Physical Environment and Safety Standards

Introduction to Anesthesia TechnologyANES 1501

Module 7

Part 2

Overview

1. Surgery Department Physical Design

2. Areas of the O.R.3. Additional Rooms4. Physical Components of the

Operative Suite5. Standard O.R. Furniture6. Surfaces in the O.R.7. Cabinets and Doors

10. Ventilation System11. Air Filtration12. Temperature13. Humidity14. Substerile Area15. Direct Support Services16. Hazards17. Safety Precautions18. Personal Protective Equipment

(PPE)

Physical Design of the Surgery Department

Single Corridor (“Hotel”)

The Single Corridor (or “Hotel”) model involves travel of all supplies (clean and used) as well as patients (pre and post operative) in one main corridor. There is ongoing debate as to the suitability of this approach. However, this option is considered suitable provided:• the main corridor is sufficiently wide in order to permit

separation of passage of goods and services;• handling of clean supplies and waste is carefully

managed to avoid cross contaminationA major disadvantage of this planning model is that a patient awaiting surgery may be exposed to post operative patients

Physical Design of the Surgery Department

Dual CorridorThe Dual Corridor (or “Race Track”) model allows for all the operating rooms to be accessed from an external corridor for patients and directly from a central Set Up/Sterile Stock Room for sterile goods. This model aims to separate ‘dirty' from 'clean’ traffic by controlling the uses of each corridor. In this design, there must not be cross traffic of staff and supplies from the decontaminated/ soiled areas to the sterile/ clean areas. In this model, stock and staff can be concentrated in one location, preventing duplication of equipment stock and staff.

Physical Design of the Surgery Department

ClusterIn this model Operating Rooms may be clustered according to specialty, with a shared Sterile Stock and Set-Up Room for each group or cluster. Disadvantages of this model include: • additional corridor and circulation space

required for corridors around clusters of rooms, which reduces the available space for stock;

• potential duplication of stock and additional staff requirements may result in increased operating costs.

Question to consider

• Could you explain the reasons behind each of the three designs?

?

Areas of the O.R.

Unrestricted• Street clothes are

permitted, and the area to have control point for monitoring entry for patients, staff, and materials

Semi-Restricted

• Surgical attire is required, and traffic is limited to authorized personnel. Storage and work areas for processing of instruments and corridors leading to the restricted areas are included.

Restricted• These areas include the

operating room, clean core and scrub sinks. Surgical attire and hair covering is required, along with masks where open sterile supplies are utilized.

Additional Rooms

Physical Components of the Operative Suite• Equipment• Electrical outlets• Suction outlets• Gas outlets• Lights• View box• O.R. tables• Other items

Standard O.R. Furniture

1. Backtable2. Mayo stand3. Ring stands4. Kick buckets5. Linen hamper6. Trash container7. Suction sets8. Anesthesia

carts

1 2 3 4

85 6 7

Surfaces in the O.R.

Operating Units should have the following finishes: • floors that are smooth, non-slip

impervious material laid in a continuous washable material and graded where necessary to fall to floor waste; floor material that resists staining is recommended

• wall finishes which are seamless, impervious and washable

• ceilings which are smooth and impervious • intersections of walls and architraves to

be rendered watertight junctions.

Cabinets & Doors

CabinetsRecessed wall storage cabinets, if requested, should be in addition to the square footage noted for each Operating Room. These cabinets should be used for storage of routine supplies only. When the provision of substantial numbers of storage cabinets in each Operating Room is the desire of the local staff, then the space in the clean core reserved for exchange carts with sterile supplies on them can be reduced.

DoorsThe entrance from the semi-restricted corridor, from which patients are moved in and out of the operating room, should be at least 6' wide with a pair of doors. Corridor doors should be located in such a way as to permit the bed or gurney to move as directly as possible from the corridor to the side of the operating room table. For this reason, these doors are best located toward the foot of the operating table away from the anesthesia equipment. If lead lining in the walls of any/or each of the operating rooms is required by a qualified physicist, then it is mandatory that the doors into these rooms have automatic door openers. Automatic doors must be swinging doors operated by push plates.

Ventilation Systems

Supply AirIn addition to keeping the remaining Operating Room as clean as possible, the air supply system must be designed to minimize the entrance of airborne bacteria into the sterile field as well as the area occupied by the anesthesiology staff. Air supplied to the Operating Room should be supplemented with additional clean air entering the Operating Room from the clean core. Operating Rooms and Clean Corridors shall both be maintained under positive pressure.

Exhaust AirDuring an operation, all of the space from the floor itself to a distance 15'' (380 mm) above is considered contaminated. Therefore, all exhaust/return grilles must be positioned low on the wall approximately 18'' (460 mm) above floor. The Operating Room exhaust system should include a minimum of two low exhaust/return air grills located in opposite corners to minimize recirculation of contaminated air within the Operating Room.

Air Filtration

• Filtration Proper air filtration for the surgical suite ultimately requires at least a 90 percent final filter in accordance with ASHRAE Standard 52-76. Many surgical suites incorporate the use of high-efficiency particulate filters (HEPA). Most airborne microorganisms are in the 0.5m to 5.0m diameter range.

• HEPA filters efficiently remove particles up to 0.3m and provide virtually bacteria free air to surgery. However, 90 percent filters are equally effective if maintained properly. These final filters should be located as close to the air destination (operating room) as possible. HEPA or 90 percent final filtering may not be the only filtering necessary. If odors are present, there may be a need for activated charcoal or electronic filters. The amount of pre-filtering depends upon the intake environment of the air handler.

