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New ORs allow for rapid change

Floor plan for new seven-room OR suite at St. Mary's Hospital, Rochester, Minn. (click on photo to enlarge)

View of a new operating room at St. Mary's Hospital, Rochester, Minn. (click on photo to enlarge)

A view of the cabinets in a new operating room at St. Party's Hospital, Rohester, Minn. (click on photo to enlarge)

A view of the clean core area at St. Mary's Hospital, Rochester, Minn. (click on photo to enlarge)

As surgical procedures become more advanced, with greater use of technologies like lasers and robotics, the space in which surgery is performed needs to reflect and accommodate this rapidly changing environment. Few ORs demonstrate these design advances more than the additional seven surgical suites at the Mayo Clinic’s Saint Mary’s Hospital in Rochester, Minn.

Just a decade or so ago, OR design was fairly standardized. The OR itself was built to accommodate any patient, type of procedure, surgical instruments, anesthesia equipment, and surgical team. OR surgical lights were centered over the table, and medical gas and electrical outlets were fixed. The anesthesiologist’s position in the room was set and nonflexible.

Today, as medical and communication technology continues its rapid acceleration, OR needs are changing as well. Designers have to be able to design a space that can accommodate the technological advances.

That was the challenge of the team designing the new ORs at Saint Mary’s. These ORs are a tutorial in today’s OR design. Ceiling spaces house not only general room and surgical lighting but also systems to support flat-screen video monitors, communication ports, gas lines, electrical power and lighting, and other equipment that otherwise would take up floor space.

Communication systems allow surgeons to consult with experts in another operating room. Personal computers allow surgical staff to enter procedure data at the touch of a button, and operating tables can change positions to accommodate almost any surgical or anesthesiology need. In addition, the spaces accommodate equipment such as portable C-arm x-ray machines that roll into and out of the OR as needed.

User input is a key element to a successful project. To identify current as well as future needs, the design team consulted with surgeons, surgical staff, anesthesiologists, and architects to develop a suite that meets needs now and for the future.

The design process began with a discussion with Mayo’s surgical, nursing, and facilities leaders to set outcome goals and plan the project process.

Site visits were planned to hospitals within the Mayo system and others to review technologies including articulating arms, OR lights, monitors, cameras, anesthesia equipment, and so on. Medical equipment planners and equipment vendors were invited to user meetings to discuss trends.

Once room flow, an equipment concept, and program were developed, a mock operating room was constructed. The mock OR setup was reviewed by users including physicians, nurses, sterile core staff, audiovisual personnel, and housekeeping staff. Their comments were incorporated into the final design of the rooms.

Once the design was finalized, the team was expanded to include engineers representing products such as articulating arms, monitors, audio and video systems, cameras, computers, lights, anesthesia machines, and lasers to be sure the infrastructure was coordinated to accommodate all of the needed equipment.

The first decision that needs to be made in the design of an OR is the range of procedures that will be performed in each of the ORs. At Saint Mary’s, existing OR core specialties include neurology, cardiology, orthopedics, gastrointestinal, and thoracic surgery. Each comes with its own set of technology needs.

For instance, when setting up an eye surgery room, the team has to have the ability to flip the head and foot of the operating table. As a result, the anesthesia machine and its services need to be flexible. Orthopedic surgery requires specialty tables, surgical equipment, and multiple patient positions, so the table must be easily maneuvered. Cardiac surgery requires greater floor space because of the potential for two surgical sites and a substantial amount of movable equipment.

The Saint Mary’s OR suite was designed to accommodate all surgeries except open-heart procedures. Therefore, each room was built to allow for the technologies necessary for almost any operation or surgical procedure. Storage units were built into each of the ORs to store critically needed items or items requiring frequent replacement because of contamination.

A clean core that supplies equipment and instruments to each of the ORs in the suite has shelving filled with the necessary implements for general and specialty surgery.

Air quality and infection control are essential components of a safe, sterile OR. For the Saint Mary’s project, air quality and quantity are monitored electronically. Each operating room is provided with a minimum of 25 air changes per hour and is balanced with a positive air flow to the clean core and the patient entry corridor. The air entering the operating room is first passed through 90% filtration at the air-handling unit, which is dedicated to the surgical suites. Perforated laminar flow supply air diffusers are designed to deliver air uniformly down at a low velocity and sweep it out of the room through low air-return grilles to prevent any contaminated air from circulating through the operating room.

