Physical facilities

Type of physical plant design

Most surgical suites are constructed according to a variation of one or more of four basic designs:

1. Central corridor, or hotel plan (Fig. 10-1).

2. Central core, or clean core plan with peripheral corridor (Fig. 10-2).

3. Combination central core and peripheral corridor, or racetrack plan (Fig. 10-3).

4. Grouping, or cluster plan with peripheral and central corridor (Fig. 10-4).

Each design has its advantages and disadvantages.^8,9 Efficiency is affected if corridor distances are too long in proportion to other space, if illogical relationships exist between space and function, and if inadequate consideration was given to storage space, material handling, and personnel areas.

Location

The surgical suite is usually located in an area accessible to the critical care surgical patient areas and the supporting service departments, the central service or sterile processing department, the pathology department, and the radiology department. The size of the hospital is a determining factor because locating every desirable unit or department immediately adjacent to the surgical suite is impossible.

A terminal location is necessary to prevent unrelated traffic from passing through the suite. A location on a top floor is not necessary for microbial control because all air is specially filtered to control dust. Traffic noises may be less evident above the ground floor. Artificial lighting is controllable, so the need for daylight is not a factor; in fact, daylight may be a distraction during the use of video equipment and other procedures that require a darkened environment. Most surgical suites have solid walls without windows. However, some ambulatory surgery rooms have windows to create an ambiance of openness in the suite.

Space allocation and traffic patterns

Space is allocated within the surgical suite to provide for the work to be done, with consideration given to the efficiency with which it can be accomplished. The surgical suite should be large enough to allow for correct technique yet small enough to minimize the movement of patients, personnel, and supplies.

Provision must be made for traffic control. The type of design predetermines traffic patterns. Everyone—staff, patients, and visitors—should follow the delineated patterns in appropriate attire. Signs should be posted that clearly indicate the attire and environmental controls required (Table 10-1). The surgical suite is divided into three areas that are designated by the physical activities performed in each area.

Preoperative admission and holding unit

A designated unit in the unrestricted zone should be available for preoperative patients to change from street clothes into a gown and wait with their families before their surgical procedure. The decor should create a feeling of warmth and security. Lockers should be provided for safeguarding patient clothing. The location of the area should shield the patient and family from potentially distressing sights and sounds. Lavatory facilities and handwashing stations must be available. Alcohol-based hand-rub dispensers should be conveniently located in each patient care cubicle.

The area must ensure privacy and offer 80 ft² per patient of space to accommodate a transport cart.^a It may be compartmentalized with individual cubicles or be an open area with curtains. Curtains do not deflect sound and offer little privacy when the nurse is performing assessment and having conversations with the patient. Curtains also accumulate dust and particles and should be laundered on a regular basis.

Insertion of intravenous (IV) lines may be done here. In some cases, nerve blockades for pain management may be done in the holding area as ambulatory procedures. These procedures require good lighting. Each cubicle is equipped with oxygen, suction, and devices for monitoring blood pressure. A crash cart should be easily accessible for emergencies.

A nurses’ station within the area provides close patient observation and dispensers for medication storage. Computer access to patient electronic medical records (EMRs), such as laboratory reports, and to patient care documentation facilitates documentation in patient records. Care is taken not to have loud conversations at the nurses’ station. Private information may be overheard by patients and families.

Assignment and scheduling boards should not be within the view of the patients to avoid breaching privacy standards. When wipe-off boards are used for daily scheduling, care is taken not to use patient names. Coordination of the holding room staff and the personnel managing the surgical schedule is essential to prevent delays. More information about preoperative patient care areas is available in Chapter 21.

Some preoperative holding units serve as ambulatory care areas after the surgical procedure. Patients who are admitted in the morning are brought back to the holding unit to recover. They can go home a few hours after the surgical procedure.

Induction room

Some surgical departments have an induction room within the restricted area adjacent to each OR, or pair of ORs, where the patient is prepared physiologically for anesthesia administration preoperatively and before actual induction of general anesthesia and airway management. Families of patients are not permitted in this area. Appropriate surgical attire is required, including a mask.

Peripheral IV lines, central lines, and invasive arterial monitoring lines are placed and regional anesthesia (i.e., epidural catheter for postoperative pain management) may be induced in this area. Performing these procedures in an induction room saves actual OR time, which is more costly to provide. Induction rooms are more common in larger facilities, where procedures, such as open heart surgery or transplantation, are performed.

In some induction rooms (not all), patients are premedicated and stabilized on the same OR bed that will be used for the procedure. The OR bed is used as the transport vehicle to the OR, where it is connected and locked to a base unit permanently mounted in the floor. This minimizes the number of times critically ill patients are moved from one surface to another.

