Professional Documents
Culture Documents
Surgical procedures were not always performed within the confines of a formal
hospital setting. The surgeon made house calls when summoned to see a patient. In
the early 1900s, the surgical nurse was sent to prepare a suitable room with little
traffic and ambient noise for the surgical procedure-usually the dining room, but
occasionally the kitchen. Everything was removed from the room, especially
carpets, drapes, pictures, and unnecessary furniture. The room was fumigated with
sulfur dioxide for 12 hours if time allowed. This was accomplished by burning 3
pounds of sulfur in an iron pot for each 1000 cubic feet of air space. The windows
and doors were sealed shut as much as possible. When the fumigation was
complete, the walls and surfaces were scrubbed with 5% carbolic acid or hot soda
solution. Von Esmarch described cleansing of wallpaper by a process that involved
rubbing the surface with soft bread. He based this activity on personal experiments.
If time did not permit the fumigation/scrubbing process, the room was to be
penetrated with steam from a kettle.
Linen napkins and towels were boiled for 5 minutes in soda solution for use as
sponges. The stove and oven were useful as sterilizers. Bricks were kept in the oven
for use as warming devices for chilly patients. The kitchen or dining room table was
padded for use as the operating bed and placed under the chandelier, with the head
toward a north window. For privacy, fine white tissue paper was secured to the
window using flour paste. Many surgeons had portable lamps for use in homes
equipped with electricity. This was useful at night. White bed sheets were nailed to
all of the walls as protective coverings.
The physical environment was of keen importance to the surgeon. The temperature
of the room was to be maintained at 75 to 80 F and additional warming measures,
such as heated blankets, hot water bottles, and heated bricks wrapped in flannel
were used. In addition to preparing the environment, the nurse was required to have
10 gallons of hot sterile water and 10 gallons of cold sterile water ready for use. Her
role included preparing sterile saline by boiling a large container of water and
adding 2 teaspoons of table salt. The mixture was boiled for 30 minutes then
filtered through cotton that has been baked to a brownish color into a sterile bottle.
A cork was used to seal the opening. If the solution was to be kept for future use,
the sealed bottle was boiled for 20 minutes for 3 consecutive days. This was
believed to prevent spore generation.
At the conclusion of the surgical procedure the nurse was required to disassemble,
boil, dry, and pack the surgeons private instrumentation into his black bag. The
room was returned to its original condition by removing the sheets from the walls
and sending them out for laundering and restoring carpets and furniture to their
usual position. The aim of the nurse was to leave the place as she found it.
Efficient use of the physical facilities is important. The design of the surgical suite
offers a challenge to the planning team to optimize efficiency by creating realistic
traffic and workflow patterns for patients, visitors, personnel, and supplies. The
design also should allow for flexibility and future expansion and should control for
environmental atmospheric regulation (Table 10-1). Architects consult surgeons,
perioperative nurses, and surgical services administrative personnel before
allocating space.
Construction or Renovation Planning and Design Team
The planning and design of the perioperative environment require a
multidisciplinary team, which may include the following:
Department director
Nurse manager
Architect
Interior decorator
each
Type and distribution by specialties of the surgical staff and equipment for
Environmental Controls
OR
Postanesthesia Care Unit
Storage Areas
Temperature
68-73 F (20-22 C)
70-75 F (21-24- C)
68-73 F (20-22 C)
Humidity
30%-60%
30%-60%
30%-60%
Air exchanges per hour
15
6
4 (minimum)
Recirculated by room unit
Pressure related to adjacent areas
Exchanges with outdoor air per hour
No
Positive
3
No
N/A
2
No
N/A
N/A
Scheduling policies related to the number of hours per day and days per
week the suite will be in use and staffing needs
Consideration of volume changes and need for future expansion
capabilities
Location
The surgical suite is usually located in an area accessible to the critical care surgical
patient areas and the supporting service departments, the central service or sterile
processing department, the pathology department, and the radiology department.
