac rhythm devices, which could
be adversely affected by the magnetic fields and radiofrequency waves.
MRI suites have been categorized by the ASA and American College of Radiology (ACR) into
three facility levels: 1) Level I facilities, where no anesthetic care is provided; 2) Level II facilities,
where patients may require monitoring and life support; and Level III facilities, where operative
procedures are performed. In this chapter, we will discuss the MRI suites associated with Level
II facilities.
The ASA and ACR have also agreed on the delineation of zones to describe the physical plan of
the MRI suite. This categorization is important in that it defines the effect of the magnetic field
on each geographic area and, therefore, describes the potential hazard to patients and staff in
that area. It is important to remember throughout the design process that the magnet is always
on, and exerting a magnetic field of (typically) 1.5 to 3 Tesla (the earths magnetic field is less
than 1 Gauss; 1000 Gauss = 1 Tesla).
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Zone 1
Zone 1 is the main entry to the facility. It is generally outside of the MRI suite and freely
accessible to the public.
Zone II
Zone II is generally the meet and greet area. It should include an area where anesthesia personnel and
support personnel may be screened, with provisions for securing any personal items that are
incompatible with an MRI environment. In Zone II, it is useful to have a room away from patient viewing
where induction of anesthesia and/or recovery can safely take place using standard (ferromagnetic)
monitors and equipment. An area for storage and deployment of resuscitative equipment will also be
needed in this zone. This equipment should include a defibrillator, airway equipment, both wall and
backup oxygen supplies, suction, and a code cart with appropriate resuscitative drugs. This zone should
also be equipped to serve as a recovery area where postanesthesia care may be provided when
necessary.
While it may be possible to perform an anesthetic induction with the associated airway management
utilizing MRI-safe/conditional instrumentation in Zone IV, many practitioners find it more practical to
perform this in Zone II and then (after shedding all MRI-unsafe objects) safely move the patient to Zones
III and IV.
Zone III
Zone III is the restricted access area just outside the scanner magnet room. All MRI-unsafe
objects should be eliminated prior to entry into Zone III. This zone should provide the
anesthesiologist with the best possible view (beyond Zone IV), preferably a direct line of sight,
of the patient during the scanning procedure. A video camera/monitor system may be
necessary to optimize visual monitoring of the patient. Zone III should have slave displays of
patient monitors that are housed in Zone IV. If possible, these displays should have remote
control capabilities. An anesthesia machine or monitor kept within Zone III may have its
breathing circuits or cables/tubing passed through wave guides between Zones III and IV. There
must also be a readily available means of communication, providing the anesthesiologist with
the ability to rapidly summon emergency assistance. Access to hospital information systems
should also be available to the anesthesiologist.
Zone IV
Zone IV is the MRI scanner magnet room itself. Admission to this zone must be limited to
screened individuals and MRI-safe/conditional objects. Any leads, tubing, or circuits leading
from Zone IV to Zone III should be passed through a wave guide to prevent radiofrequency
interference within the scanner. The room should be designed so that an anesthesiologist in
Zone III can have an unobstructed and, if possible, direct line of sight of the patient. The room
must contain what has been outlined above as necessary to conduct a safe anesthetic. It is
imperative that MRI-safe/conditional airway equipment and suction be immediately available in
Zone IV at all times, and a space should be provided for its storage.
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The design should provide for rapid patient egress in the case of an emergency. Management of
a cardiac arrest requires patient movement to Zone II or III or an area equipped for this
purpose. There is significant danger to the patient and medical staff if more than minimal
patient interventions (e.g., suctioning or simple airway maneuvers) are performed in Zone IV
due to inevitable non-MRI compatible equipment migration into this zone during an
emergency. Provisions should be made for the use of an MRI-conditional anesthesia machine
and installed oxygen supply and waste gas disposal. MRI-conditional monitors and infusion
pumps are also available with slave devices that can be placed in Zone III.
Placement of these conditional items requires that the biomedical engineers have located
Gauss lines within Zone IV. These lines indicate the magnitude of the magnetic field in different
parts of the room relative to the magnet bore. Identifying Gauss lines allows safe placement of
anesthetic machines and monitors, which contain some ferromagnetic material. Locating Gauss
lines early in the design process will determine not only where movable equipment is placed
relative to the patient, but also where to locate fixed wall medical gases and evacuation lines.
Extra-long circuits are sometimes necessary to keep the anesthesia machine at the appropriate
distance from the magnet bore.
Controversy exists within the anesthesia community regarding the best place to observe the
patient during administration of anesthesia for MRI. Depending on the placement of the
magnet, it is sometimes easier to actually visualize the patient within the bore from Zone III. If
monitors and anesthesia machines are appropriately located, it is often possible to meticulously
observe and monitor the patient without being in the magnet room, which minimizes the
caregivers exposure to high-decibel noise. In other design configurations (particularly locations
that are retrofitted for acute care), it may not be possible to observe well without being in Zone
IV with the patient, in which case hearing protection is required. With older magnets with
which shielding is less robust, it may be necessary to locate all conditional equipment (including
the anesthesia machine, monitors, and pumps) in Zone III, as no area of Zone IV has a low
enough magnetic field to allow their use (Gauss line is actually in Zone III). In this case, all lines
and tubing are passed through wave guides to reach the patient, as previously discussed.
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Figure 1
Green = wall gases, evacuation; white = anesthesia machine; orange = monitors and infusion
pumps with slave.
A typical design for an MRI suite is illustrated above. Note the availability of wall gases and
evacuation in each patient care location, the ability to have patient line of sight from the
console window, as well as the ability to observe monitors and anesthesia machine information
from the window. There is also space for the anesthesia caregiver within the magnet suite, if
necessary, with views of the monitor and anesthesia machine.
Biomedical engineers should determine where the Gauss line is located in Zone IV in order to
ensure safe placement of conditional equipment. For well-shielded magnets, the gauss line may
drop to almost zero at the end of the patient table, but be very high at a 45 angle.
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Figure 2
Radiology
Unfortunately, anesthesia involvement in the planning of radiology facilities is often an