Postanesthesia care unit

The postanesthesia care unit (PACU) may be outside the surgical suite, or it may be adjacent to the suite so that it may be incorporated into the unrestricted area with access from both the semirestricted area and an outside corridor. In the latter design, the PACU becomes a transition zone for the departure of patients.

Hospitals and ambulatory care facilities accommodate patients and their families during the perioperative waiting period. A designated waiting area is provided for families of surgical patients. This is most conveniently located outside the surgical suite adjacent to the recovery area. More information about the PACU can be found in Chapter 30.

Central control desk

From a central control point, traffic in and out of the surgical suite may be observed. This area usually is within the unrestricted area but adjacent to the semirestricted corridor. The clerk-receptionist is located at the control desk to coordinate communications. A pass-through window may be used to stop unauthorized people, to schedule surgical procedures with surgeons, and to receive drugs, blood, and various small supplies. A computerized pneumatic tube system within the hospital can speed the delivery of small items and paperwork, thus eliminating some courier services, such as from the pharmacy to the control desk. Tissue specimens and blood samples also can be sent to the laboratory through some tube systems. The tubes used to send items should be periodically cleaned with an approved disinfectant solution.

Computers and printers may be located in the control area. Information systems and computers assist in financial management, statistical recording and analysis, scheduling of patients and personnel, materials management, and other functions that evaluate the use of facilities. An integrated system interfaces with other hospital departments. It may have a hard-wired modem or wireless Internet that allows surgeons to schedule surgical procedures directly from their offices.

Retrieval for review of patient records gives the perioperative nurse manager the opportunity to evaluate the patient care given and documented by nurses. Personnel records can be maintained. Other essential records can be stored in and retrieved from computer databases on a password-controlled basis. The central processing unit for the OR computer system usually is located in or near the central administrative control area. A fax machine may be available for the electronic transfer of documents, records, and patient care orders between the OR and surgeons’ offices.

Security systems usually can be monitored from the central administrative control area. Alarms are incorporated into electrical and piped-in systems to alert personnel to the location of a system failure. A centralized emergency call system facilitates summoning help. Some facilities have a panic button to summon the security department. Narcotics are kept in locked cabinets and can be signed out only by appropriate personnel.

Access to exchange areas, offices, and storage areas may be limited during evening and night hours and on weekends. Doors may be locked. Some hospitals use alarm systems, video surveillance in hallways and ORs, and electronic metal detection devices to control intruders and to prevent theft or vandalism. Computers and records must be secured to protect patient confidentiality.

Offices

Offices for the administrative patient care personnel and the anesthesia department should be located with access to both unrestricted and semirestricted areas. The staff members frequently need to confer with outside people and need to be kept informed of activities within all areas of the suite.

Locker rooms and lounges

Dressing rooms with secure lockers are provided for both male and female personnel to change from street clothes into OR attire before entering the semirestricted area, and vice versa. The area should be secure from unauthorized personnel. Doors separate this area from lavatory facilities and adjacent lounges.

Walls in the lounge areas should have an aesthetically pleasing color or combination of colors to foster a calming atmosphere. A window view of the outdoors is psychologically desirable because many staff members arrive for the day shift when it is still dark outside. Affect is enhanced by natural sunlight. Some personnel bring a meal, so a refrigerator designated only for food should be located in this room. A routine refrigerator cleaning schedule should be established. Antiseptic hand-rub dispensers should be conveniently located at the entrance and near all food storage areas.

Dictating equipment, computers, and telephones should be available for surgeons in the physicians’ lounge or in an adjacent semirestricted area.

Conference room/classroom

Ideally, a conference room or a classroom is located within the semirestricted area with entrance/exit doors to unrestricted areas. This room is used for patient care staff inservice educational programs and is used by the surgical staff for teaching. Closed-circuit television and video equipment may also be available for self-study. The departmental reference library may be housed here. Tables and chairs for staff should be sturdy and easily cleanable. Shoe covers and masks should not be worn in this room. Antiseptic hand-rub dispensers should be conveniently located at the entrance.

Some facilities permit covered beverages and small snacks during meetings. Departmental holiday parties or special event celebrations may be set up in here.

Support services

The size of the health care facility and the types of services provided determine whether laboratory and radiology equipment is needed within the surgical suite.

Work and storage areas

Clean and sterile supplies and equipment are separated from soiled items and trash. If the surgical suite has a clean core area, only clean or sterile items are stored there. The air handlers are set to positive pressure as in the restricted area, so the doors should always remain closed when traffic is not entering or leaving.

Soiled items are taken to the decontamination area for processing before being stored, or they are taken to the disposal area. The air handlers in the contaminated areas are set to negative pressure as in the corridors, so the doors should remain closed when personnel are not entering or leaving. Work and storage areas are provided for handling all types of supplies and equipment, whether clean or contaminated.

