Title: Surgeons may be desperate But there are no short cuts to good operating suites
Pages: 44 - 49
Text: Surgeons may be desperate But there are no short cuts to good operating suites
There is no place for compromise when lives depend on design efficiency. Smooth, swift, sterile functioning is the aim - and only the best will do. When the pressure is on, it's a temptation to feel that anything goes. But this summary of a three-year research project shows that details count all the time.
The first and most important point to be realised when new operating suites are being considered is that they must be designed in detail from the start. It is no use taking the easy way out by handing the contractor small scale drawings and then proceeding to modify the structure and add the engineering services piecemeal as the work proceeds. This method has produced unsound and expensive units which are inconvenient in use and bring discredit on the architectural and engineering professions.
Contributory factors to the general poor standards of design are (a) desperation on the part of surgeons operating in antiquated rooms, who will accept almost anything offered as an improvement on their present conditions; (b) shortage of funds and time at the planning stage; and (c) inadequate information for medical advisers, architectural, engineering and design consultants, and equipment manufacturers.
Go to work on a fact
During the last five years, it has been realised that, if future operating suites are to be of real value, the advisers must continually study the changing needs and design trends in this and other countries; that a busy, brilliant surgeon is not necessarily aware of the planning requirements and equipment available; and that few designers have seen the inside of an operating suite or understand its working. The project architects and engineers must be given a comprehensive written brief.
In America and Europo, I found that those concerned with the design of most of the operating suites I saw had given much more thought to the needs of the department, and to the movement of the patients and staff, than was usual in this country.
The full report of the project, Finishes and Fittings in Operating Suites, summarised in this article, is available from the Secretary to the Newcastle Regional Hospital Board, price 1 7s 6d
2 Engineering service pipes installed at an early stage of construction at Holy Cross Hospital, Silver Spring, Maryland, USA.
3 Instrument storage and packaging room at Passavant Memorial Hospital, Chicago, USA.
Their co-operation and co-ordination was evident in the improved convenience and sound construction that resulted. 2 shows a ward at the Holy Cross Hospital, Maryland, USA, during construction - the engineering services were designed and the pipes and conduits installed before the partitions were erected. The American bench fitting and steriliser manufacturers carry out their own research and offer recommended layouts and equipment for such rooms as glove processing and instrument storage, a. The Honeywell modular theatre (see pages 62-65) is an ideal example of the work now going ahead in this country; but theaim must be for all operating suites to be of a high standard. At present, there are just a few outstanding examples which have received special attention.
Streamlining the operating room
The operating room is the central feature of the suite; the streamlining of the finishes and fittings, and their arrangement so as to limit unnecessary movement, are all important in the design. It must be remembered that these rooms are cleaned very frequently, and that every projection requiring particular attention increases the work involved; also, the risk of infection increases in relation to the number of persons in the room. Ideally, it should be possible for maintenance staff to attend to the services from outside the operating suite, or at least outside the operating room: a service area immediately above the operating suite is recommended.
1~ indicates a typical layout for an operating room and suite suitable for most surgical procedures. The following points should be noted: 1 The normal position of the operating table is in the centre of the room on the long axis (if any), with the head of the patient and the anaesthetist towards the anaesthetic room. 2 For operations on the upper abdomen and chest, surgeons generally prefer to operate standing to the right of the patient, with the 'scrubbed' nurse handing him the instruments standing opposite and the 'run about' nurses beyond the patient's feet. 3 The positions of the fittings, doorways and ancillary rooms are related to those of the patient and staff in the operating room (so that, eg, the surgeon can enter from the scrub room, examine x-ray films on the viewing box and approach the patient without disturbing the instrument trolley, etc; and so that supplies can arrive and be taken away without passing the patient). 4 Operating rooms should not have external windows, the factors against them
4 Nurses' panel at Dryburn Hospital, Durham. Fitted with recessed specimen cupboard, time elapse clock, intercommunication unit, magnetic swab count board and operating list holder.
5 Operating room at Dryburn Hospital, Durham. Surgeons' panel has recessed ventilation controls and gauges, viewing box and electrical controls. There is a recessed through cupboard for the anaesthetist.
6 Operating room at Ryhope General Hospital, Sunderland. The anaesthetic machine is connected to a fixed SellerToury operating table with medical gas, suction, diathermy and electrical outlets mounted in the base.
outweighing those in favour (though windows should be provided in the rest rooms).
Rather than have items of equipment fixed haphazardly over the wall area, it is desirable for them to be grouped so as to simplify installation and the decoration of the remaining surface - provided that the grouping does not restrict the use of the equipment. 4 shows a nurses' panel which is sited beyond the foot of the table, and 5 shows a surgeons' panel on the side wall.