afterthought. By that time, radiology equipment is fixed and unmovable. Ideally, anesthesia
considerations should be examined in the initial design phase. Besides designating and
equipping areas for pre-anesthesia and post-anesthesia care, the greatest issue is competition
for space within the radiology examination room. In cardiac catheterization, interventional
radiology, fluoroscopy, and neuroradiology suites, the anesthesia machine and radiology
equipment often compete for the same space.
The rooms should be designed so that the anesthesia equipment can be easily and safely
moved and accessed while still connected to the patient to permit movement of overhead
imaging equipment and the necessary radiological examination. Additionally, electrical cords
and gas lines need to be placed to allow access but not act as a potential safety hazard to the
staff as they move around the room. Depending on the nature of the study, the examination
table is often moved during the radiological procedure. Connection to the anesthesia
equipment needs to be guaranteed as the table moves. Many radiological studies do not
require anesthesia assistance. During the design process, a determination where anesthesia
equipment is to be stored when not needed is necessary.
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It is important to locate sufficient electrical supply as well as wall medical gases and evacuation
at every location in the suite where the anesthesia machine might be placed. Because different
procedures require the patient, imaging equipment, and radiology staff to move, it is necessary
to consider several room locations for anesthetic care. Sharing electrical resources may
compromise anesthesia machines.
Radiation Therapy
Radiation therapy units are often located far from the main perioperative complex both for the
convenience of ambulatory patients, who often come for daily treatments for several weeks,
and because of the innate hazards of high-dose radiation. Because of the distance from the
main perioperative areas, clear plans for induction and recovery of patients onsite are
necessary.
Because of the intensity of the radiation, the radiation therapy suite needs to be designed to
allow monitoring of an anesthetized patient from the device control room. In addition to the
patient camera that is a part of the standard design of radiation rooms, the anesthesia care
giver must be able to see the patient monitor from outside of the room. Placement of gas,
vacuum, and electrical lines in the treatment room should correspond to where the anesthesia
equipment is needed. Most radiation procedures are very short (lasting only seconds to
minutes), and most of the patients requiring anesthetics for treatment are children. Further,
these procedures are not in themselves painful. Although resuscitative equipment must always
be available, it is not usually necessary to have consistent availability of anesthetic machines
and extensive patient monitoring, as some type of rapid-acting intravenous anesthetic is usually
sufficient.
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CHAPTER 17
HYBRID OPERATING ROOMS
Authors: John Rogoski, DO, Assistant Professor of Clinical Anesthesiology, Ohio State University
College of Medicine, Columbus, OH; Timothy J. Shine, MD, Department of Anesthesiology,
Mayo Clinic, Jacksonville, FL; Bruce Leone, MD, Department of Anesthesiology, Mayo Clinic,
Jacksonville, FL; Barbara Rogers, MD, Assistant Professor of Clinical Anesthesiology, Ohio State
University College of Medicine, Columbus, OH; Erika Puente, MD, Research Assistant, Ohio
State University College of Medicine, Columbus, OH; Chris Annis, MD, Resident, Ohio State
University College of Medicine, Columbus, OH
Checklist
Using an intraoperative magnetic resonance imaging (IMRI) suite

Isolating radiofrequency using the Faraday cage
Restricting access
Managing fixed and mobile anesthesia equipment
Marking Gauss lines
The hybrid operating room (OR) is an interesting concept, marrying two areas with distinct and
different problems and concerns. Under this category would be the IMRI suite and angiography
operating suite. The considerations for hazardous areas as described in Chapter 16 apply to
these hybrid areas as well.
Intraoperative Magnetic Resonance Imaging
IMRI is an emerging concept marrying operative interventions, most commonly intracranial
neurosurgical procedures, with MRI for immediate intraoperative evaluation of cerebral
interventions and resections. The ability to obtain an accurate MRI during an operative
intervention allows for further resections and additional interventions without transporting the
patient from the sterile OR environment. Working in a magnetic field requires significantly
increased safety precautions. The OR environment is not always easily adapted to the safety
required to work in the magnetic environment of a strong-field MRI required for cranial
imaging. Thus, OR design must incorporate changes to allow surgical interventions and MRI
examinations to take place in the same environment.
There are two approaches currently used to adapt space for use IMRI suites. The first approach
entails movement of the patient from the OR to the MRI scanner (fixed); the second design is
for the scanner to be moved to the patient (mobile). Both approaches require careful planning
and involvement of all team members, especially anesthesiology, at the earliest stages prior to
construction.
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Design Considerations
The initial phases of implementation of an IMRI neurosurgical program involve the planning and
consideration of space and money for construction. The initial design decision must be whether
the patient will be intraoperatively moved to the MRI scanner or whether a suite will be
designed with enough room to allow for construction of an OR capable of having an MRI
scanner moved into it. The design of an OR without accommodating an MRI scanner is relatively
straightforward. The OR should be designed according to accepted standards and located as
close to the MRI scanner as possible. Systems can then be purchased that allow the patient to
be transported to the MRI scanner either while on the operating table or via a wheeled
transport cart. This is analogous to what presently occurs when a patient requires a
postoperative MRI scan. The patients are transported, awake or under controlled ventilation, to
the MRI scanner, and imaging is accomplished. As this design does not involve alterations to
normal OR specifications and construction, it will not be discussed further. This design does
allow access from more than one operating suite, providing more flexibility and possibly more
use.
Design of an IMRI suite usually entails design of two component areas: an OR suite and a
diagnostic imaging suite. This design allows maximum benefit from the MRI scanner and
maximal use of a high-cost capital equipment item. The business plan may incorporate a
diagnostic imaging area to allow for continued use of the MRI system when not required for
operative use (Figure 1). This entails a design that allows patients from outside of the OR to
access the imaging system but protects the cleanliness of the operative environment. As a
result, placing the unit on the outside of the complex near elevators and stairs is important.
From a safety perspective, a patient staging area is usually required immediately outside the
scanner so that the proper screening for ferrous metals can occur prior to taking the patient
into the scanner room. In an emergency, this area can also be used as a resuscitation space for
the MRI patient, since resuscitation inside the room is dangerous for both the staff and patient.
Figure 1
Example of an intraoperative magnetic resonance imaging suite design incorporating an

operative suite (yellow area), diagnostic scanning area (red area), and a common control area
(purple area).
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The design of an MRI room must consider the specific requirements in obtaining an adequate
MRI scan: medical imaging in a high magnetic field and isolation from radiofrequency artifact.
The former, the safe conduct of imaging in a high-Gauss magnetic field, usually receives the
bulk of consideration from the medical personnel. The latter, radiofrequency isolation, is
possibly the more difficult task and receives priority from physicists involved within the project
and is merely assumed by most personnel not familiar with the process of obtaining an MRI.
The need for radiofrequency isolation is due to the signals produced by MRI examination and
converted to images. MRI involves no radiation exposure and, thus, requires no special
protective equipment for patients or for medical personnel. However, the rapidly changing
magnetic field fluctuations produce substantial noise, necessitating the use of protective
devices (i.e., ear plugs or earphones) to preserve patient and personnel hearing. The MRI
produces small variations in radiofrequency emissions as the magnetic fields vary in location
and orientation, as atomic reorientation occurs with changes in the magnetic fields. The
radiofrequency emitted by atoms as they relax to their normal state is detected by
radiofrequency coils placed close to the body area of examination, with these radiofrequency
emanations then being interpreted by computerized programs to yield a high-definition image
of the patients anatomy. The presence of metallic objects (e.g., implants) within the patients
body or the presence of radiofrequency interference will significantly degrade the images
obtained.
Understanding these caveats of MRI is crucial when designing an OR to be functional as an IMRI
examination room. Firstly, in order to eliminate extraneous sources of radiofrequency
interference, a Faraday cage must be constructed to isolate the entire OR from radiofrequency
interference. It is common to make the entire room a Faraday cage (Figure 2) to isolate
radiofrequency. However, the Faraday cage must be violated of necessity to have the
appropriate medical gasses and electrical outlets available for anesthesia and surgical
equipment. It is important for meetings to take place prior to approving final design plans in
order that the Faraday cage is constructed to allow the minimum amount of outside access to
pierce the cage and be available within the OR area (Figure 2).
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Figure 2
Copper lining within the walls of an intraoperative magnetic resonance imaging suite make a Faraday
cage inside the suite to isolate the area from radiofrequency interference.
Much is made of MRI safety in the context of ferromagnetic items being drawn into the
magnetic bore and causing considerable damage and, rarely, patient harm. The crucial aspect of
design of an IMRI is to allow enough square footage for ferromagnetic instruments to be safely
removed from the magnetic field. This involves a large, relatively square room design to allow
such surgical instruments as operating microscopes, imaging adjuncts (e.g., image-linked
operative guidance systems), and ferrous surgical instruments to be removed from the
magnetic field, typically to areas of the IMRI suite that experience less than 5-Gauss magnetic
field strength. Even with a sufficiently large room, however, it is prudent to allow for the
placement of tethering bars around the periphery of the room to physically restrain larger
items (e.g., operative light booms, operating microscopes, surgical instrument tables, etc.) with
tethering cords (Figure 3). It is also helpful to mark the Gauss lines on the floor (50, 5, and 0)
and to color code each line. When the mobile magnet is brought into the operating suite, all
unsafe material is located behind the 0 line. When the mobile magnet is not in the room, it can
be housed in a hangar with shielded doors. It is important to mark the Gauss lines around the
hangar when the doors are closed, as the magnetic field will still likely extend into the room in
front of the doors.
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Figure 3
A blue tethering strap anchors the anesthesia machine to a tethering bar during a clinical
intraoperative magnetic resonance imaging case.
Equipment Considerations
After the design phase of the IMRI suite has been finalized, the next consideration for the
anesthesia service is obtaining appropriate equipment to safely administer anesthesia for
procedures performed in the suite. Intracranial operations comprise the bulk of the procedures
currently performed. The ability to have standard monitoring devices along with invasive
monitors, such as intra-arterial pressure monitoring and central venous pressure monitoring, is
essential. The caveat is that these monitors, while initially placed in the absence of a magnetic
field, would then need to be functional when the MRI phase of the procedure is required. Of
note, the MRI is generally performed at the conclusion of the surgical procedure, but, on
occasion, further operation is performed and a second MRI would be obtained. Thus, one
cannot assume that the monitors could be discontinued or not actively displayed during the
MRI phase, as this may not be the conclusion of the surgical procedure. Secondly, as inferred
above, the monitoring devices themselves should be MRI safe or conditional. Most equipment
has ferrous elements or gives off radiofrequency interference such that it is not suitable in the
IMRI area. For instance, commonly used displays for monitoring devices have significant
radiofrequency emanations that would preclude obtaining a high-resolution MRI scan. Thus,
specialized radiofrequency-isolated displays are required to allow for adequate scans.
Much of the equipment in a normal anesthesia supply cart needs to be carefully examined, and
replacement nonmagnetic counterparts found. For example, it is common to need a flashlight
during the MRI scan (even fluorescent lights are significantly radiofrequency dirty), yet trying
to obtain a nonferromagnetic, battery-powered flashlight is extremely difficult. Many MRI96

