The Making of the Modern OR
By Kathy Dix
What should an operating room (OR) include, if it is designed for minimally invasive surgery (MIS) or outpatient surgery? What kinds of improvements are being added when ORs are remodeled? What is being included in new construction? As technology improves at an exponential rate, administrators and OR managers are faced with a multitude of choices. How does one choose among all the options and upgrades?
Although Miami's Baptist Health South Florida is fairly modernized, Kate Moses, quality management nurse for Baptist Outpatient Services, says their Medical Arts Surgery Center will be making significant changes during the next year. "We're going to be getting a laser in the next year; we have several uses for it: ENT, GYN and oral/maxillo-facial surgery," she says.
Because their OR is only six years old, there has not been a need for drastic change. Most replacements are for beds, stretchers or instrumentation. "In ambulatory surgery you don't always have the bells and whistles, like the hospital surgery centers, but we have newer versions of some of the equipment because we are smaller and have less to buy," says Moses. "In fact, for the eye rooms, we have the stretcher beds that the patients stay on from when they get into the pre-op suite until they go home."
One item that many facilities will find themselves needing is up-to-date software. Patient record-keeping is moving increasingly to the electronic format, and some of these methods are even being required by law.
In fact, the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification provisions require the Department of Health and Human Services to establish national standards for electronic healthcare transactions and national identifiers for providers, health plans, and employers. HIPAA also addresses the security and privacy of health data.1
Moses' workplace is acquiring iPath, which is a system for scheduling and keeping electronic records. "I know it's a mandate that hospitals are going to have to go to the electronic record," she says. "We already have the Pyxis system for obtaining medications on the unit and we are looking into some newer anesthesia machines that would have the same system built into their carts for controlled medications. Pyxis and Steris both have machines in which you actually have a medication cart within the anesthesia cart." That, Moses states, is a boon to ORs.
In the past, to obtain narcotics, nurses would have to go to pre-op or recovery. Now, the staff has transitioned to a system of fanny-pack storage; narcotics are carefully tracked, and signed out at the beginning and end of a shift. "What would be really ideal would be to have these new anesthesia carts," envisions Moses. "They are set up in such a way that the only access is by your personal code to get into the controlled substances drawers. It will print out what was used and by whom, and will alleviate incorrect counts and missed documentation."
The benefit to electronics is two-fold, Moses says: better control and more accuracy. "We will be better able to qualify and quantify the nursing care given to the patient. With the new PNDS system that the Association of periOperative Registered Nurses (AORN) has developed during the past few years, we'll be able to do reports on that."
There is an additional advantage to the electronic system: eliminating the need to translate handwriting. "There's always room for error in interpretation, whereas (with the electronic) way, there would be no doubt as to which choice was taken," she explains. There is also the issue of different terminology from person to person. "The new electronic system will increase patient safety by decreasing errors," she affirms. "Since my job is quality management, it will make my job a whole lot easier."
Many factors contribute to outfitting an OR properly. "Look at the modality -- is this a room that will be doing the minimally invasive technique, and who are the clients to be served by this room?" asks Trudy Kenyon, MIS education coordinator at Legacy Health Systems in Portland, Ore. "Is there pediatric, ortho, neuro, geriatric surgery? Once you figure out what your program needs are, you can be more cost-efficient with the dollars you have." Robotic systems can be a useful addition, but "if you're talking about the OR of the future, people aren't going to think of robotics first," she says.
"We were one of the first hospitals to build a minimally invasive suite," she recalls. "At the time, there were some other hospitals that had started working with that idea, and they just basically took a cart hanging from the ceiling. We thought about a lot of different components and anesthesia and the suite design."
The level of technology is also something to consider. Will you be using columns or booms at the surgical field? Will your system will be digital? "I think these are all kind of key components of where we are now," states Kenyon. "We may see more wireless technology being applied. There are a lot of applications for having control of the environment at the nurse's station or the surgical field.
Although that technology is not necessarily new, not every facility has that much control of the surgical field, Kenyon remarks. "If you look at MIS suites across the nation, (that number is) still fairly small compared to how many people are doing minimally invasive procedures. The minimally invasive suite is the gold standard for doing video-assisted surgery," she adds.
When building a new OR or when upgrading an existing one, the end result will probably be similar. There will be a difference between the two in cost, but new construction may not carry as many constraints. For example, Kenyon says, if an OR built in the 1970s were being remodeled, it might be limited in size, because ORs 30 years ago did not have to include as much equipment as they do now, and were consequently built smaller than their modern counterparts.
Regardless of the situation, Kenyon suggests cameras be integrated with the monitors, with the columns and with control at the nurse's station or surgical field. "Where you begin to save your money depends on how many monitors you need within that room, which would relate to the number of columns to support the monitors," she points out.
Kenyon says their OR was designed with two camera systems, so one is available as a backup. "It gives you more dual intraoperative places to observe, like performing an EGD procedure while you're doing a laparoscopic procedure," she notes. "Many systems need to incorporate other components, like fluoroscopy or ultrasound. If you're a teaching facility, having an overhead camera where you can document surgical techniques on the outside of the patient may become important as a teaching tool."
Another component to consider is telementoring, adds Kenyon. "Telesurgery has a big presence in a lot of teaching facilities, where people are trying to learn minimally invasive procedures. I think its application is growing, as far as being able to use it for telementoring and using that as a means to get a second consult. It could be done locally, or potentially at a national level."
In that case, a surgeon in a small community hospital could get a consultation with someone elsewhere in the country. "Calling a surgeon at a university-based hospital for a consult can be an important tool," adds Kenyon. "I think societies like ACS and SAGES are looking at those issues of telementoring and telesurgery and developing guidelines for those applications."