Renovating Central Processing

Renovating Central Processing
Tucson Medical Center improves its facilities with minimal taskdisruption

By Heather Schrader

Central Supply (CS)/Central Processing (CP) is often the heart of operationsin the hospital. Unless CP runs properly, surgical procedures can't takeplace--causing delays and inconvenience for patients and staff. So what do youdo when it's time to renovate CP? With a department that often runs 24 hours perday, 7 days a week, it's not an easy undertaking. Consider the capitalequipment. CP requires special ventilation, electricity, and plumbing, makingrenovation 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 surgeryareas, the hospital has a total of 25 operating rooms. The main ORs handle about35 cases per day and the outpatient surgery centers handle an additional 15-20cases per day. With one CP processing all the instruments, the department isbusy.

TMC is the country's largest one-story hospital, licensed for 609 hospitalbeds, 62 psychiatric beds and 90 bassinets. TMC services more than 30,000inpatients and 122,000 outpatients yearly with 1,000 physicians representing 60specialties. TMC can trace its roots back to a first-class tuberculosis facilitythat opened in 1927 on a 300-acre site. The Desert Sanatorium was donated duringWorld War II, leading to the establishment of the not-for-profit communityhospital now known as TMC. The first patient was admitted to TMC in November1944. The first CP renovations began about 30-40 years later, and since thattime no other major renovations or construction have occurred in the CP.

Getting Started

Initially, TMC thought they would thoroughly clean the CP and purchase newequipment. But when they looked into the idea, it involved putting a Band-Aid ona department that required major wound protection. No substantial changes hadoccurred since the purchase of new equipment more than 20 years prior. TMCneeded to look into the facility's future and the future needs of the CP. Afterdoing so, it became evident they could not move forward without making a capitalinvestment 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 fora mobile CP trailer (like a MASH surgery unit), renting/buying double-widetrailers for the parking lot to use as a temporary CP, renovating the CP aroundcurrent CP functions, and finally, looking for a temporary location within theTMC 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 Departmentat TMC provided the planning team with a list of criteria that had to beconsidered before any move could be made. Using Guidelines for Design andConstruction of Hospital and Health Care Facilities, as well as otherguidelines from various other sources, the following list was created to ensuresafety 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. Aftercontacting several vendors, TMC learned that no one had a mobile CP that couldbe rolled in and set up in the parking lot. Doublewide trailers didn't seemlogical. Employees would have to go inside/outside and the cost of purchasingand equipping trailers was prohibitive. Outsourcing provided various challengesincluding infection and safety issues, as well as cost and time of processing.Renovating the CP around the current CP seemed a logical choice. However, itoffered numerous challenges including maintaining a clean side, the length oftime construction would take, and the challenge of working around the staff.Renovations would have taken at least five months with this plan--much too longfor 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 invarious areas including representatives from the architectural firm, facilitiesmanagement, CP, infection control, safety, and surgery. These departments becameimmersed in the process. TMC wanted the people who were going to use the CP tobe involved right from the beginning and to have an active role in the processand take ownership of the renovations.

The actual CP design went through a year's worth of revisions beforeconstruction began.

"It started out as a much smaller project," says project managerRichard Prevallet. "We were initially just going to purchase some equipmentand clean up CP. But with Administration's support throughout the process, wewere 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. Theylistened to us, and as the scope of the project expanded they provided theapprovals to spend the additional money in support. Basically, they have stayedout of our way, and have not been looking over our shoulders, they have trustedus and our choices--and allowed us to develop this. Their support has beeninvaluable to the success of this project."

With the support of Administration, and their investment in the future of theCP, TMC was able to design a state-of-the art CP with the future in mind--anexpandable CP to meet the growing needs of the hospital.

The temporary CP was to be located in the former Break-A-Way Café. A largepatio area used for outdoor seating was removed, and the outer wall expanded toaccommodate the dirty side of the CP. An air handling system had to be added tocreate a safe CP environment. Soiled items would go through a hallway (incovered containers and carts), through the old patio area and into the temporaryCPs soiled side. New mechanical systems were installed outside, properventilation and ductwork created, and the necessary plumbing and electricitywere installed. After approximately two weeks of renovations and passing thesafety and infection control indoor air quality testing, the old snack barbecame the temporary CP. While in their temporary location, massive renovationscould occur in the old CP area.

"I knew a year ago that we were going to renovate," says supervisorDale Davis. "I was excited about it. One thing was for certain--we weredefinitely in need of new equipment." Prior to the renovations, the old CPused technology that was cutting edge 20 years ago including awasher/sterilizer, washer/ decontaminator, two large floor loader steamsterilizers, and four EO sterilizers.

Prior to moving to the temporary CP, TMC purchased new equipment. Theyweighed the pros and cons of using EO. After considerable research and costanalysis, they decided EO would no longer be used at the facility. They decidedto use gas plasma Sterrad (ASP) units. The units were installed, and allinstruments, except for some flexible scopes, continued to be processed. Thisprocess was simplified by the easy installation of the new equipment.

The temporary CP houses new equipment including two 200 Series steamsterilizers (Getinge/Castle); two 8666 Washer/Disinfectors (Getinge/Castle); atemporary cart wash area; and two plasma Sterrad units. The biggest obstacle forthe 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 thetemporary CP, as well as a new pit-mounted cart washer (Getinge/Castle), apumping system that dispenses and monitors the detergents to the washers, aswell as a T-DOC Cycle Documentation and Instrument Tracking System and two newfloor loader sterilizers. Accommodations have been made for a third sterilizeras well as a third washer/disinfector.

The Move to the Temporary CP

The clean side in temporary CP with two 8666 Washers (Getinge/Castle).

The CP has 13 full time employees (FTEs) who have staggered shifts to keepthe 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 CPwas up and running in just one morning. The CP didn't have to shut down andremained fully functional during the transition. However, there was a back-upplan; area hospitals were on alert and ready to help out if needed. Supplieswere loaded onto extra linen carts ahead of time and just wheeled to the newlocation 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 footdepartment was complete. Included in this construction is an area that will beused for implementing a new case cart system. The move to the new CP followedthe same procedures as the move to the temporary CP. As a result of carefulplanning 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 justsuccessfully 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 theirMarketing Communications Department.

·Special thanks to everyone who contributed to this article.

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