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PubMed2006

Maximizing operating room and recovery room capacity in an era of constrained resources.

HYPOTHESIS: Three parallel processing operating rooms (ORs) (concurrent induction and turnover) with a dedicated 3-bed mini-recovery room (mini-postanesthesia care unit [PACU]) will optimize patient throughput and main PACU workload when compared with 4 traditional ORs or 4 parallel processing ORs. DESIGN: Statistical and mathematical models projected the impact of parallel processing on case throughput and PACU use. SETTING: Academic medical center with 48 traditional ORs using serial induction and turnover and 1 experimental OR, the operating room of the future, with parallel processing. PARTICIPANTS: All surgical cases from October 2002 through March 2004 (N = 49 887). INTERVENTIONS: A statistical model projected the duration of induction, surgery, turnover, and PACU stay for cases performed in a traditional OR (n = 48 667) based on the operating room of the future (n = 1220) experience. A fluid queuing model compared each combination using specific probability density functions. MAIN OUTCOME MEASURES: Each OR configuration was evaluated for case throughput and minutes of work sent to the PACU. RESULTS: Although all cases save OR time with parallel processing, only select surgeon-case combinations translate time saved into additional cases per day (26%). Without additional PACU slots, output from 4 parallel processing ORs further stresses the PACU. Three parallel processing ORs and a mini-PACU balances incremental volume by offsetting PACU utilization in 84% of cases. CONCLUSION: In a PACU-constrained environment, 3 parallel processing ORs with a mini-PACU configuration offers increased throughput and decreased PACU workload.

Academic Medical Centers↗
PubMed1998

Successful strategies for improving operating room efficiency at academic institutions.

UNLABELLED: In this prospective study, we evaluated the etiology of operating room (OR) delays in an academic institution, examined the impact of multidisciplinary strategies to improve OR efficiency, and established OR timing benchmarks for use in future OR efficiency studies. OR times and delay etiologies were collected for 94 cases during the initial phase of the study. Timing data and delay etiologies were analyzed, and 2 wk of multidisciplinary OR efficiency awareness education was conducted for the nursing, surgical, and anesthesia staff. After the education period, timing data were collected from 1787 cases, and monthly reports listing individual case delays and timing data were sent to the Chiefs of Service. For the first case of the day, patient in room, anesthesia ready, surgical preparation start, and procedure start time were significantly earlier (P < 0.01) in the posteducation period compared with the preeducation period, and the procedure start time for the first case of the day occurred, on average, 22 min earlier than all other procedures. For all cases combined, turnover time decreased, on average, by 16 min. Unavailability of surgeons, anesthesiologists, and residents decreased significantly (P < 0.05) as causes of OR delays. Anesthesia induction times were consistently longer for the vascular and cardiothoracic services, whereas surgical preparation time was increased for the neurosurgical and orthopedic services (P < 0.05). Identification of the etiology of OR inefficiency, combined with multidisciplinary awareness training and personal accountability, can improve OR efficiency. The time savings realized are probably most cost-effective when combined with more flexible OR staffing and improved OR scheduling. IMPLICATIONS: We achieved significant improvements in operating room efficiency by analyzing operating room data on causes of delays, devising strategies for minimizing the most common delays, and subsequently measuring delay data. Personal accountability, streamlining of procedures, interdisciplinary team work, and accurate data collection were all important contributors to improved efficiency.

Academic Medical Centers↗
PubMed1992

Sister-chromatid exchanges in operating room personnel.

Sister-chromatid exchange (SCE) analysis was carried out in 67 operating room personnel (anaesthetists M.D.; anaesthesia nurses and anaesthesia unit technicians) exposed to waste anaesthetic gases such as halothane, nitrous oxide and isoflurane and in 50 healthy unexposed controls. The SCE frequencies were increased significantly in operating room personnel as compared to controls. A significant increase in SCEs was found in non-smoking operating room personnel as compared to non-smoking controls. This study supports the existence of an association between occupational exposure to mutagens and an increase in SCEs in lymphocytes.

Adult↗
PubMed2006

Radiation exposure to the patient and operating room personnel during percutaneous nephrolithotomy.

