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

Proposing Design Evaluation Metrics for Anesthesia Providers' Workspace in Ambulatory Surgical Settings

Objective: This paper describes the development and utilization of two design evaluation metrics aimed to measure design performance for improving circulation and workflow, situational awareness, and visibility for medication-related activities for anesthesia providers' within their workspace in operating rooms. Background: Proactive performance evaluation of the design of critical areas such as operating rooms can help improve the safety of patients and staff workflows. This paper builds on previous work on task-switching behaviors in anesthesia workspaces to develop performance-based design evaluation metrics for anesthesia providers' workspaces based on their tasks performed during the patient preparation, intra-operative, and post-operative phases of the surgery, considering the presence of multiple anesthesia providers. Methods: Pre-coded observational data for five ear, nose, and throat surgeries was analyzed to determine the task-location and task-durations for anesthesia providers while performing various medication-related tasks. The distance between task-locations and the frequency of anesthesia providers' movement between these locations informed the proximity metric, whereas the anesthesia providers' visibility of the patient and the vitals screen from these locations informed the visibility metric. These metrics were used to compare four anesthesia providers' workspace layouts: observed operating room, prototype operating room, and two newly developed design configurations A1 and A2. Results: The proximity metric suggests that layout A2 supported better circulation and workflow for anesthesia providers, whereas the visibility metric indicated that they had improved situational awareness in both A1 and A2. Conclusions: Both metrics can be used to proactively evaluate anesthesia providers' workspaces early in the design process, to improve patient care in future operating rooms.

Can Operating Room Design Make Orthopedic Surgeries Shorter, Safer, and More Efficient?: A Quasi-Experimental Study

OBJECTIVES

The study aimed to fill the knowledge gap about how operating room (OR) design could reduce orthopedic surgery duration and contribute to surgical care safety and efficiency.

BACKGROUND

Long surgery duration may lead to delays and cancellations of surgeries, deteriorated patient experiences, postoperative complications, and waste of healthcare resources. The OR physical environment may contribute to the reduction of surgery duration by minimizing workflow disruptions and personnel movements during surgeries.

METHODS

Unobtrusive observations were conducted of 70 unilateral total knee or hip replacement surgeries in two differently designed ORs at a community hospital in the United States. A set of computer-based forms adapted from recent research was used to measure the surgery duration, environment-related disruptions, and ambulatory movements involving circulators. Potential confounding factors like surgery type were controlled in statistical analyses.

RESULTS

Significantly shorter surgery durations were recorded in the larger OR with more clearances on both sides of the operating table, a wider door located on the sidewall, more cabinets, and more clearance between the circulator workstation and the sterile field (p =.019). The better-designed OR was also associated with less frequent disruptions and fewer movements per case (p < .001). Significant correlations existed between surgery duration, the number of disruptions, and the number of movements (rs = .576-.700, ps < .001).

CONCLUSIONS

The study demonstrated the important role of OR physical environment in supporting the safe and efficient delivery of surgical care, which should be further enhanced through research and design innovations.

Identifying Built Environment Risk Factors to Provider Workflow and Patient Safety Using Simulation-Based Evaluation of a Pediatric ICU Room

OBJECTIVE

This study aimed to identify latent conditions in a pediatric intensive care unit (PICU) by analyzing characteristics of flow disruptions (FD) during a simulation of a three-phased scenario.

BACKGROUND

The built environment of healthcare facilities contributes to FD that can lead to clinical errors and patient harm. In the facility design process, there is an opportunity to identify built environment features that cause FD and pose safety risks. Simulation-based evaluation of proposed designs may help in identifying and mitigating safety concerns before construction and occupancy.

METHODOLOGY

During design development for a new 400-bed children's hospital, a series of simulations were conducted using physical mock-ups in a large warehouse. A three-phased scenario, (1) admission and intubation, (2) cardiac arrest, and (3) bedside surgery involving a cannulation to extracorporeal membrane oxygenation, was conducted in a PICU room mock-up. Each scenario was video recorded from four angles. The videos were systematically coded to identify FD.

RESULTS

Analysis identified FDs in three ICU zones: respiratory therapists (RT) zone, nurse zone, and head of the patient. Challenges in these zones were related to spatial constraints in the RT zone and head of the bed, equipment positioning in the RT zone and nurse zone, and impeded visibility related to the location of the boom monitor in the nurse zone.

CONCLUSION

Simulation-based evaluation of prototypes of patient care spaces can help identify characteristics of minor and major FD related to the built environment and can provide valuable information to inform the iterative design process.