Storage

Technology nearly tripled the need for storage space in the twenty-first century. Many older surgical suites have inadequate facilities for storage of sterile supplies, instruments, and bulky equipment. Those responsible for calculating adequate storage space for instruments, sterile and unsterile supplies, and mobile equipment, such as special OR beds, specialty carts, and equipment, should consider the size of the entire surgical suite. American Institute of Architects (AIA) 2010 Guidelines state that a minimum of 150 ft² or 50 ft² per OR, whichever is greater, should be dedicated to equipment storage to prevent accumulation of machines and supplies in hallways. Blocked hallways prevent rapid transfer of crash carts and emergency equipment.

The OR storage space does not include additional storage space needed for postanesthesia equipment. Anesthesia storage should be considered separately. Use of a case cart system may slightly decrease the amount of instrument space needed. Plans should include accommodation for the size of each type of case cart used and the numbers that will be in the suite at a given point in the daily surgical schedule.

Scrub room

An enclosed area for preoperative cleansing of hands and arms should be provided adjacent to each OR. Water spills on the floor are particularly hazardous if the scrub area is in a traffic corridor. An enclosed scrub room is a restricted area within the surgical suite. Paper towel dispensers and mirrors should be located in this area. Trash receptacles, limited to only those items used within this room, should be emptied several times per day. Some facilities have boxes of additional caps, masks, shoe covers, and eye protection in the event of biologic contamination requiring a change of these items during a procedure. The contaminated item should be discarded in the biohazard trash bin in the OR after changing.

Categories of operating rooms

The American College of Surgeons (ACS) defines three categories or classes of surgical facilities based on the types of procedures performed therein. The AIA Guidelines in cooperation with the ACS use specific criteria when determining safe environmental factors for surgical facilities and include provision for all types of surgical interventions. The criteria include minimal floor space, types of anesthetics used, and circumferential clearance around the OR bed. The classes of ORs with minimal floor space are as follows:

Other ORs not designated by class range in size from 600 to 650 ft² with a 24- to 25-foot width and accommodate multiple ceiling-mounted booms, monitors, and high-technology equipment such as robotics and controlling consoles.

Size determinations

The size of individual ORs varies according to use. Class A ORs are commonly used for smaller procedures performed with topical, local, or limited regional blocks that have minimal equipment needs. Many ambulatory centers have procedure rooms that fit this usage.

Class B rooms are better suited for procedures in which the patient may be sedated and physiologically supported with IV medication. General anesthesia and spinal or epidural blocks can be used. Intermediate to complex procedures are performed in these rooms. Additional space is appropriate where the potential for larger equipment and longer procedures is possible.

It is desirable to have the ORs in a hospital setting the same size so that they can be used interchangeably to accommodate elective and emergency surgical procedures. Class C ORs provide adequate space for typical multipurpose procedure rooms with at least 400 ft² of clear floor space. Approximately 20 ft² of space should be planned between fixed cabinets and shelves on two opposing walls if possible. A specialized room, such as one equipped for cardiopulmonary bypass or trauma, may require as much as 600 ft² of useful space.

A room may be designed for a specialty service if use by that service will be high. The room must accommodate equipment, such as lasers, microscopes, or video equipment, either fixed (permanently installed) or portable (movable). Portable equipment requires more floor space.

Some rooms are designated for special procedures, such as gastrointestinal endoscopy, interventional radiologic studies, or the application of casts. Other rooms have adjacent areas used for specific purposes, such as visitor viewing galleries, or for installing special equipment, such as monitors or x-ray devices for imaging.

Operating room humidity

An air-conditioning system controls humidity. High relative humidity (weight of water vapor present) should be maintained between 30% and 60%. Moisture provides a conductive medium and allows a static charge to flow to ground as fast as a spark is generated.

The humidity gradient standard in current use is based on previous decades when the use of flammable anesthetics posed the risk of explosion after a spark. The AIA is planning to lower the requirements in the 2012 Guidelines because flammable anesthetics are no longer used.

Operating room temperature

OR temperature is maintained within a range of 68° F to 73° F (20° C to 23° C). A thermostat to control room temperature can be advantageous to meet patient needs; for example, the temperature can be increased to prevent hypothermia in pediatric, geriatric, and burn patients. Overmanipulation of controls can result in calibration problems. Controls should not be adjusted solely for the comfort of team members; patient normothermia is a strong consideration. Only the maintenance department can regulate temperature in some surgical suites; this department should be called early enough to reset the temperature for patients at risk for hypothermia.