The size of the hospital is a determining factor because it is impossible to locate
every desirable unit or department immediately adjacent to the surgical suite. A
terminal location is necessary to prevent unrelated trafficral and central corridor
(Fig. 10-4)
from passing through the suite. A location on a top floor is not necessary for
microbial control because all air is specially filtered to control dust. Traffic noises
may be less evident above the ground floor. Artificial lighting is controllable, so the
need for daylight is not a factor; in fact, it may be a distraction during the use of
video equipment and other procedures requiring a darkened environment. Most
surgical suites have solid walls without windows.
Restricted Area. Masks are required to supplement OR attire where open sterile
supplies or scrubbed personnel are located. Sterile procedures are carried out in the
OR. The area also includes scrub sink areas and substerile rooms or clean core
area(s) where unwrapped supplies are sterilized. Personnel entering this area for
short periods, such as labo-ratory technicians, may wear clean surgical coveralls or
jumpsuits to cover street clothes. Hair covering is worn and masks are donned as
appropriate.
TBA
Both patients and personnel enter the semirestricted and restricted areas of the
surgical suite through a transition zone. This transition zone, inside the entrance to
the surgical suite, separates the OR corridors from the rest of the facility.
regional blocks. These procedures require good lighting. Each patient area is
equipped with oxygen, suction, and devices for monitoring and cardiopulmonary
resuscitation.
A nurses station within the area provides for medication storage and preparation
and for interdepartmental and intradepartmental communication. Computer access
to patient information, such as laboratory reports, and to patient care
documentation facilitates completion of patients records, if necessary. Coordination
with people managing the surgical schedule is essential to prevent delays.
Induction Room
Some hospitals have an induction room adjacent to each OR, where the patient
waits and is prepared preoperatively before administration of anesthesia. Invasive
IV lines are placed and/or regional anesthesia may be induced in this area. These
are more common in larger facilities, where procedures such as open heart surgery
or transplantation is performed.
equipment, supply, and utility rooms and housekeeping determines support space
requirements. Equipment and supply rooms should be decentralized, placing them
near the appropriate ORs.
Offices
Offices for the administrative patient care personnel and the anesthesia department
should be located with access to both unrestricted and semirestricted areas. The
staff members frequently need to confer with outside people and to be kept
informed of activities within all areas of the suite.
Conference Room/Classroom
Ideally, a conference room or a classroom is located within the semirestricted area.
This is used for patient care staff inservice educational programs and is used by the
surgical staff for teaching. Closed-circuit television and/or video-cassettes may also
be available for self-study. The depart-mental reference library may be housed here.
Support Services
The size of the health care facility and the types of services provided determine
whether laboratory and radiology equipment is needed within the surgical suite.
Laboratory. A small laboratory where the pathologist can examine tissue specimens
and perform frozen sections expedites the decisions that the surgeon must make
during a surgical procedure when a diagnosis is questionable. A designated
refrigerator for storing blood for transfusions also may be located in this room.
Tissue specimens may be tested here by frozen section before they are delivered to
the pathology department for permanent section.
Radiology Services. Special procedure rooms may be outfitted with radiologic and
other imaging equipment for diagnostic and invasive radiologic procedures or
insertion of catheters, pacemakers, and other devices. The walls of these rooms
contain lead shields to confine radiation. A darkroom for processing radiographic
films usually is available within the surgical suite for immediate processing of scout
films or contrast dye studies of organ systems.
Work and Storage Areas
Clean and sterile supplies and equipment are separated from soiled items and
trash. If the surgical suite has a clean core area, only clean or sterile items are
stored there. Soiled items are taken to the decontamination area for processing
before being stored, or they are taken to the disposal area. Work and storage areas
are provided for handling all types of supplies and equipment, whether clean or
contaminated.
Anesthesia Work and Storage Areas. Space must be provided for storing anesthesia
equipment and supplies. Gas tanks are stored in a well-ventilated area separated
from other supplies. Care is taken not to allow tanks or cylinders to be knocked over
or damaged. They should stand upright in a secure, stable base for safety.