To keep the ORs uncluttered, accommodating monitoring and anesthesia equipment became a primary focus. The standard immobile columns that normally hang from the ceiling took on new dimensions. Draping of cords and hoses to wall outlets was eliminated.

Articulating columns were the answer to an uncluttered environment. Though articulating arms add to the cost of a project, the team may decide the cost is justified by the convenience and flexibility. Three columns were installed for lighting, nursing/monitoring, and anesthesia. These movable columns house normal and critical power outlets, medical air, vacuum, oxygen, nitrogen, nitrous oxide, and data ports as well as mounted video monitors, surgical lights, and a small video camera. The anesthesia column contains gases, data ports, and anesthesia ports. A nursing column provides physiological monitoring devices at eye level. And a lighting column includes surgical lights, with a camera mounted into the center of the lights. The camera allows surgical teams and residents to study procedures in real time or for later review.

The movable columns—which can rotate 359 degrees and move vertically—offer advantages over standard immobile columns. With the movable columns, surgeons can position video monitors anywhere around the bed. The anesthesiology equipment can be moved to any location as well. Surgical lighting with the incorporated camera can be focused on the surgical site.

Designing the articulating columns presented challenges. The system had to be arranged so each of the three columns could move without bumping into one another or adjacent walls.

Coordinating construction with ceiling-installed items such as recessed sprinkler heads, smoke detectors, motion detectors for lighting and building automation systems, cameras, and so on was critical. The design team organized meetings with manufacturers of surgical lights, articulating arms, monitors, anesthesia machines, audio and video equipment, sterilizers, warmers, film illuminators, cameras, computers, and procedure tables for exact locations and utility requirements. Computer-generated models as well as three-dimensional mockups of the space helped to accomplish these goals.

The communication systems built into the Saint Mary’s suite will allow surgeons to speak with other ORs and surgical staff during surgery. All wiring panels and equipment for the systems are in a central closet near the ORs for easy accessibility for repairs, updating, or replacing. A video hub room near the ORs receives, records, and sends signals from all of the surgical rooms.

A PC workstation in each OR allows the staff to chart on the spot and track supply usage by case. The workstation is away from the OR table but provides a view of the monitors. The station also serves as the video hub and control point for the surgical lights. In the future, the staff will be able to pull up medical records and other case information during surgery. Eventually, this PC will link to the automated billing system and electronic medical records. Computers in the clean core can be used to pull up the pick lists for the next day’s procedures to allow staff to assemble case carts in advance. They also can be used to track inventory and order new instruments and equipment.

To accommodate current and future communication needs, a cable tray system is installed in the ceiling space above all the corridors, branching into each OR. This tray system allows for quick installation, additions, and upgrades of communications cable and fiber that may be needed. An empty conduit and junction box system is also in place to add technologies as needed.

Housing computers, monitors, video equipment, film illuminators, telephones, and other services within the OR enhances efficiency because the team can request or review patient information without leaving the room.

Another efficiency is pass-through cabinets from the clean core into each of the ORs. At Saint Mary’s, an additional pass-through is a blanket and fluid warmer. This simple change allows the staff to concentrate on the surgery rather than making a trip down the hall for extra blankets or warmed fluids.

A clean core that services the equipment and instrument needs of all seven ORs in the suite also contributes to efficiency. Washer sterilizers and steam sterilizers allow clean core staff in the OR suite to perform much of the sterilization process without leaving the area. Having instruments usable and accessible right outside the OR improves efficiency. Computers for input of inventory information are provided in this decentralized clean core, and racks of steel shelving house the sterile equipment.

Once instruments become contaminated during a case, they are taken out through the entrance door of the OR on enclosed carts to the instrument processing room. Instruments are placed in the washer/disinfector and then returned to the suite’s clean core for final processing.

By gathering input from all the users of the OR, the design team can develop a plan that provides an efficient, flexible environment for the surgical team. Articulating columns, hands-free communication systems, flat-screen monitors, PCs, pass-through cabinets, warmers, and sterilizers are all technologies designed to aid the surgical team so they can focus their attention on the patient. The space is designed to be efficient today and versatile enough to meet the needs of tomorrow.

Reprinted from OR Manager newsletter, December 2001. Copyright © 2001. OR Manager, Inc. All rights reserved. 800/442-9918. www.ormanager.com .

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