The future calls

In “Jetsons” fashion, hospital operating rooms have become smart. Radiology images, patient records, lab results, telecommunications linkages to other departments, remote audiovisual observation, room temperature, lighting levels and other functionalities may now be operated from a single technology station located within each operating room. The station systems may be preprogrammed to automatically recalculate room settings to specific case type or specific physician preferences, right down to the choice of music to be played for staff during a surgical procedure.

Integrated technology and image- guided surgery are increasing surgeon accuracy and speed. Information to enable physician decision-making in the operating room can be made instantly available—electronically. Picture archiving and communication systems (PACS) images, patient data, test results and connectivity with other modalities, such as cath lab, critical care and pathology, as well as other vital information may be accessed within seconds for use by the surgeon and anesthesiologist.

For example, the image of a frozen section specimen that a clinical pathologist is viewing under a microscope in a remote hospital lab may be displayed in the operating room for simultaneous viewing by the surgeon. In previous times, the surgeon would have had to wait for a phone call from the lab and the pronouncement of the pathologist, but could not have viewed the laboratory image personally.

Another technological advance involves the preoperative image being married to an electrophysiologically based intraoperative image and displayed on video screens; markers may be applied to non-fluoroscopic 3-D imaging. It is no longer necessary for physicians to personally view the human surgical site on the interior, thus reducing the need for large patient incisions.

All surgical equipment and technology (e.g., booms, lights, monitors, endoscopic equipment and stereotactic/navigational and robotics equipment) is integratable and can be managed and synchronized from an OR technology control station according to the needs and preferences of the physicians. This station, consisting of equipment mounted on an adjustable arm with a stool, should be located facing the sterile field within the operating room to accommodate the circulating nurse and one additional floating staff.

Surgeons may view digital information on flat-screen monitors mounted above the operating table and collaborate with remote medical experts or document findings during a given patient surgery, as programmed at this control station. Knowledge boards displaying aggregate patient case information add value to the overall quality assurance of each case. The possibilities are vast. Most equipment, cameras and monitors may be boom-mounted for clear visibility and ease of access by the physicians and scrub nurse.

Advanced video conferencing adapted with noise/echo filtering features that eradicate ambient noise will enhance audio integrity in voice-activated processes and remote communications.

Staffing changes follow

Hand in hand with these technological advances, many organizations are finding that a new type of operating room expert is needed. One or more floating surgical technology specialists should be available to move from OR to OR on an as-needed basis to address technology requirements. Consequently, a separate arm may be required at the technology control stations to enable the technology specialist to work simultaneously without disrupting the case documentation under way by the circulator nurse.

Also, there should be far less need for the circulating nurse to leave the operating room during a case. He or she may signal for items to be delivered to recessed OR pass-through storage cabinets and may remain in the OR to respond to physician requests and to manage the OR-integrated technology from the single-source station.

Operating room technology closets should also be designed for dual access so the surgical technology specialists may service equipment from the corridor without entering the OR. In selected settings, the circulator nurse may function in a dual role—managing the OR technology control station while providing nursing care and assistance.

Planning requirements

Despite a wealth of in-house expertise, there may be no single individual within a given health care provider organization that possesses the experience or breadth of knowledge to successfully execute the desired surgery techno-program. Faced with the technological complexities in today’s fast-paced environment, one may find that professional integrated technology consultants will be required to assist in planning and implementation.

It is advisable to add capital dollars to project budgets for these services and to involve consultants during the early design process. Such consultants can orchestrate the successful connectivity and operations of the architecture, engineering, information and telecom systems, robotics, teleconferencing, telemedicine, audio/voice capability, lighting and other low-voltage OR systems.

Through collaboration with internal medical, clinical, imaging, PACS and biomedical engineering and maintenance staffs, integrated OR consultants can ensure connectivity success and quality assurance. The corresponding workload is significant. Process workflow diagrams and process improvement targets must first be documented, validated and incorporated.

Moreover, room-by-room decisions will be required. For example: Will wall-mounted, 42-inch flat liquid crystal diode (LCD) screens be adequately visible or will boom-mounted monitors at the surgical field suffice? Each ceiling-mounted boom must be detailed as to which monitors, gas outlets and other equipment must be fitted to it; the number of booms per room must also be confirmed—the surgeon, anesthesiologist and scrub nurse may each need one. Additionally, operating room space needs, system components and intermediate distribution frame closet needs must also be identified.

Moreover, PACS monitor resolution needs in megapixels must be determined by location and a host of questions must be answered, including: Where must images be displayed (e.g., physician office)? What information should be displayed at each location? What image modality exams are necessary in each OR?

Physiological monitoring, network, electrosurgery devices and other surgery aspects also require thoughtful consideration. Network, typology, wide area network (WAN) and local area network (LAN) communication routing and requirements, conduit/back boxes, points of connection (POCs) plus routing, cable types/quantity/termination requirements, sleeve and mechanical-electrical-plumbing rough-in requirements and electrical power planning typically require fine-tuning and implementation monitoring.

Time should be built into the construction project schedule for performance testing, hospital linkages and connectivity, calibration and trouble-shooting prior to occupancy. Advice associated with vendor selection and contracting is a welcome aid, in addition to physician and staff training program development, which experienced consultants can deliver. Business interruption plan development is another critical activity.

Alternative imaging

In addition to integrated technology considerations, combination surgical-imaging rooms are also being tested in surgical suites. In addition to the operating room table centered within the OR and surrounded by needed technology and professionals, imaging equipment (e.g., magnetic resonance imaging (MRI) or computed tomography (CT)) may be installed within individual ORs. Combination rooms, such as CT/ORs and MRI/angiography rooms, enable surgeons and interventional radiologists to optimize surgery results and patient procedure times, thereby increasing the likelihood of improved patient outcomes and enhanced service-line efficiencies.

In these situations, a single operating or procedure room houses the equipment; the patient is transported between the image scanner and the operating field on a single track during a single care-giving event.

Of course, nonmetal surgical instruments and nonferrous equipment must be utilized in OR/MRI combo rooms, further complicating planning, cost and operations. Moreover, most medical centers are discovering that unless the caseload justifies this arrangement (e.g., continuous patient throughput), the combo room model is cost-prohibitive. The imaging equipment simply isn’t well-utilized. It makes more sense to locate an MRI and/or CT room within the operating room suite for easy access by multiple surgery patients.

Presurgical induction

Some institutions have also introduced the European model of presurgical induction rooms and postsurgical emergence rooms into the surgical suite. With this model, it is thought that expensive operating rooms can be utilized more effectively if patients are induced and observed while emerging from anesthesia outside the OR in adjacent rooms, thereby shortening the case time required in each OR and increasing patient throughput.

This is not a bad concept, but it will add expense to each case. For instance, patients being induced anesthetically require constant supervision by anesthesiologists or clinical registered nurse anesthetists in addition to orderlies. In addition to increasing staffing costs, the induction/emergence room model also adds significantly to the costs of construction and facilities management because of the additional space needs that lead to larger suites and greater traveling distances.

As an alternative, organizations are designating several bays within the phase II preoperative area for the purposes of elective non-OR induction. This area should be configured in close proximity to the operating rooms for swift patient transport and should be equipped similarly to recovery room patient stations.

Whichever operating room theater design is chosen, full-scale, equipped and operating mock-up rooms are recommended during the architectural design period, so physicians and staff may fully understand the impacts and opportunities of technology options prior to construction.

Additionally, integrated OR technology is expensive and may require a phased implementation based on affordability and specific site requirements.

More planning tips

Beyond these considerations, other planning tips may be employed for these new-generation operating rooms. They include the following: