Work 33 (2009) 145164 DOI 10.

3233/WOR-2009-0861 IOS Press

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The operating room: Architectural conditions and potential hazards

Sonja Koneczny
Experimental-OR, University Hospital Tuebingen, Tuebingen, Germany Tuebingen Center for Patient Safety and Simulation, University Hospital Tuebingen, Tuebingen, Germany Tel.: +49 179 4751715; E-mail: sonja.koneczny@web.de

Received 5 February 2007 Accepted 17 September 2008

Abstract. Ergonomics is still not fully implemented in the design of operation rooms (ORs). The OR staff has to deal with various ergonomic deciencies which may be associated with potential hazards for the patient and/or the OR team. Three surveys were conducted among German OR staff at major conferences. Two of them dealt with the working conditions in the OR and were conducted among surgeons and OR nurses. The third survey queried OR nurses about the electrical safety in the OR. In addition, a specially developed checklist was used to evaluate the work place OR in ve German OR units and the staff of these OR units were queried with questionnaires adapted from the surveys. For this article a few of the deciencies found in the ORs were chosen to serve as examples for the plethora of results gathered. Findings showed that there was a high potential for ergonomic improvement and therefore an increase in safety and comfort. Many of these deciencies may be eased by simple means such as the reduction of the number of different devices and mandatory training in the use of the devices since device operation is one of the main causes leading to potential hazards in the OR. Other deciencies, such as the cable routing in the OR, require more extensive intervention and/or the implementation of new techniques, for example the wireless OR. All these deciencies demonstrate the need for better implementation of ergonomics into the OR and for individual solutions, as there is no such thing as an one-size-ts-all solution for OR units. Keywords: Operating room, OR, architecture, checklist, survey, hazards, cables, devices

1. Introduction 1.1. General overview The operating room (OR) is the operative core unit of every surgical clinic. It is also one of the most sensitive areas as herein invasive manipulation on the patient takes place. Therefore, focus lies on the well-being of the patient and the medical staff puts up with personal restrictions mostly without protest. This might be an explanation for why the OR, as well as the entire OR unit, has mostly been exempted from the ergonomic work place design efforts. In the operating room, the ergonomic deciencies and the resulting problems diminish the satisfaction and

comfort both for the patients and medical personnel as well as increasing risks for both personnel and patients. To prevent this, the existing deciencies need to be identied, quantied and then eliminated with sufcient solutions. In order to identify the improvement opportunities for the conditions at the work place OR, the present state needs to be described and evaluated rst. For data collection in the present project, the approach using a combination of questionnaires/surveys and checklists was chosen. The results from the completed questionnaires deliver subjective information from the employees about the stresses derived from their work places. Objective conclusions about the work place strains can be drawn from the ndings of the checklists. This com-

1051-9815/09/$17.00 2009 IOS Press and the authors. All rights reserved

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bination delivers a complete picture of the particular work place and detailed problems can be described as a basis from where improvement can be developed. To reach employees from as many different hospitals in Germany as possible, surveys regarding the working conditions in the OR were conducted at two national conferences one in 2004 querying 475 surgeons and one in 2005 querying 190 OR nurses. An additional survey conducted in 2006 among 164 OR nurses dealt with the electrical safety in the OR. Using the checklist especially developed for this project, data were gathered OR units of ve different German hospitals on architecture, equipment and work processes. In parallel the respective OR employees were asked to complete questionnaires about their personal impressions, responsibilities and work processes. For this article a few selected examples from the ORs were chosen. 1.2. Scientic background The demographic changes of our society demands that with increasing frequency, older patients need to be treated [20]. These are often multi-morbid patients who are associated with extended surgical procedure times. Medical progress on one hand makes more treatments possible, but on the other hand causes the devices used for treatment to become more and more complex and fraught with risk. This leads to the devices being more and more difcult to operate and new risks occurring with it resulting, to extended treatment times and the associated additional costs, in medical errors. In addition, devices with the same functionality often have completely different operational concepts. From literature it is known that medical error can be found among the ten leading causes of death and that in the USA every year between 44000 and 98000 patients die from the effects of medical error [4,9,10,13,22]. For the design of OR units in the context of building new settings as well as converting old ones, a multitude of regulations need to be met. Many of those regulations were not especially developed for ORs or hospitals, but were derived and adapted from related regulations from other areas. In addition, various recommendations exist regarding, for example, the minimum requirements in the means of room size and equipment of the ORs and the auxiliary rooms. A very detailed recommendation was developed by the German Federal Armed Forces for the OR units in their hospitals [8]. Even if all those regulations and recommendations are considered and met, the anticipated results a maxi-