INTRODUCTION: The increased use of fluoroscopy during percutaneous nephrolithotomy (PCNL) places the urologist and operating room personnel at an occupational risk for measurable radiation exposure. We evaluated the degree of radiation exposure received by the patient and operating room personnel at our endourology facility during PCNL. PATIENTS AND METHOD: The incident radiation dose to the patient and the urologist during 50 consecutive PCNL procedures was monitored using lithium fluoride thermo-luminescent dosimeter chips (TLD chips). A hand held radiation survey meter was used to measure the radiation in air at different positions occupied by various operating room personnel. The approximate distances of the various personnel from the X-ray tube were also measured. RESULTS: PCNL was performed upon 35 males and 15 females. The average time for the procedure was 75 minutes (range: 30-150 min). The mean fluoroscopy screening time during the procedure was 6.04 min (range 1.8-12.16 min) with a mean fluoroscopy tube potential of 68 kVp and a mean tube current of 2.76 mA. The mean radiation exposure dose to the patient was 0.56 mSv (SD +/- 0.35), while the mean incident radiation exposure to the finger of the urologist was 0.28 mSv (SD +/- 0.13). CONCLUSION: The various operating room personnel are within safe radiation dose limits during PCNL. Efficient fluoroscopy further reduces the radiation scatter. All occupational personnel should 'achieve as low as reasonably achievable' dose by adhering to good practices.

Adolescent↗
PubMed1996

[Exposure of operating room personnel to anesthetic gases during ENT interventions].

During ENT surgical procedures under general anesthesia contamination of the operating room air through waste anesthetic gases seems unavoidable. A resulting chronic low-level exposure to anesthetic gases in subanesthetic concentrations (m1/m3 = ppm) may cause various negative health effects. The aim of this study was to quantify possible side effects on operating room personnel. By using a highly sensitive, direct reading instrument for determining contamination leakage from a patient's mouth and resulting concentrations in the breathing zone of the surgeon and anesthetist, levels of isoflurane and nitrous oxide were measured at 2-min intervals during 20 ENT surgical procedures performed under usual workplace conditions. Despite high concentrations of anesthetic at the mouth of each patient, personnel-related mean values remained under recommended threshold values (TLV) of 10 ppm isoflurane. A TLV of 100 ppm nitrous oxide was exceeded in 20% of the operations. Furthermore, a safe TLV for pregnant staff was 25 ppm nitrous oxide. This value was exceeded during nearly all operations (93%) for the group "surgeon". High leakages at the patient's mouth led to an undesirably high contamination of operating room personnel by nitrous oxide. Although threshold values were mostly not exceeded in available working conditions (i.e., adequate air conditioning and intubation cuff pressure control), present health and safety regulations concerning pregnant women showed that the values of nitrous oxide were still too high to allow such women to work safely in operating rooms during surgery. However, exposure to isoflurane was too slight to classify.

Adult↗
PubMed1997

[A study of waste anesthetic gases monitoring and working environmental controls in hospital operating rooms].

There are hazardous factors threatening health care workers, and many hazardous chemical substances have been reported in operating rooms, central supply facilities, laboratories and so on. In Japan, little attention has been paid to exposure to these chemicals and to working environmental controls. Waste anesthetic gases are chemicals concerned, and we conducted environmental monitoring continuously and measured exposure to nitrous oxide, isoflurane and sevoflurane in operating rooms, and examined working environmental controls. The average environmental concentrations of nitrous oxide were about 400 ppm in anesthetists' working areas, and about 180 ppm in surgeons' and instrument nurses' working areas under unscavenged conditions. Under scavenged conditions, environmental concentrations were 70-190 ppm in anesthetists' zones, and 70-90 ppm in surgeons' and instrument nurses' zones. Even under scavenged conditions, operating room personnel are presumed to be exposed to high concentrations of nitrous oxide above ACGIH's TLV and NIOSH's REL. The level of exposure of isoflurane and sevoflurane was 2-4 ppm. Managing general ventilation system and airflow direction, working area under scavenged system, environmental concentration levels of nitrous oxide could be reduced to 20-30 ppm. In order to control occupational exposure to anesthetic gases, it is not sufficient to merely adapt scavenging systems in operating rooms. Working environmental control and occupational hygiene management should be required.

Air Pollutants, Occupational↗
PubMed2003

Telemedicine for the operating room of the future.

Telemedicine is becoming a subset of information science and should benefit tremendously from the geometric growth of information architecture in hospitals. The use of telemedicine to break the isolation of the operating room is a highly achievable goal. An open operating room has information on demand for the personnel, fluid communication among operating room personnel, and broad interaction with the learner community and consultants. In an operating room with significant data capture, the patient is brought into the process not only as a real person, but also as a huge data set that acquires all the events of the surgery. The data include the visual, electrical, and mechanical events that define the surgical procedure. As part of a dynamic electronic medical record, they are available to those who are present and those who are asked to help from even a great distance away with real-time advice. The data are also available to those who seek to understand what happened to the patient afterwards for the purpose of root cause analysis, near miss analysis, instruction, or more accurate medical records.