compatible pieces of equipment can be found online at an increased cost as compared to
ferromagnetic counterparts. Some equipment cannot be replaced or manufactured as
magnetically neutral and, thus, must be placed as far away from the magnetic bore and as
close to the minimal magnetic field area as possible. An example is a common vaporizer. The
vaporizer cannot be manufactured without significant ferromagnetic components, and it must
remain securely attached to the (otherwise nonmagnetic) anesthesia machine. No auxiliary
vaporizers are allowed in the room, for changing the vaporizer (thus, unlocking a vaporizer from
the anesthesia machine) could create a projectile when the MRI scanner enters the IMRI suite.
During the MRI, power will be shut off to all nonessential equipment. It is very important to
consult with the engineers during the design stage so that they understand that anesthesia
equipment must be powered at all times.
Lastly, as much as possible, ferromagnetic anesthesia disposable supplies should be eliminated
in the stock of the IMRI suite. All needles, guide wires, and neuromuscular monitoring devices
should be counted and securely stored outside of the 5-Gauss magnetic field prior to every MRI
phase of the procedure. We utilize a defined stock of anesthesia supplies that are counted
immediately prior to the patient entering the IMRI suite and recounted prior to every MRI scan
to ensure that no unaccounted supplies are potentially present in the IMRI suite.
Pagers, cell phones, personal digital assistants, calculators, computers, watches, telephones,
and signaling systems are necessarily turned off to eliminate radiofrequency noise and
interference. An appropriate, secured area should be identified in close proximity to the IMRI
suite to not only accommodate MRI staff personal items but also those items that are brought
in by the OR staff. The lack of a means of direct communication with the OR personnel (e.g.,
surgeon, anesthesiologist, and OR crew) should also be discussed and a protocol for
communication be designed. Thus, the design of the IMRI suite should also take into account
these factors when designing the coverage and anesthesia commitment to the project.
Access to the IMRI rooms is restricted at all times to personnel who have been screened and
trained. This means that doors remain locked and only credentialed staff have access with key
cards or other mechanisms.
Angiography Operating Rooms

Angiography ORs are used when the surgeon wishes to see vascular anatomy during the course
of the procedure. They may be used for coronary, peripheral, or cerebral vascular procedures.
Angiography suites require lead shielding of the walls, floor, and ceiling. These ORs need added
length (at least 8 ft) in the long axis to accommodate the anesthesia machine and other
equipment at the head end of the table, with the x-ray machines and viewers at the foot end.
Retrofitted angiography operating suites can end up with low ceilings because of the conflict
between ceiling height requirements of ceiling-hung C-arms and surgical lights and booms. This
will result in booms for operating lights and lower viewing screens, risking head injuries to
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personnel and hampering access to the patient. It is better to design an intraoperative
angiography suite de novo than to retrofit one. Intraoperative angiography suites require
control rooms adjacent to the ORs. With biplane fluoroscopy for the coiling of cerebral
aneurysms and arteriovenous malformations (AVMs), the anesthesia machine is usually placed
behind the fluoroscopy tube and out of range of its turning radius. There needs to be a 4-ft
clearance around the radius of rotation of the fixed-based biplane fluoroscopy to avoid hitting
the anesthesia equipment.
Challenges
One of the challenges that anesthesia providers are facing is the increasing use of remote
locations that request the use of anesthesia for either patient safety or to obtain higher quality
imaging. Our surgical colleagues continue to expand their skill sets, striving to improve patient
outcomes by reducing complications related to large incisions, prolonged recovery, and lengthy
hospital stays. They are increasingly moving away from larger procedures in favor of more
minimally invasive techniques. Endovascular repair of aneurysms throughout the body are one
such example. Like those procedures performed by surgeons, other procedures, such as
transjugular intrahepatic portosystemic shunts, thrombectomies, and embolectomies, just to
name a few, are being performed on a more regular basis by our colleagues in radiology. As
hospitals are moving toward supporting more minimally invasive techniques, the input of
anesthesiologists in designing these remote locations and hybrid ORs is becoming more
frequently requested. What are some things that one must take into consideration when aiding
in the design of these areas?
Patient Safety
First and foremost is patient safety. Prior to the administration of any anesthetic and during the
design of any remote location (with the potential to administer anesthesia) or a hybrid OR, a
series of questions must be addressed:
What does one need to safely administer anesthesia?
What resources would one need for an emergency situation?
Is the patient being kept safe from radiation hazards?
Is there a way to emergently terminate the procedure being performed?