mum of safety and comfort (for staff and patients) combined with effectiveness and efciency are usually not met to the expected extent. To detect ergonomic problems several methods can be used. One of them is the development and use of checklists: Checklist can be developed to examine specic work places. Such checklists can be helpful in the design of new work places and help to avoid errors in planning and equipment purchase [12]. An investigator trained in the use of the checklist can thoroughly evaluate the work environment. This way, for example, the positioning of the devices as well as the outline of their user interfaces (kind and position of the operational elements) can be noted. Therefore the checklist initially is non-judgmental and only documents the present state. The subsequent analysis then makes comparisons to the ideal states known from research. Positive and negative circumstances will be listed and qualitatively evaluated individually as well as summed up. Checklists are typically used by occupational health services and ergonomists to evaluate work places in industry and at ofces and to make suggestions on the optimization of these work places if needed [1,2,5,7]. For OR units only a rudimentary checklist from Patkin and the aforementioned recommendation of the German Federal Armed Forces exist [8,18]. These lists can be used for planning OR units to assure that no essential elements may be forgotten, as e.g. the mirror in the locker room. It should, however, always be taken into consideration that the structure of an OR unit undergoes constant change and thus a continuous monitoring through new planning aids is required. Another method for detecting problems is the use of questionnaires and personal interviews: Subjective information from the employees and volunteers about their work places and work conditions can be gathered via questionnaires and interviews. Therefore it is important, that the questions are asked in an unbiased and standardized way. Closed questions should always be phrased the same way. For a statistical analysis, simple answers need to be given and only a few open questions should be asked. Interviews need to be conducted by a trained team in a standardized manner. Via well directed single questions and combinations of questions, knowledge can be gained about the stresses on the employees from their work places [3,21,25]. By combining those two methods (checklists and questionnaires), a detailed picture can be drawn of the evaluated OR and the associated impacts of the work place conditions on the employees and therewith on the patients [11,14].

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2. Materials and methods 2.1. Surveys 2.1.1. Survey surgeons The rst survey conducted as a part of the project was a survey among surgeons about the work place conditions in their operating room. Therefore, an extensive questionnaire was developed. In 60 questions, covering all areas of the ORs, the surgeons could state the work conditions at their particular work places. In this study, there was no interest in judging the work practices or work behavior of the surgeons, but only the work places themselves and the work equipment provided by the employers in their particular clinics. Unbiased and standardized questions were asked, and closed questions were always phrased the same way. In order to evaluate the survey, simple answers were given and only a few open questions were asked. For a better overview, the questions were divided into ve main parts: Personal questions (discipline, status, gender, age, ...) Spatial conditions of the operating room (architecture, rooms for anesthesia induction and emergence, OR utilization, interior climate, . . . ) Technical equipment in the OR (OR tables, monitors, OR lights, device operation and instrument handling, . . . ) Work posture (pain (occurrence, reasons, treatment), . . . ) Final remarks (wishes for improvement, quantication of (potential) hazards, over-all assessment of the work place OR, . . . ) To get a maximum sized sample covering the opinions of surgeons from all-over Germany, the survey was conducted among the attendees of the 121st annual conference of the German Society of Surgeons held in April 2004 in Berlin. Interviewers which were familiar with the questionnaires and trained in their use then queried the surgeons attending the conference in oneto-one-interviews. Additionally, surgeons could either ll in the questionnaires themselves, since the questions were only closed questions with given answers to choose from, or they could verbally answer interviewers asking the same questions. The results from the questionnaires lled in by the surgeons themselves and the questionnaires lled in by the interviewers did not differ, demonstrating the questions were unbiased and neutral. The sample size of the surgeons queried on

the conference covers 11.7% of all attending surgeons working in German hospitals, which represents 3% of all surgeons working in German hospitals. 2.1.2. Survey OR nurses One year later, in May 2005, with an adapted questionnaire a similar survey was conducted among OR nurses attending a nursing conference held at the 122nd annual conference of the German Society of Surgeons. The adapted questionnaire contained 75 questions regarding various areas of the operating room. Again, only the working conditions at the work place OR were of interest, not the work behavior of the OR nurse. For a better overview the questions were divided into seven main parts: Personal prole (discipline, main area, gender, age, . . . ) OR preparation (initial checking and starting of the devices, instrument trays and trolleys, single use materials, . . . ) Anesthesia induction and patient preparation, areas for anesthesia induction, OR table accessories and storage of accessories, . . . ) Spatial conditions and surgical procedures (architecture, climate, clothing (scrubs), devices and equipment in the OR, . . . ) Emergence from anesthesia and OR wrap-up (moving patients from OR table into bed, areas for emergence from anesthesia, OR documentation, ...) Working postures (pain (presence, reasons, treatment), . . . ), Final remarks (wishes for improvement, quantication of hazards, all-over assessment of the work place OR, . . . ) This survey was conducted by trained interviewers in one-to-one-interviews and the nurses, too, could ll in the questionnaires themselves if preferred. A total of 190 OR nurses participated in this survey. This represents about 50% of the approximately 350 conference attendees, but is rather low compared to the total number of OR nurses working in German hospitals. However, they represented cross-sectional sample of employees of various German hospitals. 2.1.3. Survey electrical safety The third survey covered the topic electrical safety in the OR. This survey was conducted in October 2006 at a nursing conference held at the German conference for Orthopedics and Trauma Surgery in Berlin. The

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questionnaire comprised 15 questions regarding power outlets, power supply and emergency power in the operating room. The aim of this survey was to nd out if the OR nursing staff is familiar with the different kinds of power supply (regular power supply and uninterruptible power supply) and to detect if there are problems associated with the different systems and the related labeling. A total of 164 conference attendees participated in this study. Unfortunately, the organizers of the conference would not give the total number of conference attendees which makes it impossible to calculate the percentage of the sample size compared to the number of conference attendees. 2.2. Evaluation of OR units 2.2.1. Checklist A checklist was developed for the evaluation of OR units and was validated and improved in an iterative process to evaluate various OR units in Germany and to compare them to each other. For the operating room and the respective auxiliary rooms such detailed checklists did not exist previously. The newly developed checklist was based on a checklist by Patkin [18], which describes the individual rooms of the OR and their most important features, and checklists, which are used in other areas to evaluate work places (e.g. ofce and monitor work places) [2,5,7]. The new checklist is modular and can therefore be adjusted to the particular circumstances in the OR units which are subject to evaluation. This adjustment can be achieved by adding various individual checklist modules to one all-over checklist. For example, a separate individual module exists for every single kind of device, which asks for information about manufacturer, type, dimensions, position in the OR (accessibility), material (disinfectability), accessories, protective equipment, alarms, operational elements (design, size, kind), displays, operational concept, complexity of the (sub-) menu(s), cables and tubes into and out of the device (number, position and type of the connectors, coding by color and/or shape, stickingout connector parts, xation of the cables and tubes), etc. Such a module will be completed for each device in a particular room. The combination of all those individual modules will sum up to the device catalog for this particular room. Likewise, other structures of every single room will be covered this way. All the lists from all of the rooms of the OR unit then be summed into the overall checklist for this entire OR unit. For an