Nondisposable items must be thoroughly decontaminated and cleaned after use in
an area separate from sterile supplies. A separate workroom usually is provided for
care and processing of anesthesia equipment. Dirty and clean supplies must be kept
separated.
The storage area includes a secured space for drugs and anesthetic agents. Some
facilities have drug-dispensing machines that require positive identification to
obtain medications for . patient use. Larger facilities have pharmaceutical station
where a pharmacist dispenses drugs on a per-case basis. Signatures are required for
controlled substances. Unused drugs are returned to the pharmacist for
accountability.
General Workroom. The general work area should be as centrally located in the
surgical suite as possible to keep contamination to a minimum. The work area may
be divided into a cleaning area and a preparation area. If instruments and
equipment from the utility room are received from the pass-through washersterilizer into this room, an ultrasonic cleaner should be available here for cleaning
instruments that the washer-sterilizer has not adequately cleaned. Otherwise, the
ultrasonic cleaner may be in the utility room.
Instrument sets, basin sets, trays, and other supplies are wrapped for sterilization
here. The preparation and sterilization of instrument trays and sets in a central
room ensure control. This room also contains the stock supply of other items that
are packaged for sterilization. The sterilizers that are used in this room may open
also into the next room, the sterile supply room. This arrangement helps to
eliminate the possibility of mixing sterile and nonsterile items.
Storage
Technology nearly tripled the need for storage space in the 1980s. Many older
surgical suites have inadequate facilities for storage of sterile supplies, instruments,
and bulky equipment. Storage space should fit logically into the design of the suite.
Those responsible for calculating adequate storage space for instruments, sterile
and unsterile supplies, and mobile equipment, such as special OR beds, specialty
carts, and equipment, should consider the size of the entire surgical suite. The size
of the entire suite is calculated into square feet, and SOr6 of the total number of
square footage of the department is added to serve as storage. This floor space
does not include additional storage space needed for postanesthesia equipment.
Using a case cart system may slightly decrease the amount of instrument space
needed. Plans should include accommodation for the size of each type of case cart
used and the numbers that will be in the suite at a given point in the daily surgical
schedule.
Sterile Supply Room. Most hospitals keep a supply of sterile drapes, sponges,
gloves, gowns, and other sterile items ready for use in a sterile supply room within
the surgical suite. As many shelves as possible should be freestanding from the
walls, which permits supplies to be put into one side and removed from the other;
thus older packages are always used first. However, small items must be contained
in boxes or bins to prevent them from falling to the floor. Inventory levels should be
large enough to prevent running out of supplies, yet overstocking of sterile supplies
should be avoided. Storage should be arranged to facilitate stock rotation.
The sterile storage area should be adjacent to or as close as possible to the
sterilizing area if sterilizing is done in the surgical suite. Access to the sterile storage
area should be limited; it should be separated from high-traffic areas. Humidity
should be controlled at 30% to 60%, and temperature should be 68 to 75 F(20 to
24 C). Humidity in excess of 70% would cause concern for condensation within
sterile packages and may permit microorganism transfer by capillary action. There
should be positive pressure with a minimum of four fresh air exchanges per hour in
the sterile storage area.
Instrument Room. Most hospitals have a separate room or a section of the general
workroom designated for storing nonsterile instruments. The instrument room
contains cup-boards in which all clean and decontaminated instruments are stored
Storage Room. Some large, portable equipment must also be stored in the surgical
suite, readily accessible for use. A storage room for this equipment, such as the
orthopedic table that may not be used daily, keeps equipment out of corridors when
not in use. Lasers and video equipment can be damaged if inadvertently bumped by
a passing stretcher in a corridor.
Scrub Room
An enclosed area for preoperative cleansing of hands and arms should be provided
adjacent to each OR. Water spills on the floor are particularly hazardous if the scrub
area is in a traffic corridor. An enclosed scrub room is a restricted area within the
surgical suite. Paper towel dispensers and mirrors should be located in this area.