By surveying the area in which one will be working prior to administering the anesthetic, one
can anticipate any potential problems, such as lack of supplies or necessary equipment. When it
comes to protecting the patient from the untoward effects of ionizing radiation, it is important
to understand what type of procedure is being performed. Procedures that use general
angiography or fluoroscopy tend to have more scatter of gamma radiation, thus exposing not
only the patient, but also the anesthesia provider and other staff, to its effects. More directed
therapy, such as computed tomographyguided procedures, which will not be discussed
further, have less scatter.
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It is important to have the ability to emergently stop the procedure, whether this is through
direct communication with our surgical or radiology colleagues or via a mechanical device that
inhibits the ionizing radiation. While many of the mechanical stop functions are located at a
control desk, it is important to consider placement of the anesthesia providers area during
design of an angiography suite.
Anesthesia Provider Safety
Similar to being vigilant towards the safety of the patient, one must also be vigilant toward the
safety of the anesthesia care provider. Is he/she adequately protected from radiation
exposure? Will he/she be able to safely perform his/her job?
It was noted that as the introduction of electrophysiologic (EP) laboratories was made, the
exposure to radiation for the anesthesia care providers was doubled at that institution.1 The
article mentions that lead aprons protecting the thyroid, gonads, and sternum cover only 82%
of the active bone marrow. The use of lead screens does protect somewhat; however, they do
little to protect against scatter. Distancing oneself from the source of ionizing radiation
provides the greatest protection, with the optimum distance to minimize ones exposure to
radiation being 36 in. However, with many remote locations being already cramped sites, it is
often difficult to find those 36 in necessary to decrease ones exposure to ionizing radiation. As
mentioned in the Handbook of Ambulatory Anesthesia, a distance of 6 ft from the source of
ionizing radiation is the equivalent of wearing five lead aprons. Wearable lead shields, however,
only protect against 80% to 90% of ionizing radiation, with the rest penetrating.2 The
International Atomic Energy Agency has published guidelines in what is known as the White
Paper about what is considered an appropriately safe level of radiation exposure; for further
information, please refer to this easily accessible piece of information.
One should be mindful of the above distances, however, when designing hybrid ORs or remote
locations, such as angiography suites or EP labs. If possible, the anesthesia personnel should be,
at minimum, 3 ft from the source of the ionizing radiation. If this cannot be done, or if the
safety of the patient is jeopardized by this, the anesthesia care provider should request not only
lead aprons that cover both front and back, but also lead screens to be placed in front of the
source of the ionizing radiation. This will help deflect scatter and further decrease the exposure
to the anesthesia care provider.
Access to Patient
In keeping with the idea of protection by distance, some areas have developed the use of an
observation area while runs of angiography are being performed. During this time, the
anesthesia care provider, as well as other members in the remote location or hybrid OR, are
asked to relocate to a protected area. If this will be part of the daily function, one must be
reasonably sure that the patients vital signs are displayed on a dedicated monitor either in the
observation room or on a boom facing the observation room.
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The anesthesia care provider must also have unobstructed access to the patient from the
observation room (i.e., no operating tables, lead screens, or other obstacles to impede access
to the patient).
Some procedures allow the anesthesia provider to be directly near the patient with appropriate
shielding. If this is the case, or if this is the primary function of the room being designed, the
above protection recommendations apply. Again, though, one must be reasonably certain that
the anesthesia provider has easy access to the patients airway in an emergency.
Given the fact that many angiography tables are long and mechanically driven, as well as that
many of the sources of the ionizing radiation are mobile, it is prudent to do a trial run prior to
starting the procedure. Once the airway and patient are secure, cables, intravenous tubing, and
the anesthesia circuit should be arranged in a manner that does not obstruct the image while,
at the same time, being free to move with the patient. Once this is performed, the table is
moved in a manner that simulates motions that will be done during the procedure itself. By
taking 5 minutes at the beginning of the case, much hassle can be avoided at a later point.
Access to Anesthesia Provider
Just as important as being able to safely and quickly access the patient in the event of an
emergency, access to the anesthesia provider in the event of an emergency is tantamount.
Many times, anesthesia equipment is relegated to a corner, often with the angiography
equipment obstructing access. It is recommended that during construction of hybrid ORs or
angiography suites, the anesthesia providers area be placed either directly in front or to the
side of the entry door or at a reasonable distance from the door that allows both other
providers and anesthesia technicians quick and efficient access. Having the appropriate
protection capabilities (i.e., lead aprons and lead screens) available outside the area or upon
entry is also important.
Traffic Control
Remote locations have typically been designed without input from anesthesiologists about
space requirement. The space is routinely smaller than that to which one may be accustomed.
Maintaining an efficient and fluent traffic pattern becomes a must. When designing a remote
location where anesthesia may be provided, the patient areas that are often taken for granted
must be included in the design. If one is not in the designing stage, but rather in the
providing stage, the following must be properly accounted for before continuing with
providing the anesthetic. These include:
Patient receiving area
Anesthesia prescreening area
Patient induction area
Transportation to procedure room/area from induction area
Recovery area
Discharge area
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Adequate nursing staff must be available for the preprocedure/preoperative area as well as the
recovery area.
A model that is frequently used in outpatient surgery involves utilizing the same nursing staff
for both the prescreening area and the recovery area. Some institutions are beginning to
construct hybrid ORs that are roughly 900 to 1000 sq ft. This is to accommodate the large
monitors and imaging arms that are used in cases that involve diagnostic and therapeutic
imaging modalities, such as angiography, EP laboratories, and interventional radiology.
However, this can become somewhat inefficient in that circulators are required to take
additional steps to the central core to retrieve various items. A routine OR size is roughly 600 sq
ft. However, this does not always take into consideration the need for anesthesia equipment or
supplies. One cannot simply measure the size of the anesthesia machine and backstand and
add it to the overall size; rather, one must also factor into the design the ability to safely access
the patient as well as for others to safely access the anesthesia staff.3
Minimum Requirements
Prior to any procedure, whether in a newly designed remote location or hybrid OR designed
with input from members of the anesthesia field, a survey of the site is required. The following
items should be confirmed as being on hand before performing any anesthetic in a remote
location or hybrid OR:
Space
Electrical outlets (eight to ten for the team)
Communications system
Personnel
Lighting
Piped gases
Suction (one or two outlets)
Gas scavenging
Traffic control and radiation hazard control

If any of the above is missing, or if there are questions regarding the adequacy of the
equipment, consult the hospitals biomedical engineering department. Often, storage of
anesthesia machines and equipment and supplies becomes an issue. Many institutions have
taken to storing the anesthesia equipment behind the scanner gantry, retrieving it if necessary.
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CHAPTER 18
OBSTETRIC LABOR SUITE
Lead Authors: Hovig Chitilian, MD, Assistant in Anesthesia, Department of Anesthesia and
Critical Care, Massachusetts General Hospital, Instructor in Anesthesia, Harvard Medical School,
Boston, MA; Marianna Crowley, MD, Assistant Anesthetist, Department of Anesthesia and
Critical Care, Massachusetts General Hospital, Assistant Professor of Anesthesia, Harvard
Medical School, Boston, MA; Nancy Oriol, MD, Associate Professor of Anesthesia, Dean of
Students, Harvard Medical School, Director of Faculty Development, Department of Anesthesia
and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA
Checklist
Space considerations for obstetricians/midwives, neonatologists, nurses, and others?