OR unit with three operating rooms and the respective auxiliary rooms this results in a checklist of about 500 pages. For better handling the checklist is divided into six main parts for each room: Spatial and architectural conditions (room sizes, oors, walls, windows, doors, . . . ) Permanently installed equipment (surgical air ceiling, ceiling service units (CSUs), lighting (only room illumination not OR lights), permanently installed cabinets for material and medication, permanently installed shelves and work surfaces, sinks, . . . ) Connections, supply and disposal (power sockets and other electrical connectors, gas connectors and gas bottles, smoke and re detectors, sprinkler system, telephone, intercom, beeper management, garbage disposal carts, . . . ) Equipment of the (operating) room (OR tables, OR lights, OR chairs, instrument trolleys, X-ray image displays, PCs, mobile MIS-towers (oor based not CSUs), . . . ) Devices of the (operating) room (monitors, anesthesia and respiratory devices, radio frequency devices, suction, insufation, heart-lung-machines, cell-saver, laser, C-bow, debrillation, various other devices (such as camera, light source, . . . )) Other (steps, control elements, OR table accessories and accessory storage, . . . ) 2.2.2. Employee questionnaires Since the checklist provided objective data, additional questionnaires were developed to gather subjective data from the employees impressions of their evaluated OR units. These questionnaires were based on the questionnaires from the surveys about the working conditions of the operating room. To receive the most accurate picture of the OR, four individual questionnaires were developed for OR nurses, surgeons, anesthetic nurses and anesthetists. The personal impressions of other groups employed in the operating room (cleaning staff, medical technology staff) were not identied through questionnaires but in personal, questionnaire-oriented conversations with representatives of the queried groups. 2.2.3. Data collection in the OR units The data collection in the OR units always followed the same procedure: In preparation for the data collection, the checklist was adapted to the given hospital

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based on the oor plan provided by the hospital or the architect. Data were usually collected in two days from two persons. On the rst day a dialog was held with one or more persons in charge of the OR unit, who also accompanied the initial tour of the OR unit. Thereafter, the OR processes were observed, initial notes were taken, and the checklists for the auxiliary rooms which were not busy were completed. Concurrently, dialog was held with the employees (especially cleaning personal and medical technical staff) and at the end of the surgical work day, the ORs, auxiliary rooms, devices and inventories were measured and cataloged. On the second day, the questionnaires were handed to the staff and pictures were taken in all areas of the OR unit. Various OR processes and routines were observed in more detail and further dialog was held with the employees. At the end of the surgical work day nal measurements were taken from the ORs and the cataloging was completed. 2.2.4. Hospitals Five hospitals were chosen for the evaluation of OR units. Each of these hospitals shows characteristics of interest for evaluation and subsequent comparison. While hospital 1 is a specialty clinic for one discipline (cardio-thoracic surgery) and hospital 2 is a city owned clinic with eight surgical disciplines, architects ranked them both as modern state-of-the-art ORs, since the surgical areas have been built in the recent years. In contrast, hospital 3 is a maximum care University hospital which was built more than 30 years ago. Hospital 4 combines an old building with a modern extension, in which new concepts (central area for anesthesia induction) were implemented. Hospital 5 is, like hospital 1, a specialty clinic (orthopedic surgery). However, hospital 5 is a solely surgical clinic with a large number of outpatient procedures; thus always striving towards optimizing their workow procedures to meet the demands of outpatients and inpatients in equal measure due to short waiting times while increasing the total revenue.