Substerile room

A group of two, three, or four ORs may be clustered around a central scrub area, work area, and a small substerile room. Only if the last-mentioned room is immediately adjacent to the OR and separated from the scrub area is it considered the substerile room throughout this text.

A substerile room adjacent to the OR contains enclosed storage cupboards, a sink, steam sterilizer, STERIS 1E™, and a warming cabinet. Although cleaning and sterilizing facilities are centralized, either inside or outside of the surgical suite, a substerile room with this equipment offers the following advantages:

Rooms adjacent to orthopedic or cast rooms should have a sink with a plaster trap for disposal of casting solutions.

The substerile room also usually contains a combination blanket and solution warmer, cabinets for storage, and perhaps a refrigerator for blood and medications. Empty sterile specimen containers and labels may be conveniently stored in this room. Slips for charges or other records may be kept here. Individual hospitals may find it convenient to keep other items in this room to allow the circulating nurse to remain in or immediately adjacent to the OR during the surgical procedure.

Doors

Doors should be 4 ft wide for ease in moving patients on carts and in beds. Ideally, sliding doors should be used exclusively in the OR for the main corridor. They eliminate the air currents caused by swinging doors. Microorganisms that have previously settled in the room are disturbed with each swing of the door. The microbial count is usually at its peak at the time of the skin incision because this follows disturbance of air from gowning, draping, movement of personnel, and opening and closing of doors.

Sliding doors should not recede into the wall like pocket styles but should be of the surface-sliding type. Fire regulations mandate that sliding doors for ORs be of the type that can be swung open if necessary. Doors do not remain open either during or between surgical procedures. The room air-handlers generate higher pressure than in the halls to minimize the amount of dust and debris pulled in toward the sterile field. Closed doors decrease the mixing of air within the OR with that in the corridors, which may contain higher microbial counts. Air pressure in the room also is disrupted if the doors remain open.

When construction or renovation is in process, always keeping the doors closed when not transporting patients is important because the ORs are ventilated with positive pressure. The air-handling systems are under a strain because of the disrupted processes and are further compromised when the airflow is allowed to equalize. This causes unstable temperature and humidity control. The desired temperature should be between 68° F and 73° F, with a relative humidity of 30% to 60%.

The door to the substerile area is usually a swinging style door with a small window. These doors are not used for moving patients in and out of the OR and should remain closed. During the surgical procedure, the microbial count rises every time doors swing open from either direction. Also, swinging doors may touch a sterile table or person. The risk of catching hands, equipment cords, or other supplies is increased. Always look through the window before opening this door to prevent contamination or injury.

Ventilation

The OR ventilation system must ensure a controlled supply of filtered air under positive pressure. The primary concerns for flow of ventilation include how the air is distributed, filtered, and exhausted.^6,7 ACH are important concerns based on the size of the individual OR. Heating, ventilation, and air-conditioning (HVAC) manufacturers continually study the best ways to ventilate ORs and provide ventilation systems compatible with the needs of the sterile team for aseptic air quality.⁵

Air changes and circulation provide fresh air and prevent accumulation of anesthetic gases in the room. Concentration of gases depends solely on the proportion of pure air entering the air system to the air being recirculated through the system. Fifteen ACH with three exchanges of outside air (OA) are recommended for class A ORs. Class B and C ORs and cesarean delivery suites require 20 ACH with four OA exchanges according to the 2010 AIA Guidelines for Design and Construction of Health Care Facilities.^b

A gas scavenger system is used to prevent the buildup of waste anesthetic gases where general inhalation anesthesia is used. The scavenger attaches directly to the outflow of the anesthesia machine.

Various types of scavengers, vacuum systems, and smoke evacuators are used throughout the OR to minimize air pollutants that are health risks for patients and perioperative team members. The American Society of Heating, Refrigeration, and Air-conditioning Engineers (ASHRAE) sets the standard for safe ventilation.

If new air ducts are installed, they should be thoroughly cleaned before activation to prevent the dispersal of particulate material into the air. The risk for airborne contaminants is significantly increased.

Laminar airflow

Ultraclean laminar airflow is installed in some ORs to combat airborne particulate contamination by providing 70 to 160 ACH.² Laminar airflow is a high-pressure, unidirectional air-moving diffuser housed in a cluster in a wall or ceiling enclosure. It is designed to flow uninterrupted from the cleanest area to the less clean area into air return grilles in the lower sidewalls. Cool air from the laminar diffuser travels more quickly than isothermic air.^2,7

The airflow is divided into tiny linear columns of cool clean air that generates little velocity and blowing as it courses toward the sterile field. Objects that emit thermal plume, such as spotlights, persons, or equipment, cause the air currents to move in a different direction. Horizontal airflow passes from the wall diffuser to an opposite lower return grille.⁷ Objects in the air pathway shed particulate into the clean airstream (Fig. 10-6). Vertical airflow styles have fewer obstacles to the line of direction of the air. Vertical downward airflow is designed to flow from the top of the room, over the patient, lights, and equipment, and continue downward toward the lower corners of the room where the air return grilles are located.^1,4 In contemporary ORs that use laminar airflow, three styles of vertical downward-directed airflow originate in the ceiling directly clustered over the field with slightly different effects.¹¹

1. Standard vertical laminar flow provides a narrow boundary of operating space that begins at the ceiling and interfaces with the field, personnel, and ambient room air before it is exhausted through air return grilles (Fig. 10-7).