Locations where anesthesia will be administered?
Equipment needs for anesthesia?
Support space for the above?
The obstetric suite is a location in which various types of anesthesia are given. Thus, it is
important that the anesthesiologist be actively involved in the planning of such a facility and
understands the implications of design decisions. Hospitals everywhere are in a constant state
of change, reconstruction, consolidation, downsizing or upsizing, renovation, or new
construction. The anesthesia service can and should be a participant in planning any of these
types of projects. Care of the obstetric patient is a team effort, perhaps even more so than in
other parts of the hospital. Design considerations for the location in which those patients are
cared for should reflect that team approach, and anesthesiologists involved in the planning
process should consider their relationships with other members of the team. The specifics of
that process are described elsewhere in this manual.
Design Considerations: Relationships With Other Care Providers
Obstetricians/Midwives
Consider all of the points of contact the anesthesiologist might have with the obstetric care
providers and their activities. Antenatal anesthesia consults for high-risk patients are best
performed near the obstetric suite to allow best utilization of manpower, especially if the
service is small. Similarly, preoperative visits for elective Cesarean sections (C-sections) as well
as preoperative testing would optimally be conducted on or near the obstetric suite. If there
will be stress testing, or if external versions are planned, a location for these procedures in or
near the obstetric suite would be useful to facilitate operative care if trouble arises. Depending
on the size and nature of the service, multidisciplinary conference space may be desirable. If
cerclages are to be performed in the operating rooms (ORs) in the obstetric suite, consider the
route by which those patients will be admitted and recovered after anesthesia.
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If the obstetric anesthesia team is to cover oocyte harvest for in vitro fertilization procedures,
consider whether those patients are best served in the obstetric suite, around pregnant and
delivering patients, or in a separate location. If the latter is true, there are manpower
implications.
Neonatologists
Neonatal resuscitation is an important issue for the planning team. Who will be responsible for
neonatal care, evaluation and resuscitation? The American Society of Anesthesiologists (ASA)
Guidelines for Regional Anesthesia in Obstetrics state that qualified personnel other than the
anesthesiologist attending the mother must be immediately available to attend to the
newborn. This means that another anesthesiologist or other qualified personnel must be
designated as responsible for the newborn. Many departments around the country have
decided that a member of the neonatology or pediatric service should care for the baby.
Therefore, in designing the obstetric suite, proximity to the neonatal nurseries, or neonatal
intensive care unit (NICU) if there is one, should be a priority. This will allow for the quickest
response to emergency calls and minimize the distance a sick neonate must be transported.
The design team must decide where the neonatal resuscitation will be performed, in the
delivery room on the infant warmer, in a separate but nearby resuscitation room, or in a
nursery or NICU. Clearly, this decision must be made before the space is planned. If the hospital
does not have a NICU, then there should be a place to stabilize and care for a sick infant until
the baby can be transported to a NICU.
Nurses
Interaction with nurses is a very important concern in designing (and running) an obstetric
suite. An attempt should be made to keep each labor room in touch with the main nurses
station, thereby facilitating communication. Consideration should be given to the
communication system (e.g., overhead page) and the mechanism by which stat, urgent, and
nonurgent requests for anesthesia help will be made. Many units have a labor board, listing
each patient, stage of labor, gestational age, and special concerns. This is a valuable
communication tool, and its location should be considered in the design of the unit. Will the
board be replaced by a computer equivalent, and if so, where will terminals be placed? If the
traditional board is used, will it be at the nurses station, easily accessible to staff but not very
private? If not, where will it be located?
Nursing expertise and management capabilities have implications for design. If the obstetric
service will care for parturients who require invasive monitoring, nurses must be familiar with
invasive lines and monitors. If so, labor rooms must be designed with the space and accessibility
required for intensive care. Central station hemodynamic monitoring should be considered,
since most labor rooms are intentionally private, often with doors closed. It is cheaper to wire
for this while the unit is being built, although it is possible to retrofit with telemetry monitors.
At the very least, an empty conduit should be placed for future monitoring needs. Most units
will require one or more computer terminals in each labor room, as many hospitals have moved
to electronic records for nursing, obstetrics, and anesthesia, and, of course, for laboratory data.
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Emergency Room, ICU, Laboratory, and Blood Bank Personnel
When planning the obstetric suite, a decision must be made regarding the level of maternal
intensive care to be provided on the labor floor. If there is a point at which a sick parturient will
be transferred to the intensive care unit (ICU), consideration should be given to its distance
from and accessibility to the labor floor. Pregnant patients in the ICU may require nurses
familiar with labor and fetal monitoring. If so, nurses from the obstetric suite may have to
accompany and stay with the patient. When such a patient delivers, it must be decided whether
she will remain in the ICU or be transferred to the obstetric suite or the facilitys main OR suite.
Consider accessibility from the emergency room, the route from the emergency room, and the
time it will take to transport a bleeding or delivering patient to the labor floor. A keyed elevator
for emergencies is often a good idea, and appropriate personnel should carry the key at all
times.
Other concerns are the relationship to the blood bank and the laboratories, in particular the
blood gas laboratory. How fast and by what route can blood samples be delivered to the
laboratories and results returned? Some hospitals use vacuum-tube systems to rapidly
transport blood and blood samples over significant distances; others use point-of-care testing
for many tests.
Design Considerations: Anesthesia Specific
Anesthetizing Locations
During the planning process, the design team must decide what types of procedures and,
therefore, anesthetics will take place in the obstetric suite. Some facilities will have dedicated
obstetric ORs where C-sections, other operative deliveries, cerclage placements, postpartum
procedures, and dilatation and curettages may be performed. Other facilities will plan to have
some or all of these operative procedures performed in the main OR suite. If the latter
arrangement is chosen, a plan must be elaborated for transport of obstetric patients to the
main OR for emergencies.
The design team will decide whether to plan for a labor-deliver-recover (LDR) unit or a labordeliver-recover-postpartum (LDRP) unit. In the LDR unit, the patient is admitted to a room in
which she is expected to labor, deliver her baby, and recover from her delivery prior to being
transferred to a postpartum room, usually outside the labor floor. In a LDRP unit, the patients
room is reconfigured after the delivery into a postpartum room, from which she will ultimately
be discharged home. The LDR versus LDRP decision has implications for the anesthesia service.
The LDRP unit will occupy a much greater geographic area than will the LDR unit. Depending on
the size of the service, it may even be spread over two floors of the hospital. If so, where will
the ORs be located? Should there be one on each floor, requiring duplication of anesthesia
equipment? If the OR suite is on one floor, with some LDRPs on another, how will emergent Csections be performed for the patients on the other floor? Will there be enough anesthesia
personnel to cover two floors? Where will the anesthesia call room be located? Even if the
LDRP unit is confined to one floor, how will communication among caregivers be facilitated in
such a large space?
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Irrespective of the specific type of unit planned (LDR or LDRP), space must be allocated for
operating and recovery rooms. Some hospitals have created designated recovery rooms for all
patients who have operative procedures. Thus, patients who have elective C-sections or
cerclage placements would never use a labor room or LDRP room. In other facilities, all patients
are admitted to an LDRP room following obstetric procedures. The substantial rise in the Csection rate in recent years has significant implications for the planning of operative and
postoperative spaces in these units. In addition, since the Health Insurance Portability and
Accountability Act was passed in 1996, there has been increased emphasis on patient privacy.
This has led to the creation of much more private and, therefore, larger triage and recovery
spaces in all operative settings, but especially on the labor floor. In fact, Guidelines for Perinatal
Care in Obstetrics state that the room provided for a woman in labor should be private and that
each woman should have access to a private toilet and handwashing area in her room, a
departure from recommendations from even 15 years ago.
Administrators responsible for satisfying the requirements of state and other agencies will
usually ensure that enough gas and electrical outlets are planned, that lighting is adequate, and
that ventilatory standards are met. However, it is the responsibility of the anesthesia
representative to ensure that there is an adequate number of wall oxygen and vacuum sources
as well as electrical outlets and data jacks in each area where anesthesia will be administered.
The anesthesia service should ensure that gas and electrical outlets are in locations that are
appropriate to the manner in which the labor rooms and ORs will be used.
Work Force Implications
It is important to decide very early in the process how the labor floor will be staffed by the
anesthesiology department. This issue must be included in the discussion of the placement of
the labor floor within the hospital. If the obstetric suite is connected or very close to the
general ORs, cross-coverage at some level may be possible, and the need for equipment
purchases may be minimized. If a new obstetric service or the consolidation of existing services
is planned, the department must decide whether to provide anesthesia services solely
dedicated to the labor floor or to allow on call anesthesia from the main ORs or from home.
The number of anesthesia providers must be determined; this is a complicated decision. It
depends on the number of deliveries expected and on the acuity of the patients. It depends on
the emergency backup available in the hospital to supplement the basic level of coverage for
the unpredictable flurries of deliveries that are expected in obstetrics. It depends on whether
residents or nurse anesthetists are part of the service and whether anesthesia providers are
also simultaneously responsible for patient care elsewhere in the hospital.
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Equipment Implications
In order to determine the impact that anesthesia equipment will have on the functional
program, consideration must again be given to how independent the labor suite will be. If the
suite will have its own OR(s), no matter what the expected size of the service, a basic amount of
equipment will be necessary. If the labor floor is remote from the other anesthetizing locations
in the hospital, American Institute of Architect guidelines mandates an anesthesia workroom.
Some anesthesia equipment is bulky; some is less so. Some can be moved easily; some cannot.
In order to make rational decisions about room sizes, a number of determinations are
necessary. How much of each type of equipment is necessary? Where should active and backup
equipment be stored and how accessible must it be? Equipment needs are discussed further
later in this chapter. Many anesthesiology departments have technician support, and this
should be considered in planning the amount of storage necessary for basic equipment and
disposables. If someone will frequently restock medications and the many disposables used in
anesthesia, less of such items will be needed. If an anesthesia workroom is included in the
obstetric suite, it should be near the ORs. If the ORs are in a substerile corridor, it may be
preferable to arrange the suite so that there is access to the workroom from the substerile
area.
Consideration must be given to the accessibility of the anesthesia workroom. In general,
regulatory agencies, such as the Joint Commission and State Departments of Public Health,
mandate restrictions in public access to syringes, needles, and biologicals. Therefore, if the
workroom door is on the labor floor, it may have to be kept closed and locked. Clinical
circumstances may arise in which it is necessary to send a nurse or other nonanesthesia
personnel to urgently retrieve items from the workroom (e.g., emergency airway cart); in such
instances, a locked workroom could add an unnecessary delay. On the other hand, the need for
personnel to wear scrub suits and masks to access the workroom will add inconvenience to the
delivery of supplies. Wherever it is placed, the anesthesia service should make sure that the
room is sized to adequately accommodate the necessary equipment. The planning team must
decide how pharmacy needs will be met. How will drugs be dispensed and stored? Perhaps an
existing pharmacy substation can be used and no additional space will be needed. Perhaps an
automatic drug delivery machine will be used, and an alcove that is centrally located for all
users is all that is required. In many cases, a medication closet is planned at the nurses station.
Where will anesthesia medications, including narcotics, be stored? What about refrigeration? If
medications for anesthesia use are to be kept in the anesthesia workroom, they can take up a
surprising amount of shelf space and have a significant impact on the size of the room. On the
labor floor, where rapid response to emergencies is a constant concern, there must be a
balance between immediate access to necessary medications and equipment and the need to
satisfy the regulations mandating that those medications are locked away from public access.
Thus, central storage space for anesthesia equipment must be planned.
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Support Space
Once the number of obstetric anesthesia staff and the staffing model are determined, many
questions arise. Will the anesthesia staff require office space on or near the labor floor? Where
will case records and textbooks be kept, and where will telephone and computer use take
place? Is secretarial support necessary, and how is it accessible? Will prenatal and postnatal
consultation be performed on the labor floor? How many call rooms will be necessary for the
anesthesia service, and how close will they be to the labor floor? How many lockers will be
necessary, specifically for the anesthesia personnel? Will showers and bathrooms be located in
the locker rooms, near the call rooms, or both? If an anesthesia office or call room on the labor
floor is planned, it should be situated to allow easy accessibility by nursing personnel and allow
the staff to be aware of activity on the labor floor. It may be best to position the office near the
OR to facilitate emergent C-sections.
Design Considerations: Equipment