3.1. Operating rooms 3.1.1. Hospital 1 The OR unit includes four ORs of which the ORs 1 3 are about 50 m 2 and OR 4 at 44 m 2 is a little smaller. Hot water compressors for the heart-lung machines are located in front of ORs 13 with tubes installed through the wall into the ORs themselves. OR 4 originally was not planned to be a full operating room but just an intervention room and therefore has no hot water compressor. The room temperature in the ORs is about 15 C and the air conditioning is loud. Ten of the 14 employees who completed the questionnaire stated that they feel a nasty draft within the OR. ORs 13 have interconnecting doors in the back between rooms to allow staff to move easily between the rooms. Therefore, the patient in each OR is situated toward the front of the room underneath the off-center surgical air supply ceiling. A mobile cart holding perfusors, infusion pumps and monitoring is assigned to each patient as soon as they enter the OR unit. This cart accompanies the patient through the entire OR unit and can be mounted with a clamp to the left side of the OR table next to the patients head. While surgery is performed, the anesthesia devices are always placed next to the right side of the patients head. Since OR 4 originally was not planned to be a full operating room but just an intervention room, the CSU for the anesthesia devices is hanging next to the left side of the patients head, and not the right side as in the ORs 1 to 3. However, as in OR 4 the anesthesia device is placed next to the right side of the patients head like it is in the other ORs; thus, a strand of cables and tubes is routed from the CSU to the anesthesia device. An infusion stand is used to hold the strand of cables and tubes up on the side of the anesthesia devices, keeping the entrance of the OR clear (see Fig. 1). 3.1.2. Hospital 2 The ten ORs of the OR unit have a oor space of 37.5 m2 each. All of them have a 3.2 m by 3.2 m surgical air supply ceiling with side covers reaching down to a height of 1.95 m. The media bar at the lower edges of the side covers hold the power and gas supply outlets (see Fig. 2). Some of the ORs are assigned to one surgical discipline, while the others can be exibly used by all disciplines. OR 8, for example, is assigned to gynecology and ORs 1 to 3 are almost exclusively used by the orthopedics, but the other disciplines can use them as well, if they are available. All ORs with exterior walls have windows with an outside view.

3. Findings The following results are excerpts from the plethora of results, gathered from the surveys,the checklists, and the dialogs with the employees. As examples, some specialties of the operating rooms were selected.

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Fig. 1. In OR 4 a strand of cables and tubes is routed from the CSU via an infusion stand to the other side of the room where the anesthesia devices are positioned.

Fig. 2. The side covers of the surgical air supply ceiling reach down to a height of 1.95 m, where a media bar holds the connectors for power and gas supply.

3.1.3. Hospital 3 The four general surgery ORs of this OR unit each have a connecting door to the sterile corridor which is currently only used to store devices as this corridor now has connecting corridors leading to the extension of the OR unit, which was built a few years ago. Additionally, this corridor holds the daily single-use materials on carts. The circulating nurses and other staff use this corridor to move among the different ORs and

to reach the storage rooms. Therefore, the large swing doors between ORs and this sterile corridor, which can be opened using foot hooks (see also: Discussion, Operating Rooms, Hospital 3, Fig. 10), are propped open almost all the time (see Fig. 3). 3.1.4. Hospital 4 The old OR unit, which had three ORs, had an extension added. With this extension the OR unit now

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Fig. 3. The former sterile corridor is only used for device storage and as way to change between rooms since the newer OR unit extension is connected to this OR unit via this corridor. The carts holding the single-use materials for the ORs are placed here as well. Therefore the connecting doors between the ORs and the sterile corridor are open almost all the time.

Fig. 4. OR 7 has a switchable ventilation system. A light at the control panel shows the actual mode of the system.

has six regular ORs and a casting room which also can be used as a pediatric intervention room (OR 7). OR 4/5 is a wide-span OR with two OR tables in a single space with optical separation via a mobile dividing wall, but acoustical separation is missing. Within this wide-span OR almost only orthopedic surgery is performed. For easier maneuvering of the OR tables, this wide-span OR has two separate doors. OR 7 has a switchable ventilation system (see Fig. 4). If the room is used as a casting room the ventilation is set to negative pressure to prevent the cast particles from spreading over the entire OR unit. Once a week this room is used as intervention room for pediatric surgery; when the ventilation system is set to positive pressure as it is in the regular ORs, too. All the equipment needed for the casting room (e.g. the sink) is mobile and can be removed from this room to allow use as an intervention room.