2. Air curtained vertical flow uses a peripheral secondary airflow at a higher velocity to widen and frame the primary laminar flow from the ceiling to the lower pressure air return grilles in the base of the walls (Figs. 10-8 and 10-9).

3. Physical curtained vertical flow uses air foils hanging from the ceiling on four sides to maintain the downward direction of airflow. The air funnels down toward the field, flowing around and behind the team (Fig. 10-10).

Obstacles to laminar airflow effectiveness

Objects that pass between the flow of clean air and the sterile field around the patient shed particles that can contaminate the surgical site. Heat emanating and rising from the team members, the patient, and equipment referred to as thermal plume changes the course of the laminar flow (Fig. 10-11). Several physical barriers that interrupt airflow and return include the following:

• Spotlights over the field

• Ceiling booms with surgical machinery and equipment

• Mayo stands over the patient

• Microscopes, articulated laser arm, and C-arm

• Personnel and patient thermal plume

Laminar airflow was first trialed during hip replacement surgery by Sir John Charnley in Great Britain in the 1950s. Charnley believed that if particulate could be removed from the air, the 7% infection rate could drop. His studies showed that the infection rate did fall to less than 2%. Although the laminar system contributes to removing particulates, the improvements in sterile technique overall may have a larger effect on infection rate.

Other types of filtered air-delivery systems that have a high rate of airflow are as effective in controlling airborne contamination. Filtration through high-efficiency particulate air (HEPA) filters can be 99.7% efficient in removing particles that are larger than 0.3 mm. These microbial filters in ducts filter the air, practically eliminating all dust particles. The ventilating system in the surgical suite is separate from the hospital’s general system and is to be cleaned, inspected, and maintained on a preventive maintenance (PM) schedule.

Positive air pressure in each OR is greater than that in corridors, scrub areas, storage, and substerile rooms. Positive pressure forces air from the room. The air enters at the ceiling and leaves through the grilles at floor level. Microorganisms and particulate in the air can enter the room unless positive pressure is maintained. Closed doors maintain this environment and prevent equalization of air pressure. The recommended parameters include a dual filtration system with two filters in succession. The first filter should be at least 30% efficient, and the second filter should be at least 90%. Filter changes and duct cleaning should be on a PM schedule with OR maintenance.

Floors

In the past, floors were conductive enough to dissipate static from equipment and personnel but not enough to endanger personnel from shock or cause explosions from flammable anesthetic gases. Conductivity is not a prime concern in contemporary OR design because explosive anesthetic gases, such as cyclopropane, are no longer used.

The most common flooring used today is seamless polyvinyl chloride that is continued up the sides of the wall for 5 or 6 inches and welded into place. These materials should not degrade or stain with age and cleaning. Metal oxides can be incorporated to decrease the slipperiness of the surface when wet.

A variety of hard plastic, seamless materials are used for minor procedure room floors. The surface of all floors should not be porous but suitably hard for cleaning with the flooding, wet-vacuuming technique. Personnel fatigue may be related to the type of flooring, which can be too hard or too soft. Cushioned flooring is available. The floor should be slip-proof when wet because surgical hand cleansing causes splashes and spills around the scrub sink and into the OR, where the hands are dried.

Most of the glues and adhesives used in the installation of the flooring are malodorous and potentially toxic. During construction or renovation, care is taken to vent these fumes from the area. A minimum of 2 weeks may be needed to fully rid the area of the smell before it can be safely used for patient care.

Floors in older buildings may need reinforcement to support larger and more sophisticated equipment. Some of the wiring may be run in conduits under the floor.

Walls and ceiling

Finishes of all surface materials should be hard, nonporous, fire-resistant, waterproof, stainproof, seamless, nonreflective, and easy to clean. The ceiling should be a minimum of 10 ft high and have seamless construction. The height of the ceiling depends on the amount and types of ceiling-mounted equipment.⁹ The ceiling color should be white to reflect at least 90% of the light in even dispersion.