Below is a skeleton list of equipment necessary in an OR in the obstetric suite. Elsewhere in this
manual is a more complete discussion of OR equipment needs. They are essentially the same as
those for a C-section room. In addition, some sort of device to achieve left uterine displacement
should be available, whether it is a hip wedge or just a rolled-up blanket. A warming cabinet for
fluids and blankets is desirable but not mandatory.
Anesthesia Equipment Needs for Labor and Delivery Suite
Fixed C-section rooms:

o Anesthesia machine, equipped with accurate vaporizers, oxygen analyzer, fail-safe
device, and scavenging device
o Monitors: Electrocardiogram, invasive pressure monitor, capnograph, pulse oximeter,
temperature monitor, and nerve stimulator
o Ancillary equipment: Laryngoscopes with various blades and short handles,
endotracheal tubes and stylets, oral and nasal airways, fluid warmers, rapid infusion
device, uterine displacement device, drugs as per any other OR plus those to increase
uterine tone, stethoscope, syringes, intravenous catheters, oral/nasal gastric tubes,
suction catheters, esophageal stethoscopes, laryngeal mask airways, etc., as per any OR
Fixed labor rooms: Ambulatory bag and mask, oxygen saturation monitor, noninvasive
blood pressure monitoring device, oxygen, and suction
Emergency:
o Extra anesthesia machine and monitors
o Difficult airway cart: Fiberoptic laryngoscope, laryngeal mask airway, variety of airways,
viscous and aerosolized local anesthetic, bougie, transtracheal jet ventilator, and
cricothyrotomy kit
o Tracheostomy instruments
o Malignant hyperthermia kit
o Latex allergy kit
o Defibrillator
108
o
o
o
o
o
o
o
o
Newborn:
Oxygen supply
Wall suction: Adjustable, with DeLee and bulb suction devices
Radiant heater with servomechanism
Laryngoscope with size 0 and 1 straight blades
Endotracheal tubes, sizes 2.0, 2.5, and 3.0
Oral airways, sizes 00 and 0
Portable, nonemergency:
Regional anesthesia cart: Epidural and spinal trays, extra spinal and epidural needles,
ephedrine, sterile gloves, and various types of tape
Epidural infusion pump
Narcotics and sedatives: Nurse dispensed versus direct pharmacy distribution versus
automated distribution device
Fixed Labor Rooms