Humans↗
PubMedDate not supplied

Operating room management: what goes wrong and how to fix it.

Operating rooms are probably the most difficult of all hospital areas to manage. This article describes a number of common management problems in operating rooms and identifies four broad management areas that must be adequately addressed to ensure an effectively run O.R. It also suggests possible approaches for dealing with the four areas.

Efficiency↗
PubMed1999

Causes of nitrous oxide contamination in operating rooms.

BACKGROUND: To reduce the ambient concentration of waste anesthetic agents, exhaust gas scavenging systems are standard in almost all operating rooms. The incidence of contamination and the factors that may increase the concentrations of ambient anesthetic gases have not been evaluated fully during routine circumstances, however. METHODS: Concentrations of nitrous oxide (N2O) in ambient air were monitored automatically in 10 operating rooms in Kagoshima University Hospital from January to March 1997. Ambient air was sampled automatically from each operating room, and the concentrations of N2O were analyzed every 22 min by an infrared spectrophotometer. The output of the N2O analyzer was integrated electronically regarding time, and data were displayed on a monitor in the administrative office for anesthesia supervisors. A concentration of N2O > 50 parts per million was regarded as abnormally high and was displayed with an alarm signal. The cause of the high concentration of N2O was then sought. RESULTS: During the 3-month investigation, N2O was used in 402 cases. Abnormally high concentrations of N2O were detected at some time during 104 (25.9%) of those cases. The causes were mask ventilation (42 cases, 40.4% of detected cases), unconnected scavenging systems (20 cases, 19.2%), leak around uncuffed pediatric endotracheal tube (13 cases, 12.5%), equipment leakage (12 cases, 11.5%), and others (17 cases, 16.4%). CONCLUSIONS: N2O contamination was common during routine circumstances in our operating rooms. An unconnected scavenging system led to the highest concentrations of N2O recorded. Proper use of scavenging systems is necessary if contamination by anesthetic gas is to be limited.

Air Pollutants, Occupational↗
PubMed1993

Assessing the risk of blood exposure in the operating room.

During the past 3 years, a great deal of new information has been published on the risk of blood exposure and injury in the operating room. In addition, detailed information about the effectiveness of barrier materials, operating room garments, and gloves has also become available. On the basis of this information, it has become possible to recommend strategies, barrier materials, and garments that should reduce the risk of contracting a blood-borne infection in the operating room. Further attempts to decrease the risk of blood exposure and injury require thorough evaluation of all risk-reduction strategies and careful selection of protective apparel and barriers on the basis of well-designed studies performed in the operating room environment.

Blood-Borne Pathogens↗
PubMed2003

Recommendations for postexposure prophylaxis of operating room personnel and patients exposed to bloodborne diseases.

The purpose of this collective review is to discuss management of operating room personnel who have had occupational exposure to blood and other body fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and human T-cell lymphotropic virus type I (HTLV-I). HBV postexposure prophylaxis includes starting hepatitis B vaccine series in any susceptible unvaccinated operating room personnel who sustain an exposure to blood or body fluid during surgery. Postexposure prophylaxis with hepatitis B immune globulin (HBIG) is an important consideration after determining the hepatitis B antigen status of the patient. Ideally, all operating room personnel should be vaccinated with hepatitis B vaccine before they pursue their career in surgery. Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) should not be used for postexposure prophylaxis of operating room personnel exposed to patients with HCV; rather, follow-up HCV testing should be initiated to determine if infection develops. Postexposure prophylaxis for HIV involves a basic four-week regimen of two drugs (zidovudine and lamivudine; lamivudine and stavudine; or didanosine and stavudine) for most exposures. An expanded regimen that includes a third drug must be considered for HIV exposures that pose an increased risk for transmission. When developing a postexposure prophylaxis regimen, it is helpful to contact the National Clinicians' Postexposure Prophylaxis Hotline (1-888-448-4911).

Blood-Borne Pathogens↗
PubMedDate not supplied

[Environmental and biological control in a population exposed to isoflurane in the operating room].