A sensor-based framework for layout and workflow assessment in operating rooms

Due to their large sizes and impediments to personnel workflows, integrating robotic technologies into the existing operating rooms (OR) is a challenge. In this study, we developed an ultra-wideband sensor-based human-machine-environment framework for layout and workflow assessments within the OR. In addition to providing best practices for use of the framework, we also demonstrated its effectiveness in understanding layout and workflow inefficiencies in 12 robotic-assisted surgeries (RAS) across 4 different surgical specialties. We found avoidable movements as the circulating nurse covers at least twice the distance of any other OR personnel before the patient cart (robot) is docked. OR areas of congestion and undesirable personnel-pair proximities across RAS phases that impose extra non-technical skill challenges were determined. Our findings highlight several implications for the added complexity of integrating robotic technologies into the OR, which can serve as drivers for objective evidence-based recommendations to combat RAS OR layout and workflow inefficiencies.

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.

Understanding "Work as Done": Using a Structured Video-Based Observational Method to Understand and Model the Role of the Physical Environment in Complex Clinical Work Systems

OBJECTIVE

To describe the planning, development, and implementation of a structured video-based observational method that can be used to systematically examine and model the role of the physical environment within healthcare systems.

BACKGROUND

Direct observation methods are often used in healthcare to study complex healthcare systems. However, these observations often occur in real time, which predisposes the collected data to shortcomings such as time lags in recording of activities, overlooking events, or limiting the scope of information than can be collected. Video observation approaches eliminate many of these challenges and provide opportunities for researchers to understand and model the role of the physical environment.

METHODS

An approach to developing and implementing a structured video-based observational method to study and model complex health systems is presented.

RESULTS

A structured observational approach can be highly effective for collecting multiple layers of data necessary for understanding interactions between the physical environment and other systems components in healthcare settings. The proposed video-based observation method is effective in settings that have clearly defined environmental boundaries, limited number of people, are complex and fast-paced such as the OR, ED trauma rooms, and ICU rooms.

CONCLUSIONS

Video-based observation is an effective complement to the traditional observational method for in-depth study of the built environment in health systems, enabling researchers to employ quantitative approaches to data collection and analysis, in addition to qualitative interpretations.

Impact of Surgical Table Orientation on Flow Disruptions and Movement Patterns during Pediatric Outpatient Surgeries

(1) Background: The surgical table within a typical ambulatory surgery operating room is frequently rotated and placed in different orientations to facilitate surgery or in response to surgeon preferences. However, different surgical table orientations can impact access to different work zones, areas and equipment in the OR, potentially impacting workflow of surgical team members and creating patient safety risks; (2) Methods: This quantitative observational study used a convenience sample of 38 video recordings of the intraoperative phase of pediatric outpatient surgeries to study the impacts of surgical table orientation on flow disruptions (FDs), number of contacts between team members and distance traveled; (3) Results: This study found that the orientation of the surgical table significantly influenced staff workflow and movement in the OR with an angled surgical table orientation being least disruptive to surgical work. The anesthesia provider, scrub nurse and circulating nurse experienced more FDs compared to the surgeon; (4) Conclusions: The orientation of the surgical table matters, and clinicians and architects must consider different design and operational strategies to support optimal table orientation in the OR.

Room Size Influences Flow in Robotic-Assisted Surgery

The introduction of surgical technology into existing operating rooms (ORs) can place novel demands on staff and infrastructure. Despite the substantial physical size of the devices in robotic-assisted surgery (RAS), the workspace implications are rarely considered. This study aimed to explore the impact of OR size on the environmental causes of surgical flow disruptions (FDs) occurring during RAS. Fifty-six RAS procedures were observed at two academic hospitals between July 2019 and January 2021 across general, urologic, and gynecologic surgical specialties. A multiple regression analysis demonstrated significant effects of room size in the pre-docking phase (t = 2.170, df = 54, β = 0.017, p = 0.035) where the rate of FDs increased as room size increased, and docking phase (t = -2.488, df = 54, β = -0.017, p = 0.016) where the rate of FDs increased as room size decreased. Significant effects of site (pre-docking phase: p = 0.000 and docking phase: p = 0.000) were also demonstrated. Findings from this study demonstrate hitherto unrecognized spatial challenges involved with introducing surgical robots into the operating domain. While new technology may provide benefits towards patient safety, it is important to consider the needs of the technology prior to integration.