Operating room design using agent-based simulation to reduce room obstructions.

This study seeks to improve the safety of clinical care provided in operating rooms (OR) by examining how characteristics of both the physical environment and the procedure affect surgical team movement and contacts. We video recorded staff movements during a set of surgical procedures. Then we divided the OR into multiple zones and analyzed the frequency and duration of movement from origin to destination through zones. This data was abstracted into a generalized, agent-based, discrete event simulation model to study how OR size and OR equipment layout affected surgical staff movement and total number of surgical team contacts during a procedure. A full factorial experiment with seven input factors - OR size, OR shape, operating table orientation, circulating nurse (CN) workstation location, team size, number of doors, and procedure type - was conducted. Results were analyzed using multiple linear regression with surgical team contacts as the dependent variable. The OR size, the CN workstation location, and team size significantly affected surgical team contacts. Also, two- and three-way interactions between staff, procedure type, table orientation, and CN workstation location significantly affected contacts. We discuss implications of these findings for OR managers and for future research about designing future ORs.

Proactive Evaluation of an Operating Room Prototype: A Simulation-Based Modeling Approach.

OBJECTIVES: There is a pressing need to improve safety and efficiency in the operating room (OR). Postsurgical adverse events, such as surgical site infections and surgical flow disruption, occur at a significant rate in industrial countries where a considerable portion of such complications result in death. The aim of the study was to identify an ideal room design that improves the flow of staff members using risk and safety performance measures. METHODS: Operating room designs were compared by using computer simulation modeling to analyze traffic flow inside an OR. The study was conducted in two phases. A historical data set was first created based on surgical flow data obtained from 23 video observations of actual surgical procedures. A detailed simulation-based model was then developed. RESULTS: As room size increases, staff members have more available space to maneuver in the room, resulting in more distance walked but far fewer undesirable contacts. An angled table orientation is preferred with the circulating nurse workstation at the foot of the OR table, as it provides more space for staff to move across the room without increasing the number of contacts. Furthermore, when the nurse workstation is near the wall, staff members experience fewer undesirable contacts. CONCLUSIONS: Simulation modeling was used to assess the impact of OR layout alternatives on three performance metrics, and the medium-sized OR prototype performs well across the metrics. Future research will consider the relative influence of several factors on traffic-based safety and efficiency performance metrics, resulting in a more predictive simulation design model.

Using a systems approach to evaluate a circulating nurse's work patterns and workflow disruptions.

The physical environment affects how work is done in operating rooms (OR). The circulating nurse (CN), in particular, requires access to and interacts with materials, equipment, and technology more than other OR team members. Naturalistic study of CN behavior is therefore valuable in assessing how OR space and physical configuration influences work patterns and disruptions. This study evaluated the CNs' work patterns and flow disruptions (FD) by analyzing 25 surgeries across three different ORs. The OR layouts were divided into transitional and functional zones, and the work of CNs was categorized into patient, equipment, material, and information tasks. The results reveal that information tasks involve less movement than other types of work, while across all ORs, CNs were more likely to be involved in layout and environmental hazard FDs when involved in patient, material, or equipment-related tasks compared to information tasks. Different CN work patterns and flow disruptions between ORs suggest a link between OR layout and a CN's work. Future studies should examine how specific layout elements influence outcomes.

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room.

BACKGROUND: Studies in operating rooms (OR) show that minor disruptions tend to group together to result in serious adverse events such as surgical errors. Understanding the characteristics of these minor flow disruptions (FD) that impact major events is important in order to proactively design safer systems OBJECTIVE: The purpose of this study is to use a systems approach to investigate the aetiology of minor and major FDs in ORs in terms of the people involved, tasks performed and OR traffic, as well as the location of FDs and other environmental characteristics of the OR that may contribute to these disruptions. METHODS: Using direct observation and classification of FDs via video recordings of 28 surgical procedures, this study modelled the impact of a range of system factors-location of minor FDs, roles of staff members involved in FDs, type of staff activities as well as OR traffic-related factors-on major FDs in the OR. RESULTS: The rate of major FDs increases as the rate of minor FDs increases, especially in the context of equipment-related FDs, and specific physical locations in the OR. Circulating nurse-related minor FDs and minor FDs that took place in the transitional zone 2, near the foot of the surgical table, were also related to an increase in the rate of major FDs. This study also found that more major and minor FDs took place in the anaesthesia zone compared with all other OR zones. Layout-related disruptions comprised more than half of all observed FDs. CONCLUSION: Room design and layout issues may create barriers to task performance, potentially contributing to the escalation of FDs in the OR.

The Influence of Traffic, Area Location, and Other Factors on Operating Room Microbial Load.

OBJECTIVE To determine how the movement of patients, equipment, materials, staff, and door openings within the operating room (OR) affect microbial loads at various locations within the OR. DESIGN Observation and sampling study. SETTING Academic health center, public hospital. METHODS We first analyzed 27 videotaped procedures to determine the areas in the OR with high and low numbers of people in transit. We then placed air samplers and settle plates in representative locations during 21 procedures in 4 different ORs during 2 different seasons of the year to measure microbial load in colony-forming units (CFU). The temperature and humidity, number of door openings, physical movement, and the number of people in the OR were measured for each procedure. Statistical analysis was conducted using hierarchical regression. RESULTS The microbial load was affected by the time of year that the samples were taken. Both microbial load measured by the air samplers and by settle plates in 1 area of the OR was correlated with the physical movement of people in the same area but not with the number of door openings and the number of people in the OR. CONCLUSIONS Movement in the OR is correlated with the microbial load. Establishing operational guidelines or developing OR layouts that focus on minimizing movement by incorporating desirable internal storage points and workstations can potentially reduce microbial load, thereby potentially reducing surgical site infection risk. Infect Control Hosp Epidemiol 2018;39:391-397.

The Impact of Operating Room Layout on Circulating Nurse's Work Patterns and Flow Disruptions: A Behavioral Mapping Study.

AIM: To assess how the adjacencies of functionally different areas within operating rooms (ORs) can influence the circulating nurse's (CN) workflow patterns and disruptions. BACKGROUND: The CN plays a significant role in promoting patient safety during surgical procedures by observing, monitoring, and managing potential threats at and around the surgical field. Their work requires constant movement to different parts of the OR to support team members. The layout of the OR and crowded and cluttered environment might impact the CN's workflow and cause disruptions during the surgery. METHOD: A convenience sample of 25 surgeries were video recorded and thematically coded for CN's activities, locations, and flow disruptions. The OR layout was categorized into transitional zones and functional zones (workstations, supply zones, support zones, and sterile areas around the surgical table). CN's activities were classified into patient-, equipment-, material-, and information-related activities. Flow disruptions included those related to environmental hazards and layout. RESULTS: The CN traveled through multiple zones during 91% of the activities. The CN's workstation acted as a main hub from which the CN made frequent trips to both sides of the surgical table, the foot of the OR table, supply zones, and support zones. Transitional zones accounted for 58.3% of all flow disruption that the CN was involved in whereas 28% occurred in areas surrounding the OR bed. CONCLUSION: The similarity of the movement and flow disruption patterns, despite variations in OR layout, highlighted the adjacencies required between major zones that CNs regularly visit. These optimum adjacencies should be considered while designing ORs such that they are more efficient and safer.