Temperature

• Along with humidity, temperature plays an important role in comfort, but has not been indicated to be a direct factor in infection control. Rather, a comfortable environment in the operating room can reduce hazards created by misusing or abusing the operating room environment.

• It is recommended the surgical suite temperature be maintained in a range of 68 degrees F to 75 degrees F, with controls for selecting any desired temperature within this range. In practice, for small rooms filled with personnel and heat emitting equipment, achieving the low end of this range can be difficult and may require dedicated chiller units.

Humidity

• Operating room humidity is the most important comfort factor recognized by surgeons. A relative humidity of at least 50 percent is recommended. This level helps to dissipate electrostatic charges, which can be hazardous in an oxygen-rich environment. This level also controls airborne bacteria.

• Humidity lower than 35 percent may cause drying of mucous membranes and hypothermia of patients during lengthy procedures. Additionally, 1996 NFPA 99, paragraph 5-4.1.1 states "floating particulate increases in conditions of low relative humidity, and the fact that the incidence of would infections may be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent" are advantages.

• Humidity much above 55 percent causes undue sweating by surgeons and operating personnel. Unfortunately, when surgeons become uncomfortable, operating room personnel have been known to open windows or leave doors open. This, obviously, places the patient at a higher risk of infection.

Substerile Area

• This is a room accessible from the operating room(s) it serves. It may be located between two ORs or a group of adjacent ORs. This room contains a sink, a counter top, and a steam sterilizer for the purpose of immediate use (“flash”) sterilization.

Direct Support Services

• Preoperative or “same-day” check-in unit

• Preoperative holding area• Postanesthesia care unit (PACU)• Laboratory department

• Radiology department• Pathology department• Environmental services• Central sterile supply and

processing

Hazards

Physical Hazards• Scalding steam and heated exterior surfaces do pose a potentially serious

risk of injury to OR staff. Appropriate training for handling heated instrumentation, trays, and autoclave surfaces should be a part of any OR safety program. Temperatures of an idle autoclave can be as high as 240ºC. Thus, loading instruments into an autoclave poses a risk for injury. Instruments being removed from flash sterilizers can have extremely hot water, capable of scalding unsuspecting staff, pooled on their surfaces.

• A facility's design should address the thermal hazard of an autoclave. The design of a new facility should create appropriate traffic patterns around autoclaves. There should be adequate room to pass by the autoclave when the door is open. Another source of physical hazards is the high-pressure gases used in the OR to run air-driven surgical equipment. Healthcare workers have experienced dental, facial, and blunt trauma injuries when pressurized apparatus were handled incorrectly or inattentively.

Biological Hazards• Biological hazards are responsible for some of the greatest

changes in current healthcare practice. Potential exposure can be acute or chronic. Illness resulting from exposure can lead to autoimmune disease, liver disease, respiratory disease, neurological disease, and death. The emergence of AIDS in the mid 1980s led to the recommendation by the CDC in 1985 and implementation by OSHA in 1991 of the practice of universal precautions for protection from fluid and bloodborne pathogens. The implementation of these standards has impacted no area of the healthcare industry as broadly as the OR divisions of hospitals. However, fluid and bloodborne pathogens are not the only biological concerns of OR personnel.

Hazards

Chemical Hazards• Chemical hazards represent the broadest category of potential risk to OR personnel.

Chemical hazards come in solid, liquid, and gas/vapor forms. Potential exposure can be acute or chronic. Injuries associated with chemical hazards can include thermal injury, blunt trauma, acute toxicity, allergic sensitivity, mutagenic changes, cancer, birth defects, loss of vision, neurotoxicity, and death. Solid chemical hazards are found primarily in the form of chemical disinfectants, which must be premixed with water before they can be used as cleansers in the OR. Liquid chemical hazards are used primarily in disinfection, sterilization, medication, and tissue preservation in the OR. Gas/vapor chemicals are primarily associated with anesthesia, disinfection, sterilization, and surgical equipment in the OR.

Safety Precautions

Universal Precautions• Universal Precautions is an approach to infection control to treat all human

blood and certain human body fluids as if they were known to be infectious for HIV, HBV and other bloodborne pathogens. Bloodborne Pathogen Standard 29 CFR 1910.1030(d)(1) requires employees to observe Universal Precautions to prevent contact with blood or other potentially infectious materials (OPIM).

• Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. Treat all blood and other potentially infectious materials with appropriate precautions such as:

• Use gloves, masks, and gowns if blood or OPIM exposure is anticipated.

• Use engineering and work practice controls to limit exposure.

Standard Precautions• Standard Precautions apply to: 1) blood; 2) all body

fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood; 3) non-intact skin; and 4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.

• Standard precautions includes the use of: hand washing, appropriate personal protective equipment such as gloves, gowns, masks, whenever touching or exposure to patients' body fluids is anticipated.

Personal Protective Equipment (PPE)

• The dress code for the Operating Rooms, other invasive procedural areas, and support areas with designated semi-restricted and restricted areas shall be in accordance with Medical Center Policy No. 0051, based on AORN Recommended Practices for Surgical Attire, and this policy.

• Personal protective equipment (PPE) (gloves, gowns, masks, eyewear, and disposable, fluid resistant shoe covers) is available to all personnel at risk of exposure to potentially infective materials. PPE must be worn in accordance with guidelines as listed in the local area Exposure Control Plan Protective coverings/PPE (masks, gowns and shoe covers) must be removed prior to leaving the surgical or procedural area.