Surgical Facilities, Equipment, and Personnel and Care and Maintenance of the Surgical Environment

A variety of physical layouts are suitable for modern operating rooms (ORs) and surgical areas, but the goals of all designs are patient safety and work efficiency. In designing an OR, careful attention must be paid to traffic patterns; the number and configuration of ORs; the space required for storage, administration, and staff; the provisions for sterile processing; and the systems used to manage airborne contaminants (Allo and Tedesco, 2005). The surgical area should be close to the anesthesia and surgical preparation areas, critical care, radiology, and central supply. However, it should be isolated from general traffic flow (e.g., examination rooms, offices, reception area, wards). In large facilities, such as universities and surgical referral centers, the anesthesia and surgical preparation area should be a separate working unit that is isolated from general hospital traffic.

Structure and Design of the Surgical Area

Because of the constant danger of contamination to surgical patients, the surgical area is clearly delineated into “clean,” “mixed,” and “contaminated” areas. Clean areas include the ORs, scrub sink areas, and sterile supply rooms. Mixed areas include hallways between the ORs and nurses’ stations, instrument and supply processing areas, storage areas, and utility rooms. Contaminated areas include anesthesia and surgical preparation rooms, dressing rooms, lounges, and offices. A commonly used floor plan is one in which the surgical suites are arranged around a central work station for OR nurses. Easy access to each OR from the work station ensures efficient traffic flow, which reduces cross-contamination between areas. Clean areas should be restricted to clean traffic, and contaminated areas to contaminated traffic.

Because airborne contaminants can cause or aggravate infection, it is best to create traffic patterns that limit the movement of personnel and materials from outside the surgical suite. Every effort should be made to minimize traffic into and out of rooms. This restricts the movement of airborne contaminants, such as organisms carried and shed by people and objects. Entry into the OR and other clean areas should be limited to essential equipment and personnel (Allo and Tedesco, 2005). Individuals entering a clean area from a contaminated area must don proper surgical attire (see Chapter 6); the ideal location for moving from a contaminated area to a clean one (or vice versa) is through a locker room. Surgical personnel who leave a clean area and enter a contaminated area must cover their clothing before they leave and discard these items when they return to the clean area. Doors between clean and contaminated areas should be kept closed at all times. Food and drink are permitted only in contaminated areas. Movement of clean and sterile supplies and equipment should be separated as much as possible from movement of contaminated supplies and equipment by space, time, and traffic patterns. Soiled linen and trash should be kept in a contaminated area, and patients should be clipped and vacuumed in a contaminated area before transport to a clean area (e.g., the operating room).

Guidelines useful for limiting movement from the outside into the operating suite are included in Box 3-1. Most particles and bacteria found in operating room air are shed from skin and hair by personnel in an OR. Although no one has established a direct relationship between the number of people in an OR and the development of postoperative infection, some studies suggest that as the number of personnel in the OR increases, so does the incidence of surgical site infection (Pryor and Messner, 1998). Whether this has to do with the people themselves or the greater amount of traffic into and around the room is not clear. Opening the doors to the OR decreases the effectiveness of the ventilation system in effectively clearing potential contaminants from the OR outward. The goal is to create realistic traffic and commerce of patients, personnel, and supplies, with careful attention to “clean” and “mixed” work areas (Allo and Tedesco, 2005).

Box 3-1 Guidelines Useful for Limiting Movement into the Operating Room (OR)

1. Allow only those people who are essential to the procedure into the OR while operations are being performed.

2. Limit movement of personnel within the OR.

3. Keep the doors of ORs closed during surgeries/procedures.

NOTE • To prevent contaminating the surgical suite, clip the patient and perform the initial surgical preparation in a separate area.

Description and Function of Rooms in the Surgical Area

Dressing Room

The dressing room is used by surgical personnel for changing into proper surgical attire. It should have closed cabinets for storing scrub suits, shoe covers, masks, and caps and a separate area for hanging street clothes. A hamper for dirty laundry should be available to minimize carrying of contaminated linen through the hospital.

Anesthesia and Surgical Preparation Areas

The anesthesia induction and surgical preparation area should be adjacent to the surgical area yet out of major hospital traffic patterns. This room should be supplied with equipment and medications that may be necessary in an emergency (e.g., defibrillator, endotracheal tubes, suction, oxygen, crash cart). It also should have anesthetic equipment (machines and drugs), laryngoscopes, clippers (mounted on the wall or hanging from the ceiling), vacuums (large canister or central), skin preparation materials (antiseptic soaps, alcohol, sterile gauze sponges), sharps containers, needles and syringes, and monitoring equipment, all of which should be readily available to ensure efficient anesthesia and preoperative patient preparation.

NOTE • Drugs and equipment necessary for an emergency can be stored in a mobile crash cart; this facilitates movement from the anesthesia preparation room to the OR and to recovery.

Preparation counters and surfaces should be impervious and easily cleaned and disinfected (Table 3-1). Stainless steel preparation tables with built-in sinks are ideal. Gas scavenger systems should be present at each anesthesia preparation table. General lighting is supplied by main overhead fluorescent lights, which are supplemented by a spotlight directed at each preparation table. A sink designated for cleaning anesthetic hoses, endotracheal tubes, and rebreathing bags, plus a plastic rack for draining and drying rebreathing bags and hoses, should be available. An erasable anesthesia-surgery scheduling board, easily visible to anesthesia and surgical personnel, should list the day’s procedures.

TABLE 3-1

Common Disinfectants

Temperature in the preparation room should be kept between 62° F and 68° F (17° C and 20° C) and humidity at 50% or less to reduce microbial growth. Gurney surfaces should be padded and circulating water and/or warm air blankets should be used to prevent hypothermia. Well-constructed gurneys should be available for patient transportation. They should be made of stainless steel or other easily cleaned materials, have relatively large wheels with bearings that can be easily lubricated, and have rubber bumpers mounted on the corners to prevent damage to doors and walls. An adhesive microfilm dust pad should be placed at the doorway between the anesthesia preparation room and the surgical area to collect dust, hair, and other particulates on gurney rollers, shoes, and anesthetic equipment.

Scrub Sink Area

Scrub sink areas should be centrally located for the OR suites. Antiseptic soap in an appropriate dispenser (i.e., foot-activated or motion-sensitive), scrub brushes (i.e., sterilized reusable brushes or a disposable polyurethane brush-sponge combination, unless brushless scrub solutions are used [see Chapter 6]), and fingernail cleaners (if used; see Chapter 6) should be kept within easy reach at each scrubbing station. Deep stainless steel sinks equipped with knee-, elbow-, or foot-operated or motion-sensitive water activators are ideal. Electronic sensory activated scrub sinks as shown in Figure 3-1 allow “no touch” activation. With reusable brushes, the dispensing container and clean brushes must be detached and autoclaved regularly. The scrub sink area must be located away from wrapped sterile supplies because of possible contamination by water droplets and spray from the sinks. Scrub sinks should never be used to clean equipment or instruments or to dispose of body fluids.