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The nurses' station in an OR at Legacy Good Samaritan. (click on photo to enlarge)
An operating room at Legacy Good Samaritan. (click on photo to enlarge)
The rapid growth of minimally invasive surgery has brought new challenges. How can you design an operating room that won’t be obsolete in 5 years? How do you leave room to change as technology advances? "One of the first things we thought about was to make the suite very flexible for future applications," says Lee Swanstrom, MD. As medical director for the minimally invasive surgery (MIS) program for Legacy Good Samaritan Hospital, in Portland, Ore, he’s led a project to build two state-of-the-art ORs. A new cardiac suite, complete with 3-D imaging and robotics, also is being planned. The object is to make the rooms state-of-the-art not only now but for the future. "We made the suite so it can evolve with surgery, and we won’t have to totally redo the rooms if laparoscopes go the way of the dinosaurs some day," says Dr Swanstrom. New ORs, he says, need "to be very digital and imaging friendly." Rooms must be able to accept new kinds of input easily. He foresees that "we might be modeming x-ray images up to radiology or have pathology beam up images of what a specimen looks like under the microscope." Legacy expects to implement a totally electronic patient record in about 18 months, and the ORs are equipped to accommodate that. The downfall in some OR suites, he believes, is that "either they were totally designed by a surgeon and weren’t user friendly to the nurses. Or they were designed by the nurses and didn’t take into consideration what the surgeon might need." In the Legacy project, physicians and nurses have been part of the design process. They have been aided by an innovative project manager, Darko Spoljaric of Portland-based Val-Med Corp. Dr Swanstrom had called on Val-Med 5 years earlier to design and equip a prototype OR suite at Legacy Emanuel Hospital, also in Portland. Val-Med’s founder, Val Spoljaric, Darko’s father and a native of Croatia, designed innovative open-heart rooms for Providence St Vincent Medical Center, also in Portland. Building an up-to-the-minute operating room doesn’t necessarily mean spending a lot of money, Darko Spoljaric says. "It means communicating with the people who work there and finding solutions to make everyone’s work environment a better place." He refers to his design as "economy of flow"—meaning it economizes on motions of all members of the OR team. Spoljaric says he is approached by OR managers who don’t know where to start and ask for his help. He finds little things are what make the biggest impression. "You can have the fanciest equipment and technology, but that is what impresses people the least. It is simple things such as giving the anesthesiologists their own lighting control and centralizing controls for the nurses." In the preliminary stage for the new MIS rooms, Spoljaric asked physicians and nurses what they would like to see improved. Three areas became the focus:
A nurses’ workstation At their station in the new ORs, nurses can do charting and control equipment while being near the patient, surgeon, and anesthesiologist. "I think the nursing station concept we came up with probably is the role of OR nurses in the future," Dr Swanstrom comments. "They will be technologic captains of the ship, in a way, sitting at their control station, all the while having full view of the patient, the surgical procedure, and everyone in the room." Aides might do some of the traditional tasks of circulating, under the guidance of the RN, he adds. Spoljaric compares the nurses’ station to a production studio. Controls and equipment are within reach but streamlined and wipeable. He and the nurses decided to build the station in a corner of the room toward the patient’s left side. "The location is almost as important as building the station," says Spoljaric. "From my experience, a lot of architects overlook that." The station has a stationary desk and a mobile desk open on both sides. The surgeon can work at the mobile desk while the resident is closing the incision. When the nurse pulls out the mobile desk and is facing the patient’s head, the complete nurses’ station is to her right side. The station has two computers—one for charting and one for video applications, such as capturing images or recording live images onto the hard drive, CD ROM, or VCR. The computer monitors are on the stationary desk, and the hard drives are built in under the counter tops. The computer keyboards are on pull-out trays mounted under the desktop. On the left side are two 13-inch video monitors built in at a 45-degree angle, allowing the nurse to watch what the cameras and the surgeon are doing. Economy of motion In designing the nurses’ station, Spoljaric took advantage of what he learned in building the Legacy Emanuel rooms earlier. "A lot of what we know today was unknown 5 years ago in how to design an OR so it was ergonomically correct and has economy of flow," Spoljaric says. "Economizing motion is in direct relationship to where we place all the equipment, switches, cameras, and lighting." One thing he learned from the Emanuel suites was that the 13-inch video monitors weren’t turned so the nurse could see them well without kinking her neck. The shelves housing the equipment were gathering dust and exposing the cables, and people were piling stuff on the shelves next to the equipment. To remedy this problem, Spoljaric flush-mounted the equipment and controls on panels so there are no shelves to collect dust or unnecessary items. Storage drawers were designed for necessary supplies. Easy to upgrade When new technology is added, the nurses’ station can be upgraded merely by replacing the panels. The main middle section is in three parts. On the left are two VCRs, in the middle are the controls for the room, and on the right are a digital capture unit and a video printer. All are flush mounted. Someday if the OR wants to discard the VCRs and update to digital units, for example, the whole station does not have to be reconstructed. All that is needed is to remove one panel to expose the shelves. A cabinetmaker could make a new panel with cutouts sized to the new equipment, and the shelves could be readjusted. Behind the nurses’ station is a video closet with doors for quick access to video cabling for upgrading. Typically, video installations are mounted in the ceiling where the cabling, electronics, and connections are not easily accessible. Trudy Kenyon, RN, nurse coordinator for the MIS program at Legacy Emanuel, worked with Spoljaric on the earlier project. Some of her innovations duplicated in the Good Samaritan suite are the master controls at the nurses’ station for lighting and camera systems. She says, "It is exciting to be able to go into a