Design

When building new ORs many factors have to be considered, but there are several guiding principles that determine design:

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  Location

  
  
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  Requirements of asepsis

  
  
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  Patients and staff safety

  
  
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  Efficient use of resources

Location

The OR should ideally be positioned in a terminal location to minimize unnecessary passing traffic by visitors, patients, and staff. It should, however, be accessible to services such as the emergency department, intensive care, and other specialized departments. Good access to surgical wards is also necessary to facilitate the transport of patients to and from the OR. Long distances between wards and OR can result in long delays fetching patients, and long transfer times along corridors and in elevators with postoperative patients increases the risk of postanesthetic complications while in transit. Proximity to sterile services departments should also be considered. However, some hospitals now use off-site sterilization facilities.

It may be necessary to have ORs in more than one location within a hospital to facilitate all the above considerations, for example, having trauma ORs located next to the emergency department. This gives rise to a debate on efficiency and cost-effectiveness; some would argue that having all ORs in one location allows more efficient use of resources. A central storage area can serve all ORs within one department, while duplication of supplies is needed if ORs are located in different areas of the hospital. Rotation of staff can also be more difficult if ORs are not sited together.

The location within the building must also be decided. Historically, the top floor of a building was not considered an ideal location as it has the highest deposit of dust particles as dust transported in the atmosphere tends to rise with hot air. With the advent of modern ventilation systems this is less of a problem in modern buildings.

Whether designing a single OR or an OR suite, the principles remain the same. ORs must comply with the requirements of asepsis, they must create a safe environment for patients and staff, and use of resources must be efficient.

Asepsis

The requirement for asepsis is at the heart of OR design, and dominates all other considerations. The underlying principle for asepsis is the separation of clean and contaminated areas. There are various designs that achieve this but all work on the basis of segregating “clean” and “dirty” areas within the department. The risk of cross-contamination between these areas is minimized by good design.

Operating suites are divided into “zones” which are designated by the activities carried out in them.

The outer or reception area is located at the entrance to the OR department. Staff and visitors can access this area in outdoor clothes, supplies can be delivered, and patients enter and leave the department at this point.

Access to changing areas should be from this reception area, with a separate exit into the clean area once staff and visitors have changed into OR clothing (Fig 1.3-1).

Individual department layout will vary greatly between hospitals; however, in all cases ORs themselves and instrument storage areas should be the cleanest areas. All unnecessary traffic must be avoided, and ventilation systems (described below) designed accordingly.

Supplies and equipment should be stored adjacent to the OR in which they will be required. Some equipment, such as microscopes, attachments for trauma operating tables, and monitor stack systems for endoscopic procedures, are bulky and take up space and should be stored outside the OR.

OR equipment is delicate and expensive. Inadequate storage facilities lead to damage which is not only costly but can also delay surgery while it is being repaired.

There also needs to be a “contaminated” area within the department. This area must be clearly and physically separated from the surgical area. This is where decontamination and reprocessing of instruments is performed and contaminated waste from the OR is disposed.

Also located within the department will be a postanesthetic care unit. This should be accessible to all ORs within the department. Entrance for patients will be from the clean area, and a separate exit should be available to return patients to the wards.

Safe environment

The surgical team is responsible for delivering high-standard care to patients; to achieve this, optimal conditions must exist. The surgical environment must be safe for both patients and staff, hence the mental and physical safety of both groups must be considered during design. Space should be used in an efficient way, and work surfaces need to be created so that physical stress due to excessive lifting is reduced.

Efficient use of resources

The way in which the OR is designed should help the team to obtain best results with a minimum of energy, with consideration given to minimizing both capital and running costs. Intelligent design limits the flow of people past the OR and reduces unnecessary movement of staff and equipment within it.

OR size

The dimensions of the OR must be decided (Fig 1.3-2). This depends to some extent on the type of surgery to be performed within it. For example, an OR intended for use in trauma or orthopaedic procedures need to be larger than one for minor general surgical procedures. This is due to the amount of equipment and instrumentation required; trauma traction tables, image intensifiers, and video stacks for arthroscopy. Joint replacement and trauma surgery often require large numbers of instrument sets, which means the “sterile field” occupied by the scrub practitioner, surgical team, and instrument trolleys is a larger area than for a simple “one-set” procedure. Room is needed for the “circulating” staff to perform their duties without compromising the sterile field. Consider whether a square or rectangular OR is most suited for its required purpose.

Floors

OR flooring should be:

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  Smooth

  
  
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  Hard

  
  
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  Seamless

  
  
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  Nonslip

  
  
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  Antistatic

  
  
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  Nonporous and stain proof

  
  
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  Curved at the wall-to-floor junction

All the above comply with safety and asepsis. It is essential that the material used for flooring is easily cleaned and maintained. Flooring should be hard enough to withstand repeated use from heavy equipment. Smooth flooring is less likely to hold dirt and is more easily cleaned, although for health and safety reasons it must have a nonslip surface. A curved junction between the wall and floor and the extension of the flooring material up the wall also facilitates cleaning.

Walls

Walls and ceilings should be:

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  Nonporous surfaces

  
  
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  Free of joints and crevices

  
  
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  Nonreflective

  
  
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  Fire resistant

  
  
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  Easy to clean

  
  
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  Consideration given to color

  
  
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  Rounded wall-to-ceiling junction

It is important that walls are free from joints and crevices, as these can harbor dirt and be difficult to clean leading to an increased infection risk. Wall covering is important; while painted plaster walls give a smooth, easy-to-clean surface they are easily damaged, revealing bare plaster which is porous and impossible to clean effectively, making it the perfect breeding ground for bacteria and spores. Laminated wall cladding up to a height of 1–1.5 m prevents such damage and is nonporous and easy to clean.

If walls are painted, nongloss paint should be used to reduce glare. Choice of color is also important. Some colors, combined with artificial lighting, can alter perception of patients’ skin color which can be a problem, especially in anesthetic rooms and postanesthetic care areas. The choice of light bulbs and fitting can have a similar effect.