Ceilings in operating rooms require at least as much attention as the walls if the arrangements and support of the operating lamp, general lighting, diffusers and ceiling pendants are to be successful. Selected fluorescent lighting is used in these rooms, and this form of lighting is now recommended in the report issued by the joint committee of the Medical Research Council, the Building Research Station and the National Physical Laboratory.
Planning the services
Rooms for thoracic and neurosurgery may require additional facilities, and consequently larger rooms, so that patient monitoring, hypothermia, x-ray and blood treatment can be carried out. However, to limit the number of technicians and items of equipment in the operating room, patient monitoring (and as much other equipment as possible) should be installed, controlled and maintained in adjoining rooms. The monitor equipment panel - with its repeat oscilloscopes, transmitters, and temperature and pressure gauges - is best recessed into the operating room side wall on the patient's left, where the dials will be visible to both surgeon and anaesthetist.
Of the five basic arrangements for providing electrical and medical gas services mentioned in the report, wall mounted socket outlets are still generally preferred for the 13 amp and 30 amp electric supplies, However, rigid ceiling pendants are being prefabricated by Peacocks (Surgical and Medical Equipment) Ltd. and are now being installed in most new suites in the Newcastle region. They can be fitted with oxygen, nitrous oxide, suction and compressed air connections, 13 amp and low voltage socket outlets, and a hook from which a drip bottle may be suspended.
Three operating tables like that in 6, with additional diathermy and suction discharge services connected to the base, are now in use in the region, and the surgeons using them prefer this service arrangement. A recessed diathermy unit and suction bottle cabinet are used in conjunction with the French table at Ryhope, where the connections pass under the floor. The installation of this type of table requires considerable co-ordination between the architects and engineers at the design stage. And since many surgeons have a strong objection to floor pedestals, these tables should only be installed at their express wishes.
The design of operating tables has been influenced by the introduction of mobile image intensifiers (see page 55), which can produce immediate, moving x-ray pictures particularly suitable for such procedures as heart catheterisation and the pinning of bones. If an intensifier is to be used, the top of the table must be formed of an xray translucent material (such as Perspex) and the supports should not unduly restrict the positioning of the intensifier; this is best achieved by means of a fixed base table and a cantilevered top, which can be supported anywhere along its length. The Kifa H table is supported in this manner, but has a complex hydraulic adjustment system.
It is often maintained that operating lamps should be recessed in the walls and ceiling, or mounted above the ceiling, in order to obviate an additional source of heat (and a dust ledge) immediately over the patient. 9 shows an operating room in Paris where this type of lighting has been installed. The resulting elaborate arrangements are
7 Operating room at Royal Victoria Infirmary, Newcastle-on- Tyne. The Kifa operating table has a fixed base, with a mobile table top on a special trolley. The floor has anti-static Marley tiles with welded joints.
8 Anaesthetic room at Ryhope General Hospital, Sunderland. Suspended medical gas outlets are connected to the anaesthetic machine. There is a Hanalux examination lamp.
9 Operating room at Hospital Brousais, Paris. Two operating rooms used for thoracic surgery have a monitor room between. There is a Veller- Toury operating table and a glazed ceiling with operating lamps. o Bench unit for storage of sutures, lotions, catheters, etc. in a sterilising room at Dryburn Hospital, Durham.
11 Detail of the trough for a scrub room - an experimental design.
necessary to provide shadowless illumination for cavities (the position of which may vary from vertical to near horizontal). Most surgical advisors consider that the advantages gained by having the operating lighting outside the room are insufficient to warrant the cost of the additional height and special construction.
In this operating suite, space above the operating room is also used as an observation gallery - but again this facility can be achieved more satisfactorily and at less cost by providing an observation room fitted with television adjoining the operating room, where the observers can see the operating room in general and the wound in detail
During my visits to 43 operating departments abroad, I found that the operating room walls of 31 were finished with ceramic or glass tiles, seven had walls faced with vinyl wall covering, and only five had painted coatings (which were generally classed as
temporary finishes unsuitable for use in operating rooms). When my report was published, I considered thatbecause of ease of fabrication and resistance to damage - melamine faced panels mounted on plywood could provide one of the most satisfactory wall finishes for use in operating rooms, but that the cost of approximately £4 15s per sq yd was too high. Further, that ceramic wall tiling (with an eggshell finish, the joints pointed with a twopack grout, and exposed external angles protected from trolley damage) would provide the most consistently suitable finish at a lower cost of approximately £3 per sq yd.