OBJECTIVE: To measure the level of occupational exposure to isoflurane in the operating room, and to determine the relation between isoflurane concentration in atmospheric and exhaled air. PATIENTS AND METHODS: One hundred seventy-eight samples were obtained from 60 male and female subjects who work in the operating room of our hospital. To monitor workplace exposure we used passive diffusion samplers. Biological monitoring (isoflurane in exhaled air) was accomplished with standard adsorption tubes to collect exhaled air samples. Gases were thermically separated and analyzed by gas chromatography. RESULTS: Atmospheric isoflurane concentrations ranged between 1.14 and 157.23 mg/m3 (geometric mean 16.23 mg/m3). Exhaled isoflurane concentrations ranged from 0.15 to 26.09 mg/m3 (geometric mean 2.85 mg/m3). Atmospheric and exhaled isoflurane concentrations were strongly related (r = 0.82; p < 0.0001). Linearity was determined by the following equation: log of exhaled isoflurane concentration = -0.69 + 0.95 log of atmospheric isoflurane concentration. CONCLUSIONS: The concentrations of isoflurane in atmospheric and exhaled air found in our study exceed the maximum levels for halogenated gases recommended by the National Institute for Occupational Safety and Health, although they do not exceed the levels stipulated by Swiss authorities. In order to adequately assess operating room antipollution measures, atmospheric and biologic monitoring of isoflurane and other inhaled anesthetic gas concentrations is necessary.

Adult↗
PubMed2003

Scavenging in the operating room.

PURPOSE OF REVIEW: The use of inhalation general anesthetic gases has led to contamination of the operating room environment. Chronic exposure to these agents has been associated with a number of adverse health effects. Controversy remains with regard to these health effects, and whether further reducing the level of operating room contamination should be a high priority. Current methods are outlined by which anesthetic waste gases contaminate and are removed from the operating room. These controversies are explored in the light of recent research. RECENT FINDINGS: Recent work employing genotoxicity studies suggests that National Institute for Occupational Safety and Health recommendations may be appropriate to protect healthcare workers. New developments over the past year include the suggestion of employing devices such as the Anesthetic Scavenging Hood (ASH), SiBI tube connector and mask stopper. The use of these devices, in concert with efficient anesthesia machine scavenging, may further reduce operating room contamination. SUMMARY: The National Institute for Occupational Safety and Health calls for lower levels of exposure when compared with those found in European standards. It may be appropriate for European guidelines to be re-addressed; however, more conclusive studies need to be undertaken to identify the precise effects of these agents at a given exposure level. It may also be appropriate to expand the arena of monitoring and scavenging to all areas where inhalation anesthetics are used or emitted, such as in the post-anesthesia care unit and research laboratory settings.

Journal Article↗
PubMed2005

Construction of a high-tech operating room for image-guided surgery using VR.

This project aimed to construct an operating room to implement high dimensional (3D, 4D) medical imaging and medical virtual reality techniques that would enable clinical tests for new surgical procedures. We designed and constructed such an operating room at Dai-san Hospital, the Jikei Univ. School of Medicine, Tokyo, Japan. The room was equipped with various facilities for image-guided, robot and tele- surgery. In this report, we describe an outline of our "high-tech operating room" and future plans.

Facility Design and Construction↗
PubMed2002

Delivering images to the operating room: a web-based solution.

As radiology departments become filmless, they are discovering that some areas are particularly difficult to deliver images. Many departments have found that the operating room is one such area. There are space constraints and difficulty in manipulating the images by a sterile surgeon. This report describes one method to overcome this obstacle. The author's institution has been using picture archiving and communication system (PACS) for approximately 3 years, and it has been a filmless department for 1 year. The PACS transfers images to a webserver for distribution throughout the hospital. It is accessed by Internet Explorer without any additional software. The authors recently started a pilot program in which they installed dual panel flat screen monitors in 6 operating rooms. The computers are connected to the hospital backbone by ethernet. Graphic cards installed in the computers allow the use of dual monitors. Because the surgeons were experienced in viewing cases on the enterprise web system, they had little difficulty in adapting to the operating room (OR) system. Initial reception of the system is positive. The use of the web system was found to be superior by the surgeons because of the flexibility and manipulation of the images compared with film. Images can be magnified to facilitate viewing from across the room. The ultimate goal of electronic radiology is to replace hardcopy film in all aspects. One area that PACS has difficulty in accomplishing this goal is in the operating room. Most institutions have continued to print film for the OR. The authors have initiated a project that may allow web viewing in the OR. Because of limited space in the OR, an additional computer was undesirable. The CPU tower, keyboard, and mouse were mounted on a frame on the wall. The images were displayed on 2 flat screen monitors, which simulated the viewboxes traditionally used by the surgeons. Interviews with the surgeons have found both positive and negative aspects of the system. Overall impression is good, but the timeliness of the intraoperative films needs to be improved. The author's pilot project of installing a web-based display system in the operating room still is being evaluated. Their initial results have been positive, and if there are no major problems that arise the project will be expanded. These results show that it is possible to provide image delivery to the OR over the intranet that is acceptable to the surgeons.

