Infection Control in Robotic-Driven Operating Rooms
New OR Designs Support Automation and Help "Keep It
By Scott Hazlett, AIA
Advancements in technology continue to drive increased automation in the OR. The trend toward minimally invasive surgical procedures in robotically equipped ORs is helping to create a faster, safer, and more efficient surgical environment. However, this trend and the benefits it brings does not alter the need for continued vigilance from the standpoint of infection control. How can the individuals charged with infection control in the OR prevent a hospital-acquired infection from overshadowing the benefits of minimally invasive surgery? Fortunately, many of the design and engineering features developed to accommodate automation along with minimally invasive procedures have made it easier to keep ORs clean and infection free.
The recently completed two-room Minimally Invasive OR Suite project at the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, Pa, will serve as a case study for addressing design for infection control in a newly designed robotically-equipped OR. Designers considered important elements including the size of spaces, equipment selection, finishes, HVAC, and lighting. Individually, each of these items is important, but when all are brought together in one space, the result is a state-of-the-art surgical facility that provides the best possible environment for control of hospital-acquired infections.
Space Helps Reduce Cross-Contamination
The key design concept that helps provide infection control is adequate separation. In the past, ORs were smaller and facilities were closer together, which promoted cross contamination. In the recent project at UPMC, ORs were designed to be large (550-600 sq. ft.), allowing greater separation between the sterile field and the non-sterile perimeter that houses computers, supply carts, trash carts and other items that do not enter the sterile field. Patients and OR staff members access the ORs through separate entrances to avoid cross contamination of a scrubbed surgical team member and the transport personnel and stretcher. There are no floor penetrations for power or medical gases, and all wall and ceiling penetrations are sealed.
One design feature that was especially important to UPMC is an observation gallery that is situated between the two ORs. "Having the observation room means that we have minimized the number of people who are going in and out and that definitely impacts infection control," says Paulette Bingham, director of the ORs at UPMC Presbyterian. "Because we are a teaching hospital, students still need to be able to watch and listen to the surgeons. With the new technology, it's like being in the room but without the increased risk of contamination."
Specialized Instrumentation Reduces Contact Transmission
UPMC selected advanced hands-free or voice-activated surgical equipment to eliminate the need for surgical team members to touch equipment that may be contaminated. The rooms were designed to accommodate the latest Hermes hands-free communications technology and robotic surgery equipment such as AESOP and ZEUS. Multiple cameras in the ORs can provide live video to other locations for consulting and teaching purposes. Hands-free telephone equipment and voice-activated devices, such as OR tables that can be raised or lowered by voice command, help reduce contact transmission. Touch screen computers are used instead of keyboards.
Bill Phelps, a Facility Planning Specialist at UPMC Health System's Oakland campus in Pittsburgh, notes that integrating all of the automated technology into a seamless system was a key priority for this project, and infection control was always at the top of the list. "Video, voice, and robotic capabilities have been a tremendous asset," says Phelps. "Many of the tasks that previously required operating hand controls or typing on a keyboard--to adjust the lights or raise the table, for example--have been replaced by simple voice commands. This helps preserve the sterile field and makes for a much more efficient flow of personnel around the table, and to and from storage and support equipment," says Phelps.
Ceiling-hung equipment booms hold equipment up off of the floor, which might otherwise be cluttered with carts. All utilities and medical gases originate in the ceiling-hung equipment booms, eliminating hoses and cables running across the floor from the non-sterile into the sterile zone like strands of spaghetti.
"The boom technology clears floor space, so it's much easier to clean and disinfect the floors properly without having to relocate a lot of equipment," says Phelps. Booms also make it easier to organize power, medical gas, and electronic cabling to minimize the number of dust-gathering accessory lines.
Finishes HVAC and Lighting Enhance Infection Control
Special attention was given to finish selections to provide for ease of cleaning and durability. An epoxy terrazzo floor with integral base (no joints or seams) and ceramic tile walls were selected because they are easy to clean and resist damage from harsh cleaning solutions. Epoxy-based grout is used with the ceramic tile to prohibit moisture absorption and bacteria growth. Ceilings are made of seamless gypsum wallboard and sealed with epoxy paint. The paint used on metal and gypsum board surfaces is an anti-microbial epoxy paint used for durability and to limit bacteria growth. OR storage cabinets are made of stainless steel and glass for easy cleaning. Sealant is installed around all wall penetrations and joints between dissimilar materials to ensure that the finishes form a continuous seal around the room.
The control of airborne contaminants in an OR is an essential component in controlling transmission of infection. At UPMC, the HVAC system has been designed to meet the latest federal guidelines for air filtration, outside air, and air change requirements. The laminar flow HVAC system delivers air from the ceiling around the surgical table and exhausts it through low exhaust vents in the room's corners to provide a clean air curtain around the sterile field where the patient is located. Positive air pressure in the room keeps unfiltered non-OR grade air from entering the room through open doors. All ductwork delivering OR-grade air to the surgical suite is insulated on the exterior to eliminate surfaces inside the ductwork on which molds and bacteria can grow. Ductwork with insulation on the inside is no longer used in hospitals.
Even the OR lighting plays a role in safeguarding the patient. The lighting levels can be adjusted by voice command during surgery, eliminating the need to touch hand controls. With so many lighting levels available, room brightness can also be adjusted to make cleaning easier and more thorough. Finally, gaskets and seals on overhead light fixtures promote dust control and prevent air infiltration through the fixtures from adjacent spaces.
Many design and engineering features of robotically equipped, minimally invasive ORs actually help promote infection control, making the jobs of those responsible for assuring a sterile environment easier. The concern that the constant addition of technology to the OR might compromise the staff's ability to provide adequate infection control is unfounded. Bingham says, "The way the rooms were designed has a big impact on our ability to maintain a sterile environment. They are easy to clean and we can turn them around faster. With the new technology all of the timeframes are shortened. Because the surgeon can operate many of the systems by voice command, everything moves quicker. This means the patient is open on the table for a shorter period, and the risk of infection is lowered."
As technology continues to improve and the numbers of procedures that reduce the risk of harm to patients keep growing, the ability to provide infection control will also continue to improve.
When the architect, engineer, surgical staff, and infection control specialists work together on the design of an automated, minimally invasive OR, the end result is helpful to the patient. Patients enjoy a faster recovery and a smaller risk of contracting a post-operative infection that could be worse than the problem that required the surgery in the first place.
Scott O. Hazlett, AIA, is a senior associate with Burt Hill Kosar Rittelmann Associates, an architectural and engineering firm with offices in Butler, Pittsburgh, and Philadelphia, Pa; Boston, Mass; and Washington, DC.
His recent healthcare sector work includes projects at UPMC Presbyterian, UPMC Montifiore, and Magee-Women's hospitals in Pittsburgh, Pa; East Liverpool City Hospital, East Liverpool, Ohio; Veteran's Affairs Medical Center, Erie, Pa; and Westmoreland Regional Hospital, Greensburg, Pa.
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