3.1.5. Hospital 5 The two ORs of the OR unit are similar. Both have a CSU holding the surgical devices and another smaller CSU holding the anesthesia devices. OR 1 is a little bigger and surgical procedures, in which the surgical microscope or the navigation system are used, take place exclusively in this OR 1. Both ORs have windows, but the blinds are permanently closed. The only exception is the window between the two ORs, where the blinds are open just far enough for a glance into the neighboring OR. The reason for the blinds being closed is the architectural location of the OR unit. The OR unit is on the ground level and the walking path from the parking lot to the main entrance leads by directly at the outside windows. OR 1 has a window in the outside wall of the building. As the windows are clear and not frosted glass, patients and visitors could see directly into the OR if the blinds were open. OR 2

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Fig. 5. The blinds of OR 1 and the sterile corridor are permanently closed as the walkway between the parking lot and the main entrance leads by at these ground level windows. Also the blinds of OR 2 right across the sterile corridor window are closed all the time.

Fig. 6. Both of the ORs have a CSU each holding 13 different devices. Only a few of the devices are the same in both of the ORs.

has two windows to the sterile corridor, which has an outside window just across the hall (see Fig. 5). 3.2. Device operation 3.2.1. Device situation in the hospitals In each of the evaluated hospitals, as in most of the German clinics, a large variety of different devices from various manufacturers are present. There are devices used on a daily basis as well as devices only used occasionally for special applications. The following ndings from three of the hospitals serve only as examples. Hospital 1 has four heart-lung machines. For each surgical procedure in which a heart-lung machine is used, a cardiology technician is present in the OR to operate the heart-lung machine. In the area for anesthesia induction different anesthesia devices are used than employed in the OR, but both were manufactured by the same company.

In each of the ORs in hospital 3 about 10 medical technical devices (e.g. suction and RF devices) are permanently placed. Distributed among the various storage and anesthesia induction rooms 75 more devices can be found, which are 55 different devices with respect to type, model and manufacturer. The anesthesia devices used within the OR are different than those used in the anesthesia induction rooms, but also the devices used in the induction rooms are not all the same. However, most of the devices are manufactured by the same company. Both of the ORs in hospital 5 each have a CSU holding 13 different devices (see Fig. 6) as well as an anesthesia and respiratory device. In addition, a navigation device as well as a oor based OR microscope are present to be optionally used in OR 1. This totals 30 devices which were manufactured by 20 different companies. Many of the devices used in OR 1 are from

S. Koneczny / The operating room: Architectural conditions and potential hazards Table 1 Percentage of answers to the statement: The operational elements of the devices are self explanatory and always intuitively usable. As multiple answers were possible the overall sum is more than 100% Surgeons (n = 414) 30% 11% 51% 44% 32% OR Nurses (n = 184) 51% 10% 21% 23% 27%

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Yes. No, the knobs and switches are too small. No, the symbols are ambiguous / incomprehensible. No, the switches can not be clearly assigned to their respective functions. No, the menu is too complex (e.g., due to multiple sub-menus).

Table 2 Distribution of answers for the question: I have read the manuals for the various devices in the OR. As multiple answers were possible the over-all sum is more than 100% Survey of Surgeons (n = 418) 7% 22% 27% 4% 19% 26% Survey of OR Nurses (n = 188) 23% 36% 47% 1% 14% 6% Querying OR employees (n = 135) 11% 33% 41% 8% 30% 4%

Yes, for all the devices. Yes, for the most important devices. No, I had a personal introduction. No, it was not necessary as their operation is so obvious. No, but I know where I can nd the manuals if I need them. No, and I dont know where to nd the manuals if I need them.

different companies than the devices in OR 2 even if they are the same types of devices.