Computer Systems↗
PubMed1995

Exposure characteristics and cutaneous problems in operating room staff.

Health care personnel have exposure to a variety of cutaneous irritants and allergens and a high prevalence of cutaneous problems. The objectives of this exploratory study were to characterize the exposures and determine the prevalence of cutaneous symptoms and findings in operating room personnel, and to examine relationships between exposure characteristics and cutaneous outcomes. A questionnaire and standardized hand examination were used to assess the exposures and cutaneous status of operating room personnel. 184 operating room staff (90% of the eligible population) were assessed. Current skin problems were reported by 26%. Hand examination revealed that 9% had findings consistent with eczema and 10% changes of moderate dryness. A variety of preventive practices were being used by those with symptoms or findings. Cutaneous problems are common in operating room personnel. The use of preventive strategies (changing the type of gloves worn or the type of soap used for scrubbing, the use of glove liners and emollients) varied between different groups. These workers might benefit from more education regarding cutaneous hazards, preventive stategies and the importance of appropriate investigation of these problems.

Adult↗
PubMed2006

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

BACKGROUND: Teamwork is an important component of patient safety. In fact, communication errors are the most common cause of sentinel events and wrong-site operations in the US. Although efforts to improve patient safety through improving teamwork are growing, there is no validated tool to scientifically measure teamwork in the surgical setting. STUDY DESIGN: Operating room personnel in 60 hospitals were surveyed using the Safety Attitudes Questionnaire. Surgeons, anesthesiologists, certified registered nurse anesthetists, and operating room nurses rated their own peers and each other using a 5-point Likert scale (1 = very low, 5 = very high). RESULTS: Overall response rate was 77.1% (2,135 of 2,769). Ratings of teamwork differed substantially by operating room caregiver type, with the greatest differences in ratings shown by physicians: surgeons (F[4, 2058] = 41.73, p < 0.001), and anesthesiologists (F[4, 1990] = 53.15, p < 0.001). The percent of operating room caregivers rating the quality of collaboration and communication as "high" or "very high" was different by caregiver role and whether they were rating a peer or another type of caregiver: surgeons rated other surgeons "high" or "very high" 85% of the time, and nurses rated their collaboration with surgeons "high" or "very high" only 48% of the time. CONCLUSIONS: Considerable discrepancies in perceptions of teamwork exist in the operating room, with physicians rating the teamwork of others as good, but at the same time, nurses perceive teamwork as mediocre. Given the importance of communication and collaboration in patient safety, health care organizations should measure teamwork using a scientifically valid method. The Safety Attitudes Questionnaire can be used to measure teamwork, identify disconnects between or within disciplines, and evaluate interventions aimed at improving patient safety.

Analysis of Variance↗
PubMed1992

Implementation and financial analysis of an operating room satellite pharmacy.

The rationale and implementation of an operating room (OR) pharmacy satellite is described, and the first-year savings are evaluated. The OR in an 874-bed university teaching hospital, consisting of 17 rooms for inpatients, 6 rooms for ambulatory patients, and a postanesthesia care unit, lacked comprehensive pharmacy services; this resulted in poor drug-use control and accountability, varied controlled-substance audit trails, and suboptimal patient services. A task force examined other institutions' OR pharmacy satellites and chose to implement a satellite that provides all pharmaceuticals and i.v. admixtures by using case trays for each surgical patient. One year after implementation of the satellite, inventory in the operating-room areas was reduced by 56.5%, annual pharmaceutical costs by 2.6% (adjusted for inflation), and average cost per patient by 8.0% (adjusted for inflation). First-year cost reductions and revenue identification exceeded operating costs for materials, supplies, and labor by $271,755. Implementation of an OR pharmacy satellite reduced the net cost of providing pharmaceutical services to the OR.

Ambulatory Care↗