OR design has lagged behind and OR environmental features are often latent conditions impacting patient

safety in the OR

OR is a highly complex risk prone area

5 out of every 1000 ambulatory surgical procedures results in a post surgical acute care visit for surgical site

infections (SSI)

Distractions and errors contribute to medical errors leading to patient

harm

Disruptive developments in medical technology and medical practice are impacting how surgeries are being performed today

PROJECT 3

PROJECT 2

UNMASKING OF ANESTHESIA-RELATED ALARMS AND COMMUNICATIONS

TRAFFIC FLOW AND DOOR OPENINGS IN THE OR

INTEGRATED OR SUITE DESIGN

PROJECT 1

This work extends what is known about alarms, interruptions, and distractions in the operating room by examining them from a systems perspective.

This project will focus on understanding factors impacting traffic flow in the OR suite.

This project aims to develop an overall framework and methodology for designing an ergonomic and human-centered operating room that will improve patient and staff safety and outcomes in the OR.

USING A SYSTEMS APPROACH TO DESIGNING A SAFER AND MORE ERGONOMIC OPERATING ROOM

BACKGROUNDThe incidence of adverse events such as surgical site infections and surgical errors are a huge problem in the operating room (OR) due to the highly vulnerable state of the patient and the complex interactions required between providers of different disciplines and a range of equipment, technology and the physical space where care is provided. Clemson University and the Medical University of South Carolina have been awarded a 4-year grant from the Agency for Healthcare Research and Quality to develop a learning lab focused on patient safety in the OR. This learning lab, titled ‘Realizing Improved Patient Care through Human Centered Design in the OR (RIPCHD.OR)’ is a multidisciplinary initiative involving architects, human factors experts, industrial engineers, nurses and anesthesiologists. The goal of this paper was to develop a systems approach for observing and analyzing the OR work system and to describe how this systems approach was used to analyze operating rooms environments, finally leading to the development of design guidelines for designing operating rooms.

An in-depth literature review was conducted to develop and refine a systems approach for studying the OR work system. The OR work system (people, tasks, technology, built environment, processes) was then studied through analysis of videotapes of 35 surgeries in three different departments (general, orthopedic and pediatric). Additionally, three case studies were conducted to understand alternate approaches and best practice in OR system design. Finally, design guidelines were created to help translate research findings into the design of a prototype OR.

METHODOLOGY

Findings: Using a systems approach yielded rich insights about the tasks and activities of key stakeholders, the locations of people, objects and equipment, space needs during different phases of surgery and also the inter-dependencies and relationships between key players in the OR. The operating room needs to be flexible and adaptable to meet current and future needs. Key areas of consideration include the amount and location of storage to minimize door openings in the OR, relative location of zones in the OR to optimize flows and the need to promote situational awareness among team members for optimal communication.

FINDINGS

A systems framework provides a rigorous multi-dimensional approach for researching and designing a complex environment such as an operating room. This is a more holistic approach to designing healthcare facilities that allows for a deep understanding of the complex interplay between people, tasks, processes, technology and the built environment.

IMPLICATIONS

Study framework for RIPCHD.OR learning lab is based on the SEIPS 2.0 framework by Holden and colleagues

WORK SYSTEM PROCESSES OUTCOMES

Professional Work

Patient Work

Collaborative Care Team Patient Work

Organizational

Care Team

Patient

Organization Technology and Tools

Tasks Environment

Person

Ext

erna

l Env

ironm

ent

ADAPTATION(Holden et. al, 2013 )

PARTNERS AND PROCESS

MEDICAL UNIVERSTITY OF SOUTH CAROLINA

CLEMSON

ARCHITECTURE FIRMS

RIPCHD.OR

Research

2 Design projects Mock-up

PROJECT FRAMEWORK

DESIGN CONCEPTS

A.Z.

S.Z.

S.Z.

A.Z.

S.Z.

S.Z.

