Physical facilities

The birth of a baby via an abdominal incision.

Surgical procedures that use natural body orifices or percutaneous techniques with fiberoptic lighting to employ cameras and long specialized instruments during tissue manipulation and invasive intervention (e.g., colonoscopy, bronchoscopy).

Interventional radiographic procedure

A specialized surgical procedure that permits the use of radiologic imaging during tissue manipulation and invasive intervention through small incisional portals.

Laminar airflow

A unidirectional flow of clean air from a higher plane to lower exhaust grilles. The uninterrupted flow permits higher air changes per hour (ACH) for a cleaner environment around the sterile field.¹

Minimally invasive surgical (MIS) procedure

Surgical procedures that use small incisions and fiberoptic lighting to employ cameras and long specialized instruments during tissue manipulation and invasive intervention (i.e., laparoscopy or mediastinoscopy).

Operating room (OR)

A specialized room where the actual surgery takes place. This room is one part of the restricted area of the surgical suite.

Sterile core

A special room within the suite where sterile supplies are stored for ease of use. This room is one part of the restricted area of the surgical suite.

Substerile room

A room with a double sink that is separated from the OR by a door and where select clean and contaminated activities take place during the process of the surgical procedure. Some substerile rooms have warming cabinets for solutions or blankets and a steam autoclave. A disposal sink for contaminated fluids might be in here (e.g., hopper).

Suite

A collection of rooms that are used interactively during a surgical procedure wherein each room has a specific purpose (e.g., OR, substerile room, scrub sink room, and sterile storage core).

Thermal plume

An invisible layer of heat emanating from the equipment, team members, and the patient that can change the airflow and particulate distribution in the presence of laminar air diffusers.³^,⁴

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Physical layout of the surgical suite

Efficient use of the physical facilities is important. The design of the surgical suite offers a challenge to the planning team to optimize efficiency by creating realistic traffic and workflow patterns for patients, visitors, personnel, and supplies. The design also should allow for flexibility and future expansion. Architects consult surgeons, perioperative nurses, and surgical services administrative personnel before designating functional space within the surgical suite.¹⁰

Type of physical plant design

Most surgical suites are constructed according to a variation of one or more of four basic designs:

1. Central corridor, or hotel plan (Fig. 10-1).

FIG. 10-1 Central corridor, hotel style.

2. Central core, or clean core plan with peripheral corridor (Fig. 10-2).

FIG. 10-2 Central core, peripheral corridor style.

3. Combination central core and peripheral corridor, or racetrack plan (Fig. 10-3).

FIG. 10-3 Central corridor, racetrack style.

4. Grouping, or cluster plan with peripheral and central corridor (Fig. 10-4).

FIG. 10-4 Cluster combination, peripheral and central corridor style.

Each design has its advantages and disadvantages.⁸^,⁹ Efficiency is affected if corridor distances are too long in proportion to other space, if illogical relationships exist between space and function, and if inadequate consideration was given to storage space, material handling, and personnel areas.

Location

The surgical suite is usually located in an area accessible to the critical care surgical patient areas and the supporting service departments, the central service or sterile processing department, the pathology department, and the radiology department. The size of the hospital is a determining factor because locating every desirable unit or department immediately adjacent to the surgical suite is impossible.

A terminal location is necessary to prevent unrelated traffic from passing through the suite. A location on a top floor is not necessary for microbial control because all air is specially filtered to control dust. Traffic noises may be less evident above the ground floor. Artificial lighting is controllable, so the need for daylight is not a factor; in fact, daylight may be a distraction during the use of video equipment and other procedures that require a darkened environment. Most surgical suites have solid walls without windows. However, some ambulatory surgery rooms have windows to create an ambiance of openness in the suite.

Space allocation and traffic patterns

Space is allocated within the surgical suite to provide for the work to be done, with consideration given to the efficiency with which it can be accomplished. The surgical suite should be large enough to allow for correct technique yet small enough to minimize the movement of patients, personnel, and supplies.

Provision must be made for traffic control. The type of design predetermines traffic patterns. Everyone—staff, patients, and visitors—should follow the delineated patterns in appropriate attire. Signs should be posted that clearly indicate the attire and environmental controls required (Table 10-1). The surgical suite is divided into three areas that are designated by the physical activities performed in each area.

TABLE 10-1

Environmental Controls in the Surgical Suite

Environmental Controls	Class A OR	Class B & C OR	Cesarean Delivery Room	Storage Room	PACU
Pressure	Positive	Positive	Positive	N/A	N/A
ACH	15	20	20	4	6
OA	3	4	4	N/A	2
Humidity*	30%-60%	30%-60%	30%-60%	30%-60%	30%-60%
Temperature	68%-73%	68%-73%	68%-73%	68%-73%	70%-75%

^*Note: Humidity is expected to decrease as low as 20% by the 2012 edition of the AIA Guidelines. The rationale is that the old 30% to 60% is based on the use of flammable anesthetics and the risk of fire by static spark, which is not a consideration in modern times.

Modified from the Facility Guidelines Institute: Guidelines for design and construction of health care facilities, Chicago, 2010, ASHE (American Society for Healthcare Engineering), available at www.fgiguidelines.org/2010guidelines.html.

Transition zones

Both patients and personnel enter the semirestricted and restricted areas of the surgical suite through a transition zone. This transition zone, inside the entrance to the surgical suite, separates the OR corridors from the rest of the facility. Masks, caps, shoe covers, and cover gowns (or jumpsuits) may be located on a cart near transition zones adjacent to restricted areas. Nonsurgical personnel who need to enter the restricted zone can don a cover gown or jumpsuit, cap, shoe covers, and mask before proceeding to the designated OR.

Preoperative admission and holding unit

A designated unit in the unrestricted zone should be available for preoperative patients to change from street clothes into a gown and wait with their families before their surgical procedure. The decor should create a feeling of warmth and security. Lockers should be provided for safeguarding patient clothing. The location of the area should shield the patient and family from potentially distressing sights and sounds. Lavatory facilities and handwashing stations must be available. Alcohol-based hand-rub dispensers should be conveniently located in each patient care cubicle.

The area must ensure privacy and offer 80 ft² per patient of space to accommodate a transport cart.^a It may be compartmentalized with individual cubicles or be an open area with curtains. Curtains do not deflect sound and offer little privacy when the nurse is performing assessment and having conversations with the patient. Curtains also accumulate dust and particles and should be laundered on a regular basis.

Insertion of intravenous (IV) lines may be done here. In some cases, nerve blockades for pain management may be done in the holding area as ambulatory procedures. These procedures require good lighting. Each cubicle is equipped with oxygen, suction, and devices for monitoring blood pressure. A crash cart should be easily accessible for emergencies.

A nurses’ station within the area provides close patient observation and dispensers for medication storage. Computer access to patient electronic medical records (EMRs), such as laboratory reports, and to patient care documentation facilitates documentation in patient records. Care is taken not to have loud conversations at the nurses’ station. Private information may be overheard by patients and families.

Assignment and scheduling boards should not be within the view of the patients to avoid breaching privacy standards. When wipe-off boards are used for daily scheduling, care is taken not to use patient names. Coordination of the holding room staff and the personnel managing the surgical schedule is essential to prevent delays. More information about preoperative patient care areas is available in Chapter 21.

Some preoperative holding units serve as ambulatory care areas after the surgical procedure. Patients who are admitted in the morning are brought back to the holding unit to recover. They can go home a few hours after the surgical procedure.