Walls should be a pastel color, with paneling made of hard vinyl material that is easy to clean and maintain. Seams should be sealed with a silicone sealant. Laminated polyester or smooth painted plaster provides a seamless wall; epoxy paint has a tendency to flake or chip. Dust and microorganisms can collect between tiles because the mortar between them is not smooth. Most grout lines, including those made of latex, are porous enough to harbor microorganisms even after cleaning. Tiles can also crack and break. A material that is able to withstand considerable impact also may have some value in noise control. Stainless steel cuffs at collision corners help prevent damage.

Walls and ceilings often are used to mount devices, utilities, and equipment in an effort to reduce clutter on the floor. The ceilings should be reinforced with steel beams to support the load. In addition to the overhead operating light, the ceiling may be used for mounting an anesthesia service boom, operating microscope, x-ray image intensifier, electronic monitor, and a variety of hooks, poles, and tubes. Demands for ceiling-mounted equipment are diversified.

Suspended track mounts are not recommended because they engender fallout of dust-carrying microorganisms each time they are moved. If movable or track ceiling devices are installed, they should not be mounted directly over the operating bed but away from the center of the room and preferably recessed into the ceiling to minimize the possibility of dust accumulation and fallout.

Piped-in gases, computer lines, and electrical systems

Vacuum for suction, anesthetic gas evacuation, compressed air, oxygen, and nitrous oxide may be piped into the OR. The outlets may be located on the wall or suspended from the ceiling in either a fixed rotating boom or a retractable column. The anesthesia provider needs at least two outlets for oxygen and suction and one for nitrous oxide. To protect other rooms, the supply of oxygen and nitrous oxide to any room can be shut off at control panels in the corridor should trouble occur in a particular line. A panel light comes on, and a buzzer sounds in the room and in the maintenance department. The buzzer can be turned off, but the panel light stays on until the problem is corrected. The buzzer should be tested on a routine schedule.

Computer lines for monitors or personal computers (PCs) are commonly located adjacent to the anesthesia machine and the circulating nurse’s writing desk. Additional lines may be attached to computers used in specialties such as neurosurgery, which uses immediate computed tomography (CT) scanning images during the intraoperative care period. Care is taken not to use the keyboard with soiled hands or soiled examination gloves. The keyboard should be of a design that permits adequate cleaning between patients. Seamless touch keypads or keyboard covers are easiest to maintain and clean.

Electrical outlets are grounded and must meet the requirements of the equipment that will be used. Some machines require 220-V power lines; others operate on 110 V. Permanently mounted fixtures, such as a clock and x-ray view boxes, can be recessed into walls and wired in rather than plugged into outlets. Electrical cords that extend down the wall or across the floor are hazardous. Ceiling-mounted booms are strategically placed for bringing piped-in gases, vacuum lines, and electrical outlets close to the operating bed. They eliminate the hazard of tripping over cords.

Multiple electrical outlets should be available from separate circuits. This minimizes the possibility of a blown fuse or a faulty circuit shutting off all electricity at a critical moment. All personnel must be aware that the use of electricity introduces the hazards of electric shock, power failure, and fire. Faulty electrical equipment may cause a short circuit or the electrocution of patients or personnel. These hazards can be prevented by taking the following precautions:

Fire safety systems are installed throughout the hospital. All personnel must know the fire rules. They must be familiar with the location of the alarm box and the use of fire extinguishers. Additional information concerning OR fires can be found in Chapter 13.

Lighting

General illumination is furnished with static ceiling lights and mobile spotlights. Most room lights are white fluorescent, but they may be incandescent. Lighting should be evenly distributed throughout the room without harsh shadows, especially in the working area of the field. The anesthesia provider must have sufficient light, at least 200 foot-candles, to adequately evaluate the patient’s color. Intraoperatively, the lighting should not cause the organs to appear discolored.

For minimized eye fatigue, the ratio of intensity of general room lighting to that at the surgical site should not exceed 1:5, preferably 1:3. This contrast should be maintained in corridors and scrub areas, and in the room itself, so that the surgeon becomes accustomed to the light before entering the sterile field. Color and hue of the lights also should be consistent.

Illumination of the surgical site depends on the quality of light from an overhead spotlight source and the reflection from the drapes and tissues. Drapes should be blue, green, or gray to avoid eye fatigue. White glistening tissues need less light than dull dark tissues. Light must be of such quality that the pathologic conditions are recognizable. Some lighting systems have video cameras installed that can be connected to monitors for observation by nonsterile personnel outside the field. The view is close to the same field of vision of the surgeon and first assistant.

The overhead operating light must:

Changing the bulb should not require additional tools because time may be an issue in a critical part of a surgical procedure. The bulb is usually too hot to touch with the bare hand. Many styles are available that contain several bulbs that provide backup light when one bulb burns out.

