Renovating Central Processing
Tucson Medical Center improves its facilities with minimal task
By Heather Schrader
Demolition of the old Central Processing Department.
Central Supply (CS)/Central Processing (CP) is often the heart of operations in the hospital. Unless CP runs properly, surgical procedures can't take place--causing delays and inconvenience for patients and staff. So what do you do when it's time to renovate CP? With a department that often runs 24 hours per day, 7 days a week, it's not an easy undertaking. Consider the capital equipment. CP requires special ventilation, electricity, and plumbing, making renovation an enormous task. When Tucson Medical Center (TMC) in Tucson, Ariz, decided to renovate their CP department, they knew they were in for a challenge.
TMC is a busy facility, with 12-16 OR suites in operation at any given time (which are also undergoing current renovations). Including outpatient surgery areas, the hospital has a total of 25 operating rooms. The main ORs handle about 35 cases per day and the outpatient surgery centers handle an additional 15-20 cases per day. With one CP processing all the instruments, the department is busy.
TMC is the country's largest one-story hospital, licensed for 609 hospital beds, 62 psychiatric beds and 90 bassinets. TMC services more than 30,000 inpatients and 122,000 outpatients yearly with 1,000 physicians representing 60 specialties. TMC can trace its roots back to a first-class tuberculosis facility that opened in 1927 on a 300-acre site. The Desert Sanatorium was donated during World War II, leading to the establishment of the not-for-profit community hospital now known as TMC. The first patient was admitted to TMC in November 1944. The first CP renovations began about 30-40 years later, and since that time no other major renovations or construction have occurred in the CP.
Initially, TMC thought they would thoroughly clean the CP and purchase new equipment. But when they looked into the idea, it involved putting a Band-Aid on a department that required major wound protection. No substantial changes had occurred since the purchase of new equipment more than 20 years prior. TMC needed to look into the facility's future and the future needs of the CP. After doing so, it became evident they could not move forward without making a capital investment and taking the time to undergo major renovation.
Knowing that they couldn't shut down CP, TMC began looking for alternatives. Initial ideas included temporarily outsourcing CP responsibilities, looking for a mobile CP trailer (like a MASH surgery unit), renting/buying double-wide trailers for the parking lot to use as a temporary CP, renovating the CP around current CP functions, and finally, looking for a temporary location within the TMC facility. Time was spent evaluating and weighing the cost, ease of use, impact on infection rates, and availability of each of these options.
Before moving forward with any of the ideas, the Infection Control Department at TMC provided the planning team with a list of criteria that had to be considered before any move could be made. Using Guidelines for Design and Construction of Hospital and Health Care Facilities, as well as other guidelines from various other sources, the following list was created to ensure safety and infection control measures were met.
OR/Infection Control construction requirements/concerns included:
- Changing area for staff.
- Hand washing facilities--clean and soiled areas.
- EO sterilizer room (for plasma also). Requires 10 air exchanges per hour with all air exhausted to the outside. Air movement relationship adjacent to air in, all air exhausted to outside. No re-circulation by means of room units. Relative humidity of 30-60%. Design temperature of 75°.
- Sterilizer equipment room. Ten air exchanges per hour with all air exhausted to outside. Air movement relationship to adjacent area in.
- Clean workroom for CP. Four air exchanges per hour with no recirculation by means of room units with 30-60% relative humidity. Temperature 75° with air movement relationship to adjacent area out.
- Soiled or decontamination room for CP. Six air exchanges per hour with no recirculation by means of room units. Design temperature 68-73° with air movement relationship to adjacent area "in." All air exhausted outside. No recirculated air.
- Sterile storage. Four air exchanges per hour. Design temperature 70° maximum.
- How product is taken from CP to OR. Traffic patterns (closed and contained).
- How product is taken from OR to CP. Traffic patterns (closed and contained).
- Location/proximity to OR.
- Where will supplies go? Where will we store sterile supplies?
- Use of plasma sterilization/hydrogen peroxide/biological indicators.
- Glutaraldehyde use area requiring laminar flow hood, etc.
- Testing of area prior to opening for contaminants (particle load, Andersen air sampler and air-o-cell for fungal and bacterial growth). Flush water lines and HVAC air vents.
After reviewing these criteria, some ideas were no longer feasible. After contacting several vendors, TMC learned that no one had a mobile CP that could be rolled in and set up in the parking lot. Doublewide trailers didn't seem logical. Employees would have to go inside/outside and the cost of purchasing and equipping trailers was prohibitive. Outsourcing provided various challenges including infection and safety issues, as well as cost and time of processing. Renovating the CP around the current CP seemed a logical choice. However, it offered numerous challenges including maintaining a clean side, the length of time construction would take, and the challenge of working around the staff. Renovations would have taken at least five months with this plan--much too long for TMC to wait. Alternative locations within the facility were examined. Finally, an unused snack bar/cafeteria area was selected.
Designing the Temporary CP and New CP
The design of the temporary and new CP involved many people--all experts in various areas including representatives from the architectural firm, facilities management, CP, infection control, safety, and surgery. These departments became immersed in the process. TMC wanted the people who were going to use the CP to be involved right from the beginning and to have an active role in the process and take ownership of the renovations.
The actual CP design went through a year's worth of revisions before construction began.