Two other finishes which were considered to offer possibilities, but which had rarely been used in this country, were reinforced paints and vinyl wall coverings. The success or failure of either depends to a large extent on two factors, the choice of material and skilful application; the thinner materials are easy to apply, but are less resistant to damage.
With the assistance of a limited number of willing manufacturers - in particular British Paints and Storeys of Lancaster - and as a result of trials, most new operating rooms in the Newcastle region are now being finished with British Paint's two-pack Luxcl polyurethane paint, reinforced with Marglass 203/P704 glass fabric. It is recommended that even with this . 005 inch glass fabric, five coats (including the primer) should be applied, with rubbing down between the final coats in order to bond and mask the weave of the glass fibre. Eggshell finish should be used for the final coat, as the standard high gloss finish causes glare and highlights irregularities in the wall surface.
It has been found that the use of glass fibre increases the resistance of the paint film to damage by mobile equipment, while masking fine cracks which may occur in the plaster. When applied by an experienced craftsman, this coating (which costs approximately £1 5s per sq yd) is more likely to be satisfactory than the medium/ heavy vinyl wall coverings, but is more easily marked by mobile equipment.
The application of wall coverings is all important; no matter how good the material is, curling edges and open joints are completely unacceptable. Storey's has recently begun to manufacture heavyweight Stormur 619, a scrimbacked, smooth, vinyl faced covering which should be relatively easy to apply and still be able to withstand damage. The smooth, scrim-backed, lightweight wall coverings, such as Stormur 619 (lightweight), provide very good ceiling finishes, having the advantage over semigloss paint that, should fine cracks form in the backing, they will not show on the surface.
The colour of walls in operating rooms is not critical, provided that it is not a strong colour (particularly strong blue or green, which affect the apparent colour of the patient). Light blue-grey and beige are now preferred to the once popular pale green (BS 6069).
Terrazzo is no longer the automatic choice for operating room floors, following many failures (which were often due to the use of dividing strips of insufficient depth) and to the difficulty in achieving a consistently anti-static suspended floor; and also because of the demand for light-weight prefabricated materials. Anti-static Marley tiled flooring is proving a satisfactory alternative when properly laid on a hard, dry screed, although it is not as thick and dense as the American Amlico and Conductile floorings, which have been in use for some 12 years. However, the tiles can be welded and there is a limited colour range.
Door furniture and other fittings
Metal doorframes are used extensively in operating suites abroad, but architects in this country have found it impossible to obtain good quality metal frames preferably with stainless steel up to a height of 3 ft - which can be securely fixed, and are silent in use and of acceptable cost. The architects have generally had to be content with hardwood frames, finished with flush fitting aluminium architraves.
Melamine faced doors, with pvc edging, pull handles, and small flush-fitting observation panels, are proving satisfactory without the addition of the usual metal protection plates fitted on the face of the door.
The fittings recommended in my report for use in operating suite ancillary rooms have now been - or are being installed, and are generally approved by the staff. The anaesthetic room fittings shown in 8 are very similar. The experimental scrub trough,'', promises to be satisfactory, and surgeons who have tried the supply fittings with aerated outlets have commented that this type of outlet supplies sufficient water, reduces noise and limits splashing. However, it is difficult to obtain taps of suitable dimensions fitted with these outlets in this country.
Planning for sterility
The design of operating suite sink and sterilising rooms is changing; the use of packs of linen and instruments prepared for individual operations is becoming more widely accepted. For single operating suites, through autoclaves are being used more frequently; but built-in instrument cabinets are being replaced by packing benches. A bench unit similar to that shown in 10 will still be required in the sterile supply room for the storage of sutures, lotions, catheters, etc.
Theatre sterile supply units or central sterile supply departments, closely linked to groups of operating rooms, are taking over certain sink and sterilising room duties, thus reducing within the suites the wild heat (from sterilisers etc) which so often gave trouble in the past. The CSSD at Dryburn Hospital adjoins the triple operating suite, and from the experience gained since June 1965 it is anticipated that this department will be able to supply all the sterile instruments and linen required by the three operating suites.
An assessment of Dryburn CSSD is now being carried out, and I would recommend that in this rapidly changing world we should evaluate our buildings, their finishes and fittings more frequently in order that successful features may be standardised and so that failures may be noted and their repetition avoided.
Thomas White divisional architect with the Newcastle Regional Hospital Board, joined the regional architect's department in 1954 and was engaged in the construction of operating suites prior to being appointed architectural research fellow by the board for the period 1961-64. His research was concerned with the investigation of Finishes and Fittings in Operating Suites, and the results have been published as a final report by the Newcastle Regional Hospital Board. Copies may be obtained from the secretary, price 17s 6d.