OR WAIT null SECS
By Arlene Maloney
Thisarticle provides a step-by-step process for choosing and placing OR equipment. Just as VanGogh 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 theircreation. Before the actual equipping of an operating room suite takes place, muchpreparation is done prior to the floors, ceiling, and walls being in place. Structuralengineers calculate the strength of the overhead beams to make sure the OR lights haveadequate support. Electrical engineers consider the power needs and emergency power to runall the power equipment. In today's environment, this emergency power is more importantthan 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 ORsuite to run a certain piece of equipment (i.e., laser) after a new purchase ismade 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, waterpipes, and computer lines arranged behind the wallboard. The ceiling is completed withstructural beams in place under the ceiling tile and overhead, and in-room lighting isilluminating the room where one sees the new floor tile in place. Surely, it is time tobegin equipping the OR.
It is difficult to suggest which piece of equipment goes in first. The sterilizer, theoperating room lights, or the anesthesia gas column. It doesn't matter, but this is thefirst phase. If your hospital has a Group Purchasing Organization (GPO), it eliminates theneed to evaluate all the vendors for this equipment. It is time consuming and costly tomount OR lights or install an autoclave, and it is also difficult to schedule aninstallation when you are running a heavy OR schedule. Nonetheless, evaluations need to bedone, and if one is lucky, one or two vendors have been awarded contracts, and the processbecomes more streamlined for doing evaluations. The anesthesia column probably would notbe a piece of equipment that would be evaluated since many inspections and certificationsmust be met before this equipment can be used. Therefore, the anesthesia column is hungand provides 02, nitrogen, vacuum, and air, nitrous oxide to the ORsuite.
Then come the OR lights, seemingly an easy project to do. However, OR lights come inmany configurations. One large headlight at the head of the room with two smaller lightsat the rear is an option. If one has dedicated OR suites (i.e., neuro surgery oropen heart surgery), this configuration may change. If one does not properly plan for thetype of surgery being performed, one may find themselves with physician dismay of nothaving adequate light for their procedures.
The final piece of equipment in phase one installation would be the sterilizer. Thistoo, would have been evaluated and would have to meet required sterilization parametersbefore any surgery is performed. Oftentimes, one autoclave is installed in a subroombetween two OR suites. Good Samaritan Regional Medical Center (Phoenix, Ariz) has anautoclave in each OR. This may sound extravagant, but this OR has a circular design and nosubrooms 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 physiciandisgruntledness. For instance, permanently floor mounted OR tables meet specific surgicalrequirements if they are working properly. If the table fails, this puts an OR suite outof service until the repairs are completed. Also, more intensive surgical procedures arerequiring more radical patient positioning. Therefore, manual OR tables are not beingpurchased 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 laparoscopyprocedures. With minimally invasive surgery and laparoscopic procedures becoming thestandard and not open procedures, the importance of having the correct features on an ORtable is coming to the forefront.
A sensitive subject concerning an OR table is weight capacity. Frequently, nurses phonethe OR service manager asking how much weight a table will bear. Unfortunately, the weightof the US population is increasing, and, therefore, the OR table needs to meet thatdemand. 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, thisis a major concern that the OR table will meet the needs of the surgeon oranesthesiologist 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 herefrom the anesthesiologists. Ventilating, drug delivery, and gas delivery to the patientare important aspects of an anesthesia machine. This equipment needs to be evaluated bythese physicians, and it is imperative to have written criteria for them to rate thisequipment. The time from evaluation to implementation may be a lengthy period so havingwritten documentation will prevent headaches in the end.
The item needing evaluation for the final element of phase two is the anestheisamonitor. Blood pressure, heart rate, EKG, and EEG are all clinical requirements needing tobe monitored by the anesthesiologist. This equipment may take months before finalimplementation; therefore, written evaluation forms would be necessary here. It is notuncommon 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 uponwhich they had agreed.
With the large pieces of equipment (and the most costly) already installed in the ORsuite, now the stainless steel purchases must be made. Ring stands, back tables, mayostands, kick buckets, prep tables, IV poles, step stools, and case lockers are allnecessary to complete an OR suite. Some of this equipment is obvious in its use. IV poleshang IV fluids, and kick buckets house bloody sponges. A ring stand houses a basin forirrigation. Mayo stands and back tables house instruments, sutures, needles, blades, andother sterile material to the operative field. Step stools or stands allow the ORpersonnel (technician or RN) to stand at the same height as the surgeon and to passinstruments or any piece of material to facilitate the operation. The case locker housesthe OR pack, drapes, dressings, etc. according to the procedure being performed and to thedoctor's preference items, i.e. silicone versus PVC drain, type of suture needed toclose the incision, what dressing is requested, and what gloves are needed. The backtables are first stacked with the instrument trays, power equipment, or telescopes beforethe surgery begins. When the surgery case is "opened" in the OR suite, the backtable and mayo stand are covered with sterile drapes and towels. Quite quickly, thisstainless steel phase has added color rapidly with the draping material having many greenor 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 stoolsare purchased. In days gone by, this furniture could only be found in black. Now, thereare choices of colors and certainly the color helps offset a stark environment. Also atthis stage, some hospital environments are allowing border prints if they are washable. Ahomier, healing environment helps the patient as well as the staff to feel relaxed andhave a better mental attitude. The masterpiece is not quite done. Certainly the basic coreequipment has been addressed. Now all the specialty implements come forward. Warming unitsare needed both for the patient and for fluids. Microscopes are needed and often timescannot be configured for more than one specialty. Neuro, ENT, eyes, and hand microscopesare the typical specialties requiring different optics and observor arms. Lasers arepurchased or rented according to specialty, also. Holmium lasers, YAG, diode, or CO2lasers all have different wave lengths and mediums to meet the specific tissue, tumor, orstone removal needs.
Fiber optic headlights and light sources are needed by the surgeon to help illuminatethe cavity or portal that has been made. (Halogen light sources are quickly becoming thetop choice due to their brighter light.) Light sources are also needed for illumination oftelescopes. Arthroscopes, sinus scopes, laparoscopes, cystoscopes, flexible laryngoscopes,and ureteroscopes are just a few of the different ranges of optical instruments requiredin today's environment. The telescope is used in conjunction with a light cable that isthen plugged into the light source.
More often than not, video equipment is required with all the aforementionedtelescopes. Video equipment entails a camera, monitor, and usually a VCR and videoprinter. 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. Stillpictures 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 itis a challenge to schedule procedures when one considers a fractured hip requires anorthographic table or that a back procedure may need a Jackson or Andrew's table or that aportable cystoscopy table may be required during a gynecological surgery. The otherchallenge for these OR tables is storage since the tables are not needed for everysurgery.
Positioning aids are also a must. Gel rolls or pads help prevent decubitus ulcers. Thisis extremely important on lengthy procedures. Bean bags, sand bags, and specifically namedpositions (Montreal or Stahlberg) secure the patient to the OR table while allowing forfreedom of movement for the operative site.
In the neuro area, various headrests and skull clamps are required for positioning thepatient. Again, the patient must be positioned securely before an operation begins.Finally, the last equipment needed is the instrumentation. This phase never ends. Newtechniques warrant new instrumentation. Various retractors, specialty power equipment, andgeneral instrumentation needs are an every day juggling act in an OR. One plans for theneeds of the day before emergency procedures are added or before the surgeon findssomething totally unexpected when an incision is made. Instrumentation is the basic stapleof an OR and all the specialty equipment is added after the general instrumentation hasbeen pulled.
Now, this OR is equipped. Van Gogh nor Beethoven might not be impressed by thismasterpiece, 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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