"It started out as a much smaller project," says project manager Richard Prevallet. "We were initially just going to purchase some equipment and clean up CP. But with Administration's support throughout the process, we were able to do much more. We told them that there was a better way to do CP, that we had a better solution for the basement for the next 15 years. They listened to us, and as the scope of the project expanded they provided the approvals to spend the additional money in support. Basically, they have stayed out of our way, and have not been looking over our shoulders, they have trusted us and our choices--and allowed us to develop this. Their support has been invaluable to the success of this project."
With the support of Administration, and their investment in the future of the CP, TMC was able to design a state-of-the art CP with the future in mind--an expandable CP to meet the growing needs of the hospital.
The temporary CP was to be located in the former Break-A-Way Café. A large patio area used for outdoor seating was removed, and the outer wall expanded to accommodate the dirty side of the CP. An air handling system had to be added to create a safe CP environment. Soiled items would go through a hallway (in covered containers and carts), through the old patio area and into the temporary CPs soiled side. New mechanical systems were installed outside, proper ventilation and ductwork created, and the necessary plumbing and electricity were installed. After approximately two weeks of renovations and passing the safety and infection control indoor air quality testing, the old snack bar became the temporary CP. While in their temporary location, massive renovations could occur in the old CP area.
"I knew a year ago that we were going to renovate," says supervisor Dale Davis. "I was excited about it. One thing was for certain--we were definitely in need of new equipment." Prior to the renovations, the old CP used technology that was cutting edge 20 years ago including a washer/sterilizer, washer/ decontaminator, two large floor loader steam sterilizers, and four EO sterilizers.
Prior to moving to the temporary CP, TMC purchased new equipment. They weighed the pros and cons of using EO. After considerable research and cost analysis, they decided EO would no longer be used at the facility. They decided to use gas plasma Sterrad (ASP) units. The units were installed, and all instruments, except for some flexible scopes, continued to be processed. This process was simplified by the easy installation of the new equipment.
The temporary CP houses new equipment including two 200 Series steam sterilizers (Getinge/Castle); two 8666 Washer/Disinfectors (Getinge/Castle); a temporary cart wash area; and two plasma Sterrad units. The biggest obstacle for the CP staff was not the move, but rather learning how to use the new equipment, since everyone in the CP had always used EO.
When the new CP is complete, it will use all of the equipment from the temporary CP, as well as a new pit-mounted cart washer (Getinge/Castle), a pumping system that dispenses and monitors the detergents to the washers, as well as a T-DOC Cycle Documentation and Instrument Tracking System and two new floor loader sterilizers. Accommodations have been made for a third sterilizer as well as a third washer/disinfector.
The Move to the Temporary CP
The CP has 13 full time employees (FTEs) who have staggered shifts to keep the CP running around the clock. On any given day, 8 to 10 people are on duty. On the day of the move, with the help of plant services, the entire temporary CP was up and running in just one morning. The CP didn't have to shut down and remained fully functional during the transition. However, there was a back-up plan; area hospitals were on alert and ready to help out if needed. Supplies were loaded onto extra linen carts ahead of time and just wheeled to the new location when they were ready. No one in the hospital noticed a difference, except soiled goods were delivered to a new location.
The New CP
The new CP at TMC took eight weeks to construct before the 15,000 square foot department was complete. Included in this construction is an area that will be used for implementing a new case cart system. The move to the new CP followed the same procedures as the move to the temporary CP. As a result of careful planning and teamwork, the move was a success.
Recommendations for Others Undergoing a Major CP Renovation
Renovating your CP is not an easy task. Take some tips from people who just successfully completed one:
- Make sure there is enough time between your design phase and construction so you have a firm idea of the cost.
- Plan your renovation around your census. Don't start a major renovation project when you're at full capacity. Plan construction when the hospital numbers are down--and make sure your renovations are complete before your census peaks.
- Have the key players and experts involved from the beginning. Make sure you have committed representation from all the necessary departments.
- Get advice from experts--people who have participated in this type of renovation before. It's a unique project that doesn't happen often. Seek out colleagues who have experience in this field.
- Have vendors take you on site visits. See what other CPs around the country look like. You don't have to re-create the wheel. Most use variations of similar systems and workflows.
- Teamwork is mandatory. You have to be able to work together--which is why the renovations at TMC have been so successful. Departments working together come up with solutions that work for everyone.
- Get organized before you move. Don't be afraid to ask other departments for help.
- Rely on your vendors. Good vendors are invaluable resources for ideas, training and recommendations. Good vendors will help you see your renovations through to completion and not leave you once the equipment is delivered.
- Use local architects and contractors who are only a short drive and a phone call away. It makes working with them easier and, often, less expensive.
- Educate your contractors about proper hospital procedures. Many do not understand about clean areas, soiled areas, and sterile areas. They need to know where they can work and under what conditions. They also need to be monitored. The hospital work environment is new to them and it creates different concerns and issues for them.
- Educate your employees. They need to know what is going on around them, what construction is taking place, and what types of materials are being used. They also need to be assured that their work environment is a safe place even with construction going on.
- Overall, TMC's CP renovation was a success. By working together as a team, having the support of their administrators, and hiring reliable architects, contractors, and other vendors, TMC was able to complete a massive CP renovation with little or no disruption to the hospital.
Heather Schrader works for Getinge/Castle, Inc. (Rochester, NY) in their Marketing Communications Department.
·Special thanks to everyone who contributed to this article.
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