At a minimum, labor rooms must have oxygen and suction outlets for both mother and baby, a
resuscitation bag and mask, and a sphygmomanometer. Noninvasive automatic blood pressure
apparatus and oxygen saturation monitors are not mandatory in each labor room but must be
available, especially if labor epidurals will be performed in the room. If the labor room will also
function as a recovery room, as in LDR or LDRP units, then provisions must be made for
monitoring patients postoperatively. The ASA Guidelines for Regional Anesthesia in Obstetrics
state that patients on the labor floor must be monitored after surgery in a manner equivalent
to that in the hospital post-anesthesia care unit. In most hospitals, this will mean that
postoperative patients need to have electrocardiographic (ECG), blood pressure, and oxygen
saturation monitoring. Some fetal heart rate monitors also offer the ability to monitor the
mother. Some provide oxygen saturation and noninvasive blood pressure measurements as
well as fetal heart rate and tocodynamometry. Others provide a maternal ECG trace as well.
Emergency
If the labor floor is independent of the hospitals main OR suite, provision of an extra anesthesia
machine should be considered. The suite should be designed so that the number of ORs is
sufficient to conduct the anticipated number of surgical procedures. However, given the
episodic and unpredictable nature of obstetrics, the day may come on which the carefully
planned facilities are not enough. If an emergent C-section, postpartum hemorrhage, or
retained placenta must be dealt with in a labor room, most anesthesiologists would be more
comfortable managing the associated anesthetic with an anesthesia machine rather than a selfinflating resuscitation bag and mask. Some hospitals have decided that such overflow
procedures should instead be performed in a nonobstetric OR; in such facilities, a well thoughtout plan for emergency transport should be made, especially if the main ORs are located a
distance from the labor floor.
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At a minimum, extra monitors with invasive pressure capabilities should be available and stored
so that they are easily accessible. Portable monitors will be necessary for postoperatively
recovering patients, transporting patients, and the occasional high-risk patient who needs close
monitoring.
An emergency airway cart should be kept and maintained on the labor floor, either in the
anesthesia workroom or in the OR. Emergency airway devices, such as transtracheal jet
ventilator and the laryngeal mask airway, should be kept in the OR. Instruments for the
establishment of a surgical airway should be kept with the other surgical instruments. Kits for
the management of malignant hyperthermia and latex allergy should be kept accessible. At
least one defibrillator should be kept in the obstetric suite in a central location. The location in
the hospital of defibrillators with external pacing capability should be known by anesthesia and
nursing staff. Advanced cardiac life support protocols call for external pacing in some of the
algorithms.
Newborn
There should be separate oxygen and suction wall outlets for the infant in both the labor rooms
and C-section rooms. Suction outlets must be adjustable. For each infant, there should be a
radiant heater with servomechanism, a noncompressible resuscitation device, and an
examination mattress that allows access on three sides. Infant airway devices, such as a
ventilation bag and mask for term and preterm neonates; laryngoscope with sizes 0 and 1
blades; endotracheal tubes, sizes 2.0, 2.5, and 3.0; and oral airways, sizes 00 and 0; must be
available. Pediatric suction catheters, meconium suction apparatus, bulb suction devices, warm
or at least dry towels, stethoscope, and vascular access catheters are all required. There should
also be a wall clock.
Portable, Nonemergency
Portable equipment of interest to the obstetric anesthesiologist consists of epidural carts and
epidural infusion pumps. Many busy obstetric anesthesia services use a cart that contains all of
the supplies necessary to place an epidural or spinal catheter. Some are quite elaborate, and
their design is a matter of preference. It may be advantageous to plan for one such cart for
each labor room or a few that are stored in a central location. Each will require stocking and
maintenance. Epidural infusions have become a popular form of anesthesia for labor. Syringe
pumps are expensive and very portable and may be stolen or misplaced. Some are battery
operated and may require recharging after a few hours of use. It may be desirable to have a
pump attached to the wall or placed into a cabinet in each labor room. Doing so would prevent
the loss of the device and allow it to be kept plugged. Such an arrangement would, however,
inhibit the portability of the devices. Depending on the number of labor rooms, one pump for
each room may mean a considerable capital outlay for their purchase.
Narcotics
As previously discussed, the method for dispensing medications must be chosen, and narcotics
may be problematic, especially in an emergency, because they must be precisely accounted for
and kept under lock and key. If the labor floor is too far from the main OR to use its pharmacy,
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then a separate pharmacy substation may be necessary. If nurses dispense narcotics, then each
time an anesthesiologist needs controlled drugs, he or she must involve a nurse. Depending on
the exact mechanism adopted, this can be a major inconvenience and a point of contention
regarding responsibility. Automated drug dispensing machines are available, but these may also
be less than optimal in an emergency. The anesthesia staff could have control over their own
supply of narcotics, although this would mean that the hospital pharmacy would have to
monitor two separate groups of users of narcotics in the obstetric suite.
Summary
The aim of this chapter is to raise the questions that should be considered in the design and
planning of an obstetric suite. The design of an obstetric suite is an iterative process. There is
no unique solution, as many of the details are dependent on the specific needs of the hospital
and the service. There are issues related to the anesthetic and obstetric practices, the expected
patient volume, and the preexisting facilities. Future directions in health care must also be
considered. Shortened lengths of stay, demechanization of parturition, and consumer-driven
birth options are just some of the forces shaping obstetric care. Although designing for change
is crucial, predicting change is difficult. Flexibility is the only hope.
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CHAPTER 19
ANTICIPATING THE FUTURE
Lead Author: Frank E. Block, Jr, Clinical Professor of Anesthesiology, Virginia Commonwealth
University
Introduction
Plus a change, plus cest la mme chose. (The more things change, the more they stay the
same.)
In the French movie Les Visiteurs, two Frenchmen are magically transported from the 12th
century into the late 20th century. You can imagine the mischief as they discover paved roads,
modern transportation, electricity, running water, and toothbrushes.
If we could truly imagine the future, we could have it today! In reality, we can only make some
guesses about some of the things that may be needed in the future.
One basic starting point is that change is inevitable and that it will occur very quickly after a
new facility is opened. In one recent example, walls were knocked down and an operating room
(OR) was enlarged in a new OR suite BEFORE the suite had opened! This occurrence argues for a
just in time design plan.
Another reasonable approach would be to plan how the whole structure can be renovated in
the future. For example, should design of a new building include directions for future expansion
north, east, south, or west? Or up or down? Lengthening a hallway in the proper direction and
adding new ORs in a line with old rooms is an easy solution. Jack-hammering through the walls
of the main general surgery room and the main neurosurgery room (in a recent instance) is a
difficult solution. Availability of utility connection points (including medical gases) on that side
and a way to make that connection someday without major interruptions in the existing OR
suite would be logical.
Another way of recognizing the problem is to realize that some things are easy to move and
some are not. A future OR could be roughed out (with provision for future utilities) and used as
a locker room, storage room, or office with cubicles until the next phase of expansion is
complete. What is needed is advance planning for what the expanded facility might look like.
In another example, it could be planned that sections of the OR suite could be cordoned off for
renovation while the rest of the suite remained open for business (one of the fire safety
mandates is that access to exits must be maintained during construction). Certain designs can
make even a task such as moving a wall relatively easy.
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Utilities are a key issue. Easy access to space above the ceiling and space below the floor makes
it easier to run additional utilities wherever they might be needed. Future cables, including
possible fiber-optic cables, cables for wireless access points, additional computer networks, and
so on, can be readily installed if metal or plastic conduits are installed. These conduits may be
up to 5-10 cm in diameter.
It is regrettable that many hospital campuses do not appear to have a master plan of what
buildings might begin constructed in the next 25 years, or even in the next 3 years!
New Patients
Future planning should include the likely change in patient demographics and patient numbers.
Is the city growing or shrinking? Is it a retirement paradise or home for families? Is it a
vacationland or the place that people leave when they go on vacation? Is new industry
expected in town? Are industries expected to close down? What will be the referral patterns of