A supplemental surgical task light may be needed for a secondary surgical site, such as for the legs or arms during conduit procurement for cardiovascular procedures. Some hospitals have portable explosion-proof lights. These lights should have a wide base and should be tip-proof. Others have satellite units that are part of the overhead lighting fixture. These should be used only for secondary sites unless the manufacturer states that the additional intensity is within safe radiant energy levels when used in conjunction with the main light source. The use of multiple teams in complex multidisciplinary procedures requires adequate lighting for each operating surgeon.

A source of light from a circuit separate from the usual supply must be available for use in case of power failure. This may require a separate emergency spotlight. It is best if the operating light is equipped so that an automatic switch can be made to the emergency source of lighting when the usual power fails. Flashlights with fresh batteries should always be immediately available.

Some surgeons prefer to work in a darkened room with only indirect illumination off the surgical site during minimally invasive procedures. This is particularly true of surgeons working with endoscopic instruments and the operating microscope. If the room has windows to the hall or substerile room, lightproof shades may be drawn to darken the room when this equipment is in use. Because of the hazard of dust fallout from shades, the windows may have blinds contained between two panes of glass with a handle to open or close the louvers in rooms where this equipment is routinely used.

Although the surgeon may prefer the room darkened, the circulating nurse or anesthesia provider must be able to see adequately to observe the patient’s color and to monitor the patient’s condition. One spotlight can be aimed away from the field in the direction of the anesthesia provider. In some circumstances, the x-ray view box can be turned on for additional illumination.

Some surgeons wear an adjustable headlight designed to focus a light beam on a specific area, usually in a recessed body cavity such as the nasopharynx. Fiberoptic headlights produce a cool light and reduce shadows. Both the surgeon and first assistant may wear a headlight. Alternatively, a light source that is an integral part of a sterile instrument, such as a lighted retractor or fiberoptic cable, may be used to illuminate deep cavities or tissues difficult to see with only the overhead operating light. Fiberoptic cables should not be permitted to become detached from the instrument and shine directly on the drape for a prolonged period because a fire may ignite.

Monitoring screens

Monitors and computers are designed to keep the OR team aware of the physiologic functions of the patient throughout the surgical procedure and to record patient data. The anesthesia provider or a perioperative nurse uses monitoring devices as an added means to ensure safety for the patient during the surgical procedure.

The screens may be built into portable carts or attached to articulated arms or ceiling booms. They may be plasma or liquid crystal display (LCD) and measure 20 to 22 inches, and in some facilities up to 42 inches, in size. Plasma screens are heavier and do not last as long as LCD versions. Newer screens with surface-conduction electron emitter displays (SEDs) will likely replace LCD and plasma screens in the future.⁹

More commonly, video monitors serve a number of useful purposes for the surgeon within the OR. They are widely used for teaching surgical techniques. This minimizes the number of visitors in the OR, which, in the interest of sterile technique, is advantageous. In addition, monitors provide a better view for more people to see the surgical procedure from a remote area or through a microscope or endoscope. They can also be used for record keeping and documentation for legal purposes for the surgeon. Video recording is possible for this purpose. If video recording is done while patients are in the rooms, each patient should have the opportunity to sign a permission form.

As an aid to diagnosis, an audiovisual hookup between the OR and the radiology department permits x-rays to be viewed on the television screen in the OR without having to be transported into the OR and mounted on view boxes. With such a hookup, the surgeon gains the advantage of remote interpretive consultation when it is desired.

A two-way audiovisual system between the pathology laboratory and the OR enables the surgeon to examine the microscopic slide by video in consultation with the pathologist without leaving the operating bed. The pathologist can view the site of the pathologic lesion without entering the OR.

Radiograph screens or view boxes

Many facilities have changed from plain film viewing to digital computer monitors. The monitors may be on articulated arms that extend from the wall or ceiling. In this circumstance, lighted view boxes are still useful in the event old films are brought from the archives for comparison with the patient’s new digital images. The view boxes can also be used as indirect lighting during low-light procedures.

X-ray view boxes can be recessed into the wall. The viewing surface should accommodate a minimum of four standard-size films. The best location is in the line of vision of the surgeon standing at the operating bed. An additional view box should be located near the anesthesia provider for review of chest films. It can also provide indirect illumination of the anesthesia machine or instrument table during procedures that require a darkened room. Lights for view boxes should be of high intensity. A film-holding basket should be planned within reach of each view box station.