room and control the lighting and the camera systems with the flick of two switches." Almost all of the room’s equipment can be turned on at one spot within an 8-inch area at the nurses’ station. The station also is the centralized control point for all of the video monitors. The nurse can select which image to put on which monitor with the flick of another switch. These conveniences make day-to-day activities easier, says Kenyon. Nurses save time and muscle strain of hauling carts in and out. The staff spends less time looking for equipment. There have been fewer problems with wiring, interference, or other technical problems. "It is the difference between night and day," she says. Innovations for the surgeon Often in advanced MIS procedures, surgeons want to place images side by side for comparison. Two surgeons might be working with camera 1 and camera 2, or one surgeon might be working with camera 1 as well as an ultrasound or C-arm image. Rather than using a picture-on-picture feature, the MIS rooms have two 13-inch monitors that allow surgeons to have two full images. The two monitors are on an articulating arm that has full rotation from the head to the foot. Urologists can even position the monitors above the patient’s abdominal area and have a view of both monitors from a sitting position. The yoke carrying the monitors has an attachment for sterilizable handles, allowing surgeons to reposition the monitors during a procedure—a feature they appreciate. On top of the yoke above the monitors is a full duplex speaker phone system. Many times when a surgeon receives a phone call in the OR, the call comes into the nurses’ station. The surgeon must either walk over to the nurses’ station and talk on the speaker phone or yell over to the nurses’ station. Spoljaric linked the main telephone system from the nurses’ station to the speaker phone mounted on the yoke’s articulating arm. Now when surgeons receive calls, either from their offices or for video consulting from the conference room, the calls are transferred from the nurses’ station to the speaker phone on the articulating arm. The surgeon can continue the procedure and have a two-way conversation. Conference room link The OR is linked to a conference room with two monitors where observers can view any of the cameras and C-arm and ultrasound images. If a surgeon needs consultation during a procedure, another surgeon can go to the conference room, watch on the monitors, and give assistance without changing into scrub attire. Two other 19-inch monitors are positioned to the right side and foot side of the patient. This allows the surgeon numerous viewing capabilities, depending on the case and positioning of the patient. The new MIS suite accommodates female surgeons, who tend to be shorter than their male counterparts. The articulating arms that carry the video monitors drop down, so the surgeon’s line of vision is at the center of the monitor. Other innovations Other innovations for surgeons include a built-in microphone system for audio recordings onto a VCR. Another main articulating arm houses both camera systems on shelves. On the bottom shelf is a foot pedal storage unit. One problem Spoljaric found was that when he mounted the equipment off the floor on articulating arms, foot pedals were still on the floor. Every time someone moved an articulating arm, the foot pedals dragged along behind. He designed a double platform system that attaches neatly under the bottom shelf. All of the foot pedals are coiled underneath the bottom shelf, so there is nothing on the floor. Suction canisters also are off the floor, mounted on rails. An irrigation system is mounted to an IV pole attachment on the shelves where the rest of the equipment, foot pedals, and suction bottles are, eliminating the need for an IV pole on the floor. "Our attempt was to give optimal positioning, a clutter-free environment, and the flexibility of accommodating more than one surgeon in various positions," says Spoljaric. Aids for anesthesiologists The main articulating arm that carries the two 13-inch monitors is an electric arm that moves up and down. Nurses can raise and lower the monitors with a switch at the nurses’ station, or the anesthesiologist can raise and lower them with a switch on a panel designated for the anesthesiologists on the main articulating arm. Also in this panel is a charging unit for the MIS table hand control, which is within the anesthesiologist’s immediate reach. A popular feature is a single recessed light in the ceiling above the anesthesiologist that is controlled with a dimmer switch. The rest of the lighting is controlled from the nurses’ station. "One of the complaints from the anesthesiologists was that when the surgeon said, ‘Lights down,’ the anesthesiologist wasn’t necessarily ready to have lights down, too. So we gave them their own lighting control," Spoljaric says. "It seems simple, and it is. It is just a matter of asking the questions." Installing this light has made the whole anesthesia team happy with the room. The final improvement was to install a small 9-inch video monitor on the anesthesia machine. With this monitor, even when the patient is draped in front and the anesthesiologist is cut off from viewing the procedure and the rest of the OR, he or she can watch the monitor. "It is just a matter of isolating the three primary groups that work together as one team for the benefit of the patient in one OR. "By addressing the needs of each group, we have been able to come up with an effective and efficient design," says Spoljaric. Costs of technology How to provide for new technology in a cost-competitive environment is a key question. The funding has come from a trust left by a physician for new surgical technology. The suites, once built, have been profitable, Dr Swanstrom says, bringing surgeons to the hospital and drawing patients from across the system. The room’s design is cost-effective in the long run, he believes, because there is less wear and tear from moving equipment and fracturing cords that snake along the floor. There also is less wear and tear on the nurses who must shove heavy carts from room to room. The next project is a plan to upgrade cardiac ORs with 3-D technology, digital monitors, and robotics. The system’s nine heart surgeons perform some 1,200 adult and pediatric procedures a year. The future, in Dr Swanstrom’s view, "is to make the ORs even more digital. The first thing nurses will do is turn on the computer and log in. That will start up the cameras, lights, and other equipment. They will be able to tap into medical records and pull up a patient’s chart and go from there." —Judith M. Mathias, RN, MA Reprinted from OR Manager newsletter, May 1999. Copyright © 1999. OR Manager, Inc. All rights reserved. 800/442-9918. www.ormanager.com |
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