3.2.2. Operating the devices Questions dealing with the use of devices were asked in the questionnaires for the employees of the evaluated hospitals as well as in the surveys about the working conditions in the OR among the surgeons and the OR nurses. The survey among surgeons showed that 70% of them do not consider the operational elements of the devices to be self-explanatory nor always intuitively usable; 49% of the OR nurses see it the same way. This arises from various problems which are shown in Table 1 with their answers to the question. Another question (in the surveys as well as in the employees questionnaires) asked if the participants feel sufciently trained in the use of the devices. Forty-one percent of all surveyed surgeons do feel sufciently trained, 59% do not. Of the OR nurses 60% feel sufciently trained in the use of the devices and 40% do not. A similar number can be found among the queried OR employees: Of all 139 OR employees completing the questionnaires 63% feel sufciently trained in using the devices, 37% do not. Another question dealt with whether or not the manuals for the different devices had been read. The results are shown in Table 2. The overall sum exceeds 100% as combinations of multiple answers were possible.

3.2.3. Cables, tubes and connectors In each of the evaluated ORs cables and tubes were running over the oor and/or freely suspended through the air creating snares leading to stumbling. Sixtyseven percent of the employees in these ORs admitted this fact, 33% denied it. The same question was part of the surveys where 83% of the surgeons and the OR nurses answered that they have cables and tubes running over the oor and/or being freely suspended through the air in their ORs which create snares for stumbling. Many of them feel forced to climb over them while the surgical procedure is performed, to be able to treat the patient (surgeons: 79%; OR nurses: 94%; OR employees: 80%). Fifty-three percent of the surgeons, 64% of the OR nurses and 51% of the OR employees see these cables as a hindrance in their work; the others disagreed. Another question dealt with the connectors on the devices. Forty-six percent of the surgeons state that they are not able to correctly assign the connectors. Also 39% of the OR nurses see problems with the connectors where 51% of them are not able to assign the connectors accordingly. Sixty-three percent of the OR employees, too, have problems with the connectors. In the electrical safety survey, 86% of the participants reported having color coded power outlets for the different power circuits (e.g., white/silver for regular power supply, green for the emergency power supply and red for the uninterruptible power supply). 42% of the participants said that those differences were point-

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S. Koneczny / The operating room: Architectural conditions and potential hazards Table 3 Distribution of answers to the question: In the OR I have to work in an uncomfortable or painful working posture. Survey Surgeons (n = 424) 12% 72% 15% 1% Survey OR Nurses (n = 188) 21% 63% 13% 3% Querying OR employees (n = 130) 7% 73% 18% 3%

Yes, always. Yes, occasionally. No. I never thought about it.

Table 4 One of the previously noted problems with the medical technology or the working posture in the OR has already lead to a potentially hazardous situation (for me, the OR team or the patient) Survey of Surgeons 60% (n = 395) 61% (n = 396) 43% (n = 396) Survey of OR Nurses 48% (n = 176) 82% (n = 186) 71% (n = 182) Electrical Safety Survey 33% (n = 78) Querying OR employees 26% (n = 103) 69% (n = 120) 37% (n = 100) 66% (n = 112)

Device Operation Routing of Cables and Tubes Connectors Working Posture and Pain Power Blackout

ed out during their training; 47% disagreed and 11% could not remember). In addition, 45% of the participants said that these differences were pointed out at their present work place; 45% disagreed and 10% could not remember. According to this survey, a routine check of whether the devices are plugged into the right outlets or not, is carried out in 27% of all cases. 22% said that a routine check is conducted at least occasionally, while 51% denied having such a check. Seventy-one percent of the participants had already experienced at least one power blackout in the OR. Thirty-three percent of them said that surgery continued normally and without problems, while 38% reported minor problems. The other 29% reported that major problems occurred due to the blackout. These problems were mainly caused by devices suddenly failing due to the loss of power and by the OR suddenly being dark (56% each). Eighty-one percent of the participants said that they would prefer to have the devices labeled according to the required power supply. 3.2.4. Pain According to their own statements, many of the medical staff members in the OR are forced to work, at least occasionally, in an uncomfortable or painful working posture (see Table 3). The reasons therefore are diverse. Some of them occur due to problems with devices and instruments (as, for example, standing on one leg while operating a foot switch, retractors and instruments which are hard to hold, displays on