Clocks

Two clocks should be in each OR. A standard clock, analog or digital, for basic time observation should be visible from the field. A time-elapsed clock, which incorporates a warning signal, is useful for indicating that one or more predetermined periods of time have passed. This may be used during surgical procedures for total arterial occlusion, with use of perfusion techniques or a pneumatic tourniquet, or during cardiac arrest. Start, stop, and reset buttons should be within reach of the anesthesia provider and the circulating nurse.

Cabinets or carts

Each OR may be supplied with closed-in stationary cabinetry unless a cart system or pass-through entry is used. Supplies for the types of surgical procedures done in that room are stocked, or every OR may be stocked with a standard number and type of supplies. Having these basic supplies saves steps for the circulating nurse and helps eliminate traffic in and out of the OR. Glass shelves and sliding doors provide ease in finding and removing items.

Many cabinets are made of stainless steel or hard plastic. Wire shelving minimizes dust accumulation. Cabinets should be easy to clean. One cabinet in the room may have a pegboard at the back to hang items, such as table appliances. Gloves used in patient care should be removed when opening the cabinet and removing supplies.

Pass-through cabinets that circulate clean air through them while maintaining positive air room pressure allow transfer of supplies from outside the OR to inside it. They help ensure the rotation of supplies in storage or can be used only for passing supplies as needed from a clean center core. Some pass-through cabinets between the OR and a corridor accommodate supply carts directly from the sterile core, which are easily removable for restocking.

In lieu of or as an adjunct to cabinets, some hospitals stock carts with special sutures, instruments, drugs, and other items for some or all of the surgical specialties. The appropriate cart is brought to the room for a specific surgical procedure.

Furniture and other equipment

Stainless steel furniture is plain, durable, and easily cleaned. Each OR is equipped with the following basic items:

Communication systems

A communication system is a vital link to summon routine or emergency assistance or to relay information to and from the OR team. Many surgical suites are equipped with telephones, intercoms, call lights, video equipment, and computers. These communication systems may connect the OR with the clerk-receptionist’s desk, the nurse manager’s office, the holding area, the family waiting room, the PACU, the pathology and radiology departments, the blood bank, and the sterile processing department. These systems make instantaneous consultation possible through direct communication.

Interventional radiography room

Endovascular stenting, balloon angioplasty, cardiac catheterization, and other interventions that require fluoroscopy can be performed in a room with fixed x-ray equipment and specialized radiographic beds (Fig. 10-12). The endovascular instrument table may be double the average length because the aortic guidewires and deployment devices are extremely long. Proximity to the OR is important in case of an emergency that necessitates an open procedure. Many interventional rooms have doors that open into the semirestricted area of the surgical services department. Some interventional rooms double as minimally invasive rooms.

Cardiac catheterization (angioplasty and stenting) may be performed within the surgical suite in a room equipped for fluoroscopy. Imaging screens are located near the head of the operating bed or on articulated arms directly across the OR bed to allow the surgeon and the team to visualize the coronary arteries during the procedure. Monitors, suction, oxygen, and cardiopulmonary resuscitation equipment are available in this room for each cardiac catheterization procedure. The team must be alert for emergency situations, such as a perforated coronary artery, and be prepared for an emergency thoracotomy or transfer to an OR for an open procedure.

Minimally invasive surgery room

Some rooms are equipped specifically for laparoscopic procedures, with ceiling booms in four quadrants of the room for endoscopic light sources, camera boxes, insufflators, electrosurgical generators, and video monitors. A dedicated MIS room has all the equipment for puncture and nonpuncture endoscopy located on a large cart or a ceiling-mounted boom. The use of booms in these rooms helps minimize the amount of equipment spread around the room.

Several video monitors are located around the room on articulated arms or on the booms for ergonomic viewing of the surgical field by the surgical team. These rooms should have the capability of immediately converting to an open procedure in the event of an untoward event such as arterial or organ puncture.

Cesarean delivery room

Most facilities that have obstetric departments have a self-contained OR within the delivery suite (Fig. 10-13). This room is a restricted room with an attached substerile room and scrub sink area. The purpose of this room is to provide equipment and supplies in support of a surgical birth of the baby through the mother’s abdomen (cesarean section) instead of a vaginal birth.

A few differences of the cesarean delivery room include resuscitation supplies and equipment for the newborn and a specialized warming bed that can be used to transport the baby to the special care nursery.

Principles in construction or renovation planning

The universal problem of environmental control to prevent wound infection exerts a great influence on the design of the surgical suite and the plans for construction or renovation.^5,8,10 Surgical suites older than 20 years do not have the capability of supporting newer technology with renovation for space and technologic and electrical capabilities.

Architects, administrators, and surgical suite designers follow several concepts in planning the physical layout and construction of a surgical suite:

Physical plant design and construction/renovation planning of a surgical suite should include detailed consideration for the activities of patients, caregivers, and environmental maintenance.