Trash receptacles, limited to only those items used within this room, should be
emptied several times per day. Some facilities have boxes of additional caps, masks,
shoe covers, and eye protection in the event of biologic contamination requiring a
change of these items during a procedure. The contaminated item should be
discarded in the biohazardous trash bin in the OR after changing.
QPERATING ROOM
Each OR is a restricted area because of the need to maintain a controlled
environment for sterile and aseptic techniques (Fig. 10-5).
Size
The size of individual ORs varies. In the interest of economy and flexibility, it is
desirable to have all ORs the same size so that they can be used interchangeably to
accommodate elective and emergency surgical procedures. Adequate size for a
multipurpose procedure room for ambulatory surgery or endoscopy is at least 20 x
20 x 10 feet (6 x 6 x 3 m), or 400 square feet (approximately 37 mz) of clear floor
space. Approximately 20 square feet of space should be planned between fixed
cabinets and shelves on two opposing walls. Larger rooms for cardiac or other large
procedures are 20 x 30 x 10 feet (600 square feet [approximately 60 m2]).
Renovated rooms may be 360 square feet with 18 feet between the fixed shelving
units.
A room may be designed for a specialty service if use by that service will be high.
The room must accommodate equipment, such as lasers, microscopes, or video
equipment, either fixed (permanently installed) or portable (movable). Portable
equipment may require more floor space-a minimum of 22 x 22 x 10 feet (484
square feet [approximately 45 m2)). A specialized room, such as one equipped for
cardiopulmonary bypass or trauma, may require as much as 600 square feet
(approximately 60 m2) of useful space.
Substerile Room
A group of two, three, or four ORs may be clustered around a central scrub area,
work area, and a small substerile room. Only if the last-mentioned room is
immediately adjacent to the OR and separated from the scrub area will it be
considered the substerile room throughout this text. A substerile room adjacent to
the OR contains enclosed
storage cupboards, a sink, steam sterilizer, a STERIS unit, and a warming cabinet.
Although cleaning and sterilizing facilities are centralized, either inside or outside of
the surgical suite, a substerile room with this equipment offers thefollowing
advantages:
It saves time and steps. The circulating nurse can do emergency cleaning
and sterilization of items here. This reduces waiting time for the surgeon, reduces
anesthesia time for the patient, and saves steps for the circulating nurse. The
circulating nurse, or scrub person if necessary, can lift sterile articles directly from
the sterilizer onto the sterile instrument table without transporting them through a
corridor or another area.
It reduces the need for other personnel to obtain sterile instruments and
allows the circulating nurse to stay within the room.
It allows for better care of instruments and equipment that require special
handling. Certain delicate or sensitive instruments or perhaps a surgeons
personally owned set usually are not sent out of the surgical suite. Only the
personnel directly responsible for their use and care handle them; the circulating
nurse and scrub person can clean them within the confines of the OR and this
adjacent room.
Doors
Doors should be 4 feet wide for ease in moving patients on carts and in beds.
Ideally, sliding doors should be used exclusively in the OR. They eliminate the air
currents caused by swinging doors. Microorganisms that have previously settled in
the room are disturbed with each swing of the door. The microbial count is usually at
its peak at the time of the skin incision, because this follows disturbance of air by
gowning, draping, movement of personnel, and opening and dosing of doors. During
the surgical procedure, the microbial count rises every time doors swing open from
either direction. Also, swinging doors may touch a sterile table or person. The risk of
catching hands, equipment cords, or other supplies is increased. Doors should not
swing out into the hallway.
Sliding doors should not recede into the wall like pocket styles, but should be of the
surface-sliding type. Fire regu-lations mandate that sliding doors for ORs be of the
type that can be swung open if necessary. Doors do not remain open either during
or between surgical procedures. The room air circulation is higher pressure than in
the halls to minimize the amount of dust and debris pulled in toward the sterile
field. Closed doors decrease the mixing of air within the OR with that in the
corridors, which may contain higher microbial counts. Air pressure in the room also
is disrupted if the doors remain open.
