HCS 529 Week 5 Types of Operating Rooms, Patient Safety and Implementation Example

Standard, Integrated or Hybrid, With or Without Laminar Airflow: Choosing Operating Room Types for a Joint Replacement Surgery Center and Testing Them Before the First Patient

[Student Name]

University of Phoenix

HCS/529: Contemporary Health Care Facility Design

Week 5 Assignment

[Instructor Name]

[Date]

The health system, rooms, costs and simulations are composites written for a model paper; research findings and recommendations come from the sources listed.

Three months into design of the composite health system's surgery center, a ventilation vendor presented a proposal to install laminar airflow canopies over each of the four operating tables at about $180,000 per room, arguing that joint replacement demands it. The perioperative nurse manager asked the planning team a broader question: what kind of operating rooms does the center actually need? This paper compares operating room types, weighs laminar airflow against the evidence and describes how the rooms will be implemented and evaluated.

The Procedures Drive the Rooms

The center will perform knee and hip replacements, shoulder and knee arthroscopy, hand surgery, cataract and other eye surgery, colonoscopy and upper endoscopy and spinal injections. Joint replacements need the most space, equipment and infection control; eye and hand cases need little space but fast turnover; endoscopy and injections do not need an operating room at all.

Four Types of Rooms

Standard operating rooms provide filtered, positive-pressure air, surgical lights, anesthesia gases and space for common procedures.

Integrated operating rooms add ceiling-mounted booms, built-in video displays and centralized control of cameras, lights and recording, reducing cables on the floor and time spent setting up.

Hybrid operating rooms add fixed advanced imaging, such as an angiography system, for vascular, cardiac and complex spine surgery, at a cost of several million dollars and with much larger rooms.

Procedure rooms are designed for less invasive procedures, usually with sedation rather than general anesthesia, such as endoscopy and injections, and have simpler ventilation and space requirements.

The Choice of Room Types

None of the center's procedures needs fixed advanced imaging, so hybrid rooms were ruled out; portable imaging will serve orthopedic cases. Integrated rooms cost about $210,000 more per room than standard rooms but reduce trip hazards from cables, support arthroscopy and endoscopic video and let teams record and teach. The team chose four integrated operating rooms and two procedure rooms.

The Laminar Airflow Question

Laminar airflow systems deliver filtered air in a unidirectional flow over the surgical field, in theory sweeping particles away from the wound. The vendor cited laboratory studies showing fewer airborne particles. The team looked for evidence on infections. A German study using national surveillance data from 63 surgical departments and 99,230 operations found that, after adjustment for patient and hospital factors, the odds of severe surgical site infection after hip replacement were higher in rooms with laminar airflow than in rooms with conventional filtered ventilation, with an odds ratio of 1.63, and no protective effect for knee replacement or other procedures (Brandt et al., 2008). Global recommendations published in 2016 advised that laminar airflow not be used to reduce infection risk in total joint replacement, a conditional recommendation based on low-quality evidence (Allegranzi et al., 2016).

Why Laminar Airflow May Not Help

Several explanations have been suggested: staff and lights can disrupt the airflow, the canopy may cool patients and the surgical field and the benefit of fewer particles may be outweighed by other factors. Traffic appears to matter more. A study of 48 procedures found that door openings and surgery length were linked to higher contamination outside the laminar zone, and that inside it, the number of staff mattered (Perez et al., 2018). Fewer people and fewer door openings may protect a wound more than an expensive canopy over the table.

The Decision

The center will use conventional high-efficiency filtered ventilation with positive pressure and high air change rates in each operating room, as the building design already specifies, and will invest in traffic control instead of canopies: supply pass-throughs, a limit on staff in the room during joint replacement, closed doors during cases and door-opening counts. The decision saves $720,000, part of which will fund a second instrument set for each joint system to prevent delays and flash sterilization.

Room Size and Layout

The integrated operating rooms are planned at about 600 square feet each, enough for an orthopedic table, two instrument tables, portable imaging, a navigation or robotic system if the surgeons adopt one later and a team of six without crowding. Booms carry anesthesia gases, power and video on the anesthesia side and surgical power and displays on the other, leaving the floor clear around the table. Each room has two doors: one to the sterile corridor for patients and staff and one to the clean core for supplies, so the patient door can stay closed. The procedure rooms, at about 350 square feet, are sized for a stretcher, an endoscopy tower and a team of four.

Comparing Costs

For four rooms, the team compared three packages. Standard rooms with conventional ventilation formed the baseline. Integrated rooms added about $840,000. Integrated rooms with laminar airflow canopies would have added a further $720,000 plus higher energy costs, since canopies move large volumes of conditioned air. A hybrid room, had one been needed, would have added several million dollars and about 400 square feet. The chosen package, integrated rooms without canopies, buys the features the center's procedures use every day.

Implementation Step One: Commissioning

Before any patient is treated, an independent commissioning agent will test ventilation, pressure relationships, filtration, temperature and humidity in every room and sterile processing, verify emergency power transfer times and certify medical gas systems. Results will be documented for the state inspection and accreditation survey.

Implementation Step Two: Simulated Cases

Over two weeks, surgical teams will run 12 simulated cases in the finished rooms, including a knee replacement, a cataract procedure, a colonoscopy and emergencies such as a malignant hyperthermia crisis and a patient transfer to the hospital. Observers will record problems such as a missing outlet, a door that opens into a stretcher's path or supplies stored out of reach. Simulation in the actual space finds design problems that drawings miss, and several will be corrected before opening.

Implementation Step Three: Safety Processes

The center will use a surgical safety checklist at sign-in, time-out and sign-out for every case. In an eight-hospital international study, introducing a checklist was followed by fewer deaths, 0.8% of patients against 1.5% before, and complications dropped to 7.0% of patients from a starting level of 11.0% (Haynes et al., 2009). Staff will also be trained in the traffic control rules and the transfer protocol.

Evaluation Measures

The center will track surgical site infections at 30 days and, for joint replacements, 90 days; door openings in a sample of cases; turnover time; case start delays; checklist completion; near misses and adverse events; unplanned transfers; and patient and staff satisfaction with the rooms. Results will be reviewed monthly for the first year and compared with the system's hospital outpatient department.

Conclusion

Matching rooms to procedures led the center to four integrated operating rooms and two procedure rooms, with no hybrid room. Evidence on laminar airflow, including a large study that found no benefit and global guidance against its use in arthroplasty, led the team to invest in traffic control and instrument sets instead. Commissioning, simulated cases, a safety checklist and a set of measures will test whether the rooms deliver safe care from the first patient.

References

Allegranzi, B., Zayed, B., Bischoff, P., Kubilay, N. Z., de Jonge, S., de Vries, F., Gomes, S. M., Gans, S., Wallert, E. D., Wu, X., Abbas, M., Boermeester, M. A., Dellinger, E. P., Egger, M., Gastmeier, P., Guirao, X., Ren, J., Pittet, D., & Solomkin, J. S. (2016). New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: An evidence-based global perspective. The Lancet Infectious Diseases, 16(12), e288-e303. https://doi.org/10.1016/S1473-3099(16)30402-9

Brandt, C., Hott, U., Sohr, D., Daschner, F., Gastmeier, P., & Rüden, H. (2008). Operating room ventilation with laminar airflow shows no protective effect on the surgical site infection rate in orthopedic and abdominal surgery. Annals of Surgery, 248(5), 695-700. https://doi.org/10.1097/SLA.0b013e31818b757d

Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A.-H. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491-499. https://doi.org/10.1056/NEJMsa0810119

Perez, P., Holloway, J., Ehrenfeld, L., Cohen, S., Cunningham, L., Miley, G. B., & Hollenbeck, B. L. (2018). Door openings in the operating room are associated with increased environmental contamination. American Journal of Infection Control, 46(8), 954-956. https://doi.org/10.1016/j.ajic.2018.03.005