GB&

AC

GB&

AC

GB&

AC

GB &

AC

C

E

D

21 3

A

B

206 SFINDUCTION

206 SFALCOVE

206 SFALCOVE

579 SFO.R.

580 SFO.R.

206 SFINDUCTION

14' -

3"14

' - 3"

14' -

3 1/

2"14

' - 3

1/2"

25' - 2" 15' - 6 1/2"

13' -

9"

13' -

9"

26' -

0"

13' -

9"

6' - 0"

13' - 9"

22' - 0" 15' - 0"

Type of surgery

Number of surgeries

Range of length of surgery

Range for total number of

Room size

PEDIATRIC ORTHOPEDIC GENERAL

9 1 7

30-77 min 154 min 54-181 min

7-11 8 7-10

Main OR 11: 390 SQ FT Main OR 14: 542 SQ FT Art OR 5: 690 SQ FT

PROJECTS

VIDEO CAPTURE

DESIGN MOCK UPS

cameras mounted on poles

microphones

base machine & computer screen

connections - camera to computer

field of view

cameras mounted on poles

microphones

base machine & computer screen

connections - camera to computer

field of view

GESTURE FUNCTIONS MAPPING

1 | PATIENT PREPARATION | PATIENT ENTRY

A.Z. S.Z.

C.Z.S.Z.

GB&A C

1

A B C

2

13' - 0"14' - 3"

12' -

3 1/

2"12

' - 3

1/2"

22' - 0"

26' - 0"

Whatarethedifferenttypesofflowdisturbancesandfrequencythatoccurduringobservedsurgeries?

21

40

24

4449

75 77

115

23 26

5041

60 60

104

90

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 04 7 713

511

28

43

0 2 27

136 3

91217 14

33

16

55

2938

5 9 1016

2819 17 13

1 2 0 2 1 0 3 0 0 0 0 4 1 5 3 00

20

40

60

80

100

120

140

53.62 71.60 77.02 107.87 143.30 154.30 181.13 154.38 30.05 33.25 33.53 40.32 70.10 58.58 64.22 77.18

Art 5 Main 14 Main 11 Main 5

General Orthopedic Pediatric

Layout Equipment Failure Interruptions Environmental Hazard Usability

Duration (minutes)

OR Location

Surgery Type

Num

ber o

f dist

urba

nces

Circulating nurse makes trips to all different parts of the OR, though she/he spends the maximum time at the circulating nurse desk and interacting with the scrub nurse

Proportion of disturbances as a proportion of surgery time very high in the smaller OR in main

2

6

3

7

4

1

5

Anesthesia storage is primarily used by anesthesia personnel while general storage is accessed by all team members, though primarily the circulating nurse

The number of door openings and duration are proportionate to the length of the surgery. However, this does not seem to hold true for some of the pediatric surgeries observed.Some surgeries had a large number of clean core door openings

Layout related disturbances were the most frequently observed SFDs in all observed surgeries

High number of SFDs observed in the shorter pediatric surgeries. Also duration of door openings higher in those surgeries. Link with room size and design

Literature & Review

Data Collection

Literature Review

Bacterial LoadSampling

Coder Training

Behavior Observations of the OR System

Problem Analysis and Coding Protocol

Data Analysis

Development of Anesthesia Workstation Simulator

SEPT

- D

EC ‘1

5

DEC

‘15

FEB

- M

AY

‘16

JAN

- A

PR ‘1

6

MA

R ‘1

6

APR ‘16 ONWARDS

JAN

- A

PR ‘1

6

JULY

‘16

AU

G ‘1

6

Case Studies

AU

G ‘1

6

Focus Groups

IRB Approval

Operating Room Mock-Up

JUNE ‘16 ONWARDS

APR

‘16

Advisory Committee

Coding & DataAnalysis

MA

R -

MA

Y ’1

6

Discrete Event Simulation Model

SEP

‘16

RIPCHD.OR Workshop & Design Charrette

OC

T ‘1

6

Tape on the Floor Mock up

NO

V ‘1

6

Cardboard Mock up

DEC

‘16

High FidelityMockup

JAN

‘17

Design Refinement

AnjaliJoseph,PhD,EDAC|ClemsonUniversityKennethCatchpole,MD|MedicalUniversityofSouthCarolina

EuropeanHealthcareDesignConference|June12th-13th,2017Authors:

DESIGNDISCOVERY

DavidAllison,FAIA,FACHA|ClemsonUniversity

1/8” scale OR Model High fidelity mock-up OR concept rendering