When construction or renovation is in process, it is important to always keep the
doors closed when not trans-porting patients. The air-handling systems are under a
strain because of the disrupted processes and are further compromised when the
airflow is allowed to equalize. This causes unstable temperature and humidity
control. The desired temperature should be between 68 and 73 F(20 and 23 C),
with a relative humidity of 30% to 60%. The risk for airborne contaminants is
significantly increased.
Ventilation
The OR ventilation system must ensure a controlled supply of filtered air. Air
changes and circulation provide fresh air and prevent accumulation of anesthetic
gases in the room. Concentration of gases depends solely on the proportion of pure
air entering the air system to the air being recirculated through the system. Fifteen
air exchanges per hour with three exchanges of fresh air are recommended for
operating rooms with recirculated air. Some state building codes require 100%
fresh air; others permit up to 80% recirculation of air. If air is recirculated, a gas
scavenger system is mandatory to prevent the buildup of waste anesthetic gases.
Various types of scavengers and evacuators are used to minimize air pollutants that
are health risks for perioperative team members.
Ultraclean laminar airflow is installed in some ORs to provide up to 600 air
exchanges per hour. This high-flow, unidirectional air-blowing system is housed in a
wall or ceiling enclosure. The airflow can be vertical or horizontal. Staff should not
pass between the airflow and the sterile field or the purpose for using ultraclean air
is defeated.
Laminar airflow was first trialed during hip replacement surgery by Sir John Charnley
in Great Britain in the 1950s. Charnley believed that if particulate could be removed
from the air, the 7% infection rate could drop. His studies showed that the infection
rate did fall to less than 2%. The value of this system in reducing airborne
contamination is inconclusive because the rate continued to fall to less than 1%
with changes in surgical dressing practices. Although
the laminar system contributes to removing particulates, the improvements in
sterile technique overall may have a larger effect on infection rate.
Other types of filtered air-delivery systems that have a high rate of airflow are as
effective in controlling airborne contamination. Filtration through high-efficiency
particulate air (HEPA) filters can be 99.7% efficient in removing particles that are
larger than 0.3 mm. These microbial filters in ducts filter the air, practically
eliminating all dust particles. The ventilating system in the surgical suite is separate
from the hospitals general system and is to be cleaned, inspected, and maintained
on a preventive maintenance (PM) schedule.
Positive air pressures (0.005 inch [0.013 cm] of water pressure) of 10% in each OR
are greater than that in corridors, scrub areas, and substerile rooms. Positive
pressure forces air from the room. The inlet is at the ceiling. Air leaves through the
outlets at floor level. If the reverse is true, air is drawn into the room around the
doors and through open doors. Microorganisms in the air can enter the room unless
positive pressure is maintained. Closed doors maintain this environment and
prevent equalization of air pressure. The recommended parameters include a dual
filtration system with two filters in succession. The first filter should be at least 30%
efficient, and the second filter should be at least 90%.
An air-conditioning system controls humidity. High relative humidity (weight of water
vapor present) should be maintained between 30% and 60%. A relative humidity of
not less than 50% to 55% is ideal. Moisture provides a relatively conductive
medium, allowing static charge to leak to earth as fast as it is generated; sparks
form more readily in atmospheres of low humidity.
Operating room temperature is maintained within a range of 68 to 73 F(20 to 23
C). A thermostat to control room temperature can be advantageous to meet patient
needs; for example, the temperature can be increased to prevent hypothermia in
pediatric, geriatric, or burn patients. Overmanipulation of controls can result in
calibration problems. Controls should not be adjusted solely for the comfort of team
members; patient normothermia is a strong consideration. Only the maintenance
department can regulate temperature in some surgical suites.
