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By Scott Hazlett, AIA
Advancementsin technology continue to drive increased automation in the OR. The trend towardminimally invasive surgical procedures in robotically equipped ORs is helping tocreate a faster, safer, and more efficient surgical environment. However, thistrend and the benefits it brings does not alter the need for continued vigilancefrom the standpoint of infection control. How can the individuals charged withinfection control in the OR prevent a hospital-acquired infection fromovershadowing the benefits of minimally invasive surgery? Fortunately, many ofthe design and engineering features developed to accommodate automation alongwith minimally invasive procedures have made it easier to keep ORs clean andinfection free.
The recently completed two-room Minimally Invasive OR Suite project at theUniversity of Pittsburgh Medical Center (UPMC) in Pittsburgh, Pa, will serve asa case study for addressing design for infection control in a newly designedrobotically-equipped OR. Designers considered important elements including thesize of spaces, equipment selection, finishes, HVAC, and lighting. Individually,each of these items is important, but when all are brought together in onespace, the result is a state-of-the-art surgical facility that provides the bestpossible environment for control of hospital-acquired infections.
The key design concept that helps provide infection control is adequateseparation. In the past, ORs were smaller and facilities were closer together,which promoted cross contamination. In the recent project at UPMC, ORs weredesigned to be large (550-600 sq. ft.), allowing greater separation between thesterile 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 ORstaff members access the ORs through separate entrances to avoid crosscontamination of a scrubbed surgical team member and the transport personnel andstretcher. There are no floor penetrations for power or medical gases, and allwall and ceiling penetrations are sealed.
One design feature that was especially important to UPMC is an observationgallery that is situated between the two ORs. "Having the observation roommeans that we have minimized the number of people who are going in and out andthat definitely impacts infection control," says Paulette Bingham, directorof 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 newtechnology, it's like being in the room but without the increased risk ofcontamination."
UPMC selected advanced hands-free or voice-activated surgical equipment toeliminate the need for surgical team members to touch equipment that may becontaminated. The rooms were designed to accommodate the latest Hermeshands-free communications technology and robotic surgery equipment such as AESOPand ZEUS. Multiple cameras in the ORs can provide live video to other locationsfor consulting and teaching purposes. Hands-free telephone equipment andvoice-activated devices, such as OR tables that can be raised or lowered byvoice command, help reduce contact transmission. Touch screen computers are usedinstead of keyboards.
Bill Phelps, a Facility Planning Specialist at UPMC Health System's Oaklandcampus in Pittsburgh, notes that integrating all of the automated technologyinto a seamless system was a key priority for this project, and infectioncontrol was always at the top of the list. "Video, voice, and roboticcapabilities have been a tremendous asset," says Phelps. "Many of thetasks that previously required operating hand controls or typing on akeyboard--to adjust the lights or raise the table, for example--have beenreplaced by simple voice commands. This helps preserve the sterile field andmakes for a much more efficient flow of personnel around the table, and to andfrom storage and support equipment," says Phelps.
Ceiling-hung equipment booms hold equipment up off of the floor, which mightotherwise be cluttered with carts. All utilities and medical gases originate inthe ceiling-hung equipment booms, eliminating hoses and cables running acrossthe 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 cleanand disinfect the floors properly without having to relocate a lot ofequipment," says Phelps. Booms also make it easier to organize power,medical gas, and electronic cabling to minimize the number of dust-gatheringaccessory lines.
Special attention was given to finish selections to provide for ease ofcleaning and durability. An epoxy terrazzo floor with integral base (no jointsor seams) and ceramic tile walls were selected because they are easy to cleanand resist damage from harsh cleaning solutions. Epoxy-based grout is used withthe ceramic tile to prohibit moisture absorption and bacteria growth. Ceilingsare made of seamless gypsum wallboard and sealed with epoxy paint. The paintused on metal and gypsum board surfaces is an anti-microbial epoxy paint usedfor durability and to limit bacteria growth. OR storage cabinets are made ofstainless steel and glass for easy cleaning. Sealant is installed around allwall penetrations and joints between dissimilar materials to ensure that thefinishes form a continuous seal around the room.
The control of airborne contaminants in an OR is an essential component incontrolling transmission of infection. At UPMC, the HVAC system has beendesigned to meet the latest federal guidelines for air filtration, outside air,and air change requirements. The laminar flow HVAC system delivers air from theceiling around the surgical table and exhausts it through low exhaust vents inthe room's corners to provide a clean air curtain around the sterile field wherethe patient is located. Positive air pressure in the room keeps unfilterednon-OR grade air from entering the room through open doors. All ductworkdelivering OR-grade air to the surgical suite is insulated on the exterior toeliminate 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 lightinglevels can be adjusted by voice command during surgery, eliminating the need totouch hand controls. With so many lighting levels available, room brightness canalso be adjusted to make cleaning easier and more thorough. Finally, gaskets andseals on overhead light fixtures promote dust control and prevent airinfiltration through the fixtures from adjacent spaces.
Many design and engineering features of robotically equipped, minimallyinvasive ORs actually help promote infection control, making the jobs of thoseresponsible for assuring a sterile environment easier. The concern that theconstant addition of technology to the OR might compromise the staff's abilityto provide adequate infection control is unfounded. Bingham says, "The waythe rooms were designed has a big impact on our ability to maintain a sterileenvironment. They are easy to clean and we can turn them around faster. With thenew technology all of the timeframes are shortened. Because the surgeon canoperate many of the systems by voice command, everything moves quicker. Thismeans the patient is open on the table for a shorter period, and the risk ofinfection is lowered."
As technology continues to improve and the numbers of procedures that reducethe risk of harm to patients keep growing, the ability to provide infectioncontrol will also continue to improve.
When the architect, engineer, surgical staff, and infection controlspecialists 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 asmaller risk of contracting a post-operative infection that could be worse thanthe problem that required the surgery in the first place.
Scott O. Hazlett, AIA, is a senior associate with Burt Hill KosarRittelmann Associates, an architectural and engineering firm with offices inButler, 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 LiverpoolCity Hospital, East Liverpool, Ohio; Veteran's Affairs Medical Center, Erie, Pa;and Westmoreland Regional Hospital, Greensburg, Pa.
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