the future? Will competing hospitals be constructed? Will other hospitals siphon off your
business? Will other hospitals close, their patients coming to you?
A sad commentary is that the obesity epidemic will affect all kinds of patient-handling issues in
the future. Will ceiling hoists be needed in some areas?
New Procedures
Few could have imagined the explosion of new kinds of procedures witnessed in the past 25
years. The next generation is likely to see even more new procedures. One projected increase
will be that of noninvasive or minimally invasive procedures, through both flexible and rigid
scopes. Octopus-like tool endings with multiple implements may be expected. Procedures
that combine various forms of imaging with the surgical process will also likely multiply,
including: tumor navigation systems; real-time intraoperative computed tomography, magnetic
resonance imaging, and positron emission tomography scans; contrast media and imaging
procedures; etc. Various forms of ultrasound, including 4-dimensional and the use of
radioisotopes and other injectable markers, will also come into expanded use.
The challenges for the future will be providing space, electrical and air power outlets, heat
dissipation, and scavenging (i.e., exhaust) for these devices. Already, newly constructed ORs
seem cramped, and the amount of equipment may easily double or triple (or more) in the near
future.
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New Processes
Traffic patterns of patients, family, and personnel are extremely important, both in terms of
travel to the facility and travel within the facility. Will new parking decks be constructed, and if
so, where? Or will existing parking lots and decks become new hospital buildings? In either
case, where will people park and how will they enter the facility? Alternatively, will more
people take public transportation to reach the hospital? How will future public transit affect
traffic patterns?
New care processes may also be created. Where will induction of anesthesia take place? Will it
occur in areas that are now used for preoperative holding, with transport monitors and
ventilators so small and easy to use that it is not a problem to take them with the patient to the
OR? Will induction occur in a dedicated induction room outside each OR? With newer agents,
will all patients have to go to the traditional post-anesthesia care unit (PACU)? Will some
patients be able to go directly to a phase II recovery area? Or will the post-anesthesia care
nurse come directly into the OR and pick up the patient at the end of the case, while the
anesthesia team prepares for the next patient?
If this model is taken to an extreme, the concept of a centralized preoperative holding area and
a centralized PACU can be eliminated. In this different model, there are three rooms in a line.
The first room is a public area to allow patients to be prepared for surgery. Family members
are welcome in this area. Appropriate monitors and equipment are located in this area, and
invasive cannulae and nerve blocks can be placed in this area. Optionally, induction of
anesthesia can be accomplished in this room. The second room, which directly opens onto this
room, is the OR (there is no door from the OR to the public side). The third room is the postanesthesia care room for this patient, which also directly opens onto the OR. Again, this room is
a public area, and family can visit at the appropriate time (for high-turnover locations, an
additional post-anesthesia room could be added). With cross-training of staff, a single nurse can
be assigned to a given patient and be that patients personal nurse from preoperative holding
through circulating in the OR through the post-anesthesia care area. Handoffs then become
nonexistent because the same nurse cares for the patient from beginning through completion
of recovery.
New Layouts
Several hospitals have created innovative designs in the last two decades. In one design for
patient wards, patient doors and windows face a motel-style hallway with full-height windows
to view the outside world. This is the public side. There is also a back door to the patient
room for staff to come and go from a central core area. In this way, the equipment, charting,
etc., are not seen by the public.
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Other hospitals have used designs in which the patient stays in one place, and equipment
comes and goes as it is needed. In this model, a low-acuity room can become the highest-level
intensive care room simply by rolling needed equipment into place.
In an expanded vision of this model, one can imagine a line of intensive care unit (ICU) rooms.
The front side is a standard ICU. The back of each room has a door into the OR core. By locking
the front door, opening the back door, adjusting room ventilation, and rolling in OR equipment,
the ICU room is now transformed into an OR that meets every standard requirement. In this
model, transport of a critically ill patient to the OR becomes a thing of the past.
Conclusion
Imagining that the OR will remain as it is for the next 5 or 10 years is a fantasy. Expansion and
change are inevitable. Good planning today can make future expansion and change welcome
rather than dreaded.
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CHAPTER 20
ROGUES GALLERY
Lead Author: Frank E. Block, Jr., Clinical Professor of Anesthesiology, Virginia Commonwealth
University
This chapter is a small collection of photos of things that are and are not designed very well. It is hoped that this
chapter will be expanded in future editions of this manual.
Clocks
Clocks should be on a central system that synchronizes the time with all the hospitals
computers. In reconstructing a medical emergency, and for billing purposes, everyone must be
using the same time.
One hospital used clocks that rely upon shortwave radio signals for synchronization. In a brickand-steel building, those signals do not penetrate into the operating rooms (ORs) to
synchronize the clocks. The workaround is to place the clocks in a west-facing window at
intervals, so that they will receive the radio signals and synchronize.
In this photo, the clocks have synchronized to the correct minute, but not to the correct hour.
Some unknown person or persons have supplied labels that might explain the situation.
117
The labels read AMSTERDAM, NEW YORK, ROME, PARIS, LONDON, BRUSSELS, and MELBOURNE.
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Hoses
The following picture shows gas drop lines (pigtails) (i.e., hoses) that were positioned in front of
the door. They are in the way when patients and equipment are brought into the room. The
hoses were supposed to have been located several feet to the right, next to the overhead light.
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In the next picture, hoses are located directly over the anesthesia machine. This location makes it
extremely difficult to move the anesthesia machine, and equipment on top of the anesthesia machine
may be displaced by the hoses.
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Mirror Operating Rooms
In a two-OR freestanding surgical facility, the rooms were constructed as mirror images, so that
all the plumbing could be located in the shared wall.
Door to Operating Room 1
In this room, the OR table and the anesthesia machine are to the right as you enter the room.
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The OR table is on the right as you enter the room.
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The anesthesia machine is on the right as you enter the room. The anesthesia machine and gas
line booms are located to the right of the table. There is free access to the OR table for the
patient when entering and to the stretcher when leaving without having to reach around the
anesthesia machine and electrical/vacuum boom.
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Door to Operating Room 2
In the second room, the OR table and the anesthesia machine are to the left as you enter the
room.
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The OR table is on the left as you enter the room.
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The anesthesia machine is on the left as you enter the room. The anesthesia machine and the
ceiling boom for gases, vacuum, and electrical are located to the right of the OR table.
Therefore, at the end of the case, the stretcher is brought into the room to the right of the OR
table. To move the patient, the anesthesiologist must reach around the anesthesia machine and
boom.
Mirror image rooms are not necessarily ideal for patient care, even if this design facilitates
construction.
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2010 2011 Operating Room Manual

Lead Author: Cary Sweat; Architect

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Authorities Having Jurisdiction

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Project Budgeting and Scheduling

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Heating, Ventilation, and Air Conditioning

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Substerile Areas (Scrub Rooms)

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Communication is another important aspect of OR design. Telephones, intercoms, and

One often-overlooked aspect of OR design is materials management. This encompasses all

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ORs are noisy

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Anesthesia: The Anesthesia Cockpit

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Energy- and/or water-saving appliances can be installed. Water used in cleaning or

Energy and Atmosphere

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Materials and Resources/Indoor Environmental Quality

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Innovation and Design

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Is there sufficient storage space for present and future equipment?

Operating Room Storage

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