Floors
In the past, floors were conductive enough to dissipate static from equipment and
personnel but not enough to endanger personnel from shock or cause explosions
from flammable anesthetic gases. Conductivity is not a prime concern in OR design
because explosive anesthetic gases are no longer used. The most common flooring
used today is seamless polyvinyl chloride that is continued up the sides of the wall
for 5 or 6 inches and welded into place. These materials should not degrade or stain
with age and cleaning. Metal oxides can be incorporated to decrease the
slipperiness of the surface when wet.
A variety of hard plastic, seamless materials are used for minor procedure room
floors. The surface of all floors should not be porous but suitably hard for cleaning
by the flooding, wet-vacuuming technique. Personnel fatigue may be related to the
type of flooring, which can be too hard or too soft. Cushioned flooring is available.
The floor should be slipproof when wet because surgical hand cleansing causes
splashes and spills around the scrub sink and into the OR, where the hands are
dried.
Most of the glues and adhesives used in the installation of the flooring are
malodorous and potentially toxic. During construction or renovation, care is taken to
vent these fumes from the area. A minimum of 2 weeks may be needed to fully rid
the area of the smell before it can be safely used for patient care.
considerable impact also may have some value in noise control. Stainless steel cuffs
at collision corners help prevent damage.
Walls and ceilings often are used to mount devices, utilities, and equipment in an
effort to reduce clutter on the floor. The ceilings should be reinforced with steel
beams to support the load. In addition to the overhead operating light, the ceiling
may be used for mounting an anesthesia service column, operating microscope,
cryosurgery device, x-ray tube and image intensifier, electronic monitor, closed
circuit television monitor and camera, and a variety of hooks, poles, and tubes.
Demands for ceiling-mounted equipment are diversified.
Suspended track mounts are not recommended because they engender fallout of
dust-carrying microorganisms each time they are moved. If movable or track ceiling
devices are installed, they should not be mounted directly over the operating bed
but away from the center of the room and preferably recessed into the ceiling to
minimize the possibility of dust accumulation and fallout.
tracks must be protected from repeated flexing to prevent cracks and damage to
wires. Rigid or retractable ceiling service columns eliminate these hazards.
Multiple electrical outlets should be available from separate circuits. This minimizes
the possibility of a blown fuse or a faulty circuit shutting off all electricity at a critical
moment.
All personnel must be aware that the use of electricity introduces the hazards of
electric shock, power failure, and fire. Faulty electrical equipment may cause a short
circuit or the electrocution of patients or personnel. These hazards can be
prevented by taking the following precautions:
1. Use only electrical equipment designed and approved for use in the OR.
Equipment must have cords of adequate length and adequate current-carrying
capacity to avoid overloading.
2. Test portable equipment immediately before use.
3. Discontinue use immediately if any malfunction takes place, and report any faulty
electrical equipment.
4. If a ground fault buzzer sounds, unplug the last device engaged and remove it
from service.
Fire safety systems are installed throughout the hospital. All personnel must know
the fire rules. They must be familiar with the location of the alarm box and the use
of fire extinguishers.
Lighting
General illumination is furnished by ceiling lights. Most room lights are white
fluorescent but may be incandescent. Recessed lights do not collect dust. Lighting
should be evenly distributed throughout the room without harsh shadows. The
anesthesia provider must have sufficient light, at least 200 foot-candles, to
adequately evaluate the patients color. Intraoperatively, the lighting should not
cause the organs to appear discolored.
To minimize eye fatigue, the ratio of intensity of general room lighting to that at the
surgical site should not exceed 1:5, preferably 1:3. This contrast should be
maintained in corridors and scrub areas, as well as in the room itself, so that the
surgeon becomes accustomed to the light before entering the sterile field. Color and
hue of the lights also should be consistent.
Illumination of the surgical site depends on the quality 4 light from an overhead
spotlight source and the reflection from the drapes and tissues. Drapes should be
blue, green, or gray to avoid eye fatigue. White, glistening tissues need light than
dull, dark tissues. Light must be of such quality that the pathologic conditions are
recognizable. The overhead operating light must: