Equipping The OR

June 1, 2000

Equipping The OR

By Arlene Maloney

This
article provides a step-by-step process for choosing and placing OR equipment. Just as Van
Gogh begins with a large, white canvas and Beethoven looks at an empty music sheet,
operating room service managers start with a vacant operating room to begin their
creation. Before the actual equipping of an operating room suite takes place, much
preparation is done prior to the floors, ceiling, and walls being in place. Structural
engineers calculate the strength of the overhead beams to make sure the OR lights have
adequate support. Electrical engineers consider the power needs and emergency power to run
all the power equipment. In today's environment, this emergency power is more important
than ever--video towers, OR beds, electric cautery units, anesthesia machines, lasers,
computers, and the list goes on of the equipment requiring electricity.

One can easily find themselves in a position of not having enough power left in an OR
suite to run a certain piece of equipment (i.e., laser) after a new purchase is
made if this is not taken into consideration in the onset of the construction.

First the walls are done with the needed electrical lines, telephone lines, water
pipes, and computer lines arranged behind the wallboard. The ceiling is completed with
structural beams in place under the ceiling tile and overhead, and in-room lighting is
illuminating the room where one sees the new floor tile in place. Surely, it is time to
begin equipping the OR.

It is difficult to suggest which piece of equipment goes in first. The sterilizer, the
operating room lights, or the anesthesia gas column. It doesn't matter, but this is the
first phase. If your hospital has a Group Purchasing Organization (GPO), it eliminates the
need to evaluate all the vendors for this equipment. It is time consuming and costly to
mount OR lights or install an autoclave, and it is also difficult to schedule an
installation when you are running a heavy OR schedule. Nonetheless, evaluations need to be
done, and if one is lucky, one or two vendors have been awarded contracts, and the process
becomes more streamlined for doing evaluations. The anesthesia column probably would not
be a piece of equipment that would be evaluated since many inspections and certifications
must be met before this equipment can be used. Therefore, the anesthesia column is hung
and provides 02, nitrogen, vacuum, and air, nitrous oxide to the OR
suite.


Videotower--Top to bottom: monitor, camera box, light source,
insufflation, and VCR

Then come the OR lights, seemingly an easy project to do. However, OR lights come in
many configurations. One large headlight at the head of the room with two smaller lights
at the rear is an option. If one has dedicated OR suites (i.e., neuro surgery or
open heart surgery), this configuration may change. If one does not properly plan for the
type of surgery being performed, one may find themselves with physician dismay of not
having adequate light for their procedures.

The final piece of equipment in phase one installation would be the sterilizer. This
too, would have been evaluated and would have to meet required sterilization parameters
before any surgery is performed. Oftentimes, one autoclave is installed in a subroom
between two OR suites. Good Samaritan Regional Medical Center (Phoenix, Ariz) has an
autoclave in each OR. This may sound extravagant, but this OR has a circular design and no
subrooms could be constructed.

Phase two begins with the advent of an OR table, anesthesia machine, and monitor.
Again, an OR table purchase seems like a simple task. This too, may cause physician
disgruntledness. For instance, permanently floor mounted OR tables meet specific surgical
requirements if they are working properly. If the table fails, this puts an OR suite out
of service until the repairs are completed. Also, more intensive surgical procedures are
requiring more radical patient positioning. Therefore, manual OR tables are not being
purchased readily. Electrical OR tables are the choice table for surgeons,
anesthesiologists, and OR personnel.

Another consideration for an OR table is the ability for image intensification (x-ray).
An OR table with a sliding, longitudinal top makes the environment right for laparoscopy
procedures. With minimally invasive surgery and laparoscopic procedures becoming the
standard and not open procedures, the importance of having the correct features on an OR
table is coming to the forefront.

A sensitive subject concerning an OR table is weight capacity. Frequently, nurses phone
the OR service manager asking how much weight a table will bear. Unfortunately, the weight
of the US population is increasing, and, therefore, the OR table needs to meet that
demand. OR tables may hold 350 pounds, 500 pounds, or 850 pounds depending on vendor,
make, or model. With patients coming to the operating room weighing over 600 pounds, this
is a major concern that the OR table will meet the needs of the surgeon or
anesthesiologist to raise, tilt, or put the patient in a trendelenburg position.

The second element of phase two is the anesthesia machine. Much discussion goes on here
from the anesthesiologists. Ventilating, drug delivery, and gas delivery to the patient
are important aspects of an anesthesia machine. This equipment needs to be evaluated by
these physicians, and it is imperative to have written criteria for them to rate this
equipment. The time from evaluation to implementation may be a lengthy period so having
written documentation will prevent headaches in the end.

The item needing evaluation for the final element of phase two is the anestheisa
monitor. Blood pressure, heart rate, EKG, and EEG are all clinical requirements needing to
be monitored by the anesthesiologist. This equipment may take months before final
implementation; therefore, written evaluation forms would be necessary here. It is not
uncommon to have a 12-14 week delivery schedule after a purchase order has been given.
Taken into account that the evaluation had been done 6-8 months prior to the purchase,
written evaluation forms will refresh everyone's memory on the standards and criteria upon
which they had agreed.

With the large pieces of equipment (and the most costly) already installed in the OR
suite, now the stainless steel purchases must be made. Ring stands, back tables, mayo
stands, kick buckets, prep tables, IV poles, step stools, and case lockers are all
necessary to complete an OR suite. Some of this equipment is obvious in its use. IV poles
hang IV fluids, and kick buckets house bloody sponges. A ring stand houses a basin for
irrigation. Mayo stands and back tables house instruments, sutures, needles, blades, and
other sterile material to the operative field. Step stools or stands allow the OR
personnel (technician or RN) to stand at the same height as the surgeon and to pass
instruments or any piece of material to facilitate the operation. The case locker houses
the OR pack, drapes, dressings, etc. according to the procedure being performed and to the
doctor's preference items, i.e. silicone versus PVC drain, type of suture needed to
close the incision, what dressing is requested, and what gloves are needed. The back
tables are first stacked with the instrument trays, power equipment, or telescopes before
the surgery begins. When the surgery case is "opened" in the OR suite, the back
table and mayo stand are covered with sterile drapes and towels. Quite quickly, this
stainless steel phase has added color rapidly with the draping material having many green
or blue hues. We are well on the way to completing a masterpiece OR suite.

Finally, the finishing touches are added. In this finale, anesthesia chairs and stools
are purchased. In days gone by, this furniture could only be found in black. Now, there
are choices of colors and certainly the color helps offset a stark environment. Also at
this stage, some hospital environments are allowing border prints if they are washable. A
homier, healing environment helps the patient as well as the staff to feel relaxed and
have a better mental attitude. The masterpiece is not quite done. Certainly the basic core
equipment has been addressed. Now all the specialty implements come forward. Warming units
are needed both for the patient and for fluids. Microscopes are needed and often times
cannot be configured for more than one specialty. Neuro, ENT, eyes, and hand microscopes
are the typical specialties requiring different optics and observor arms. Lasers are
purchased or rented according to specialty, also. Holmium lasers, YAG, diode, or CO2
lasers all have different wave lengths and mediums to meet the specific tissue, tumor, or
stone removal needs.

Fiber optic headlights and light sources are needed by the surgeon to help illuminate
the cavity or portal that has been made. (Halogen light sources are quickly becoming the
top choice due to their brighter light.) Light sources are also needed for illumination of
telescopes. Arthroscopes, sinus scopes, laparoscopes, cystoscopes, flexible laryngoscopes,
and ureteroscopes are just a few of the different ranges of optical instruments required
in today's environment. The telescope is used in conjunction with a light cable that is
then plugged into the light source.

More often than not, video equipment is required with all the aforementioned
telescopes. Video equipment entails a camera, monitor, and usually a VCR and video
printer. The camera takes the image from the telescope and projects it to the TV monitor.
It is a spectacular view to see an operation being performed on the monitor. Still
pictures or a video tape can be recorded if this equipment is available at the time.
General OR tables were mentioned previously. However, specialty tables are needed, and it
is a challenge to schedule procedures when one considers a fractured hip requires an
orthographic table or that a back procedure may need a Jackson or Andrew's table or that a
portable cystoscopy table may be required during a gynecological surgery. The other
challenge for these OR tables is storage since the tables are not needed for every
surgery.

Positioning aids are also a must. Gel rolls or pads help prevent decubitus ulcers. This
is extremely important on lengthy procedures. Bean bags, sand bags, and specifically named
positions (Montreal or Stahlberg) secure the patient to the OR table while allowing for
freedom of movement for the operative site.

In the neuro area, various headrests and skull clamps are required for positioning the
patient. Again, the patient must be positioned securely before an operation begins.
Finally, the last equipment needed is the instrumentation. This phase never ends. New
techniques warrant new instrumentation. Various retractors, specialty power equipment, and
general instrumentation needs are an every day juggling act in an OR. One plans for the
needs of the day before emergency procedures are added or before the surgeon finds
something totally unexpected when an incision is made. Instrumentation is the basic staple
of an OR and all the specialty equipment is added after the general instrumentation has
been pulled.

Now, this OR is equipped. Van Gogh nor Beethoven might not be impressed by this
masterpiece, but any OR personnel would be.

Arlene Maloney is the OR Service Manger at Good Samaritan Regional Medical Center
(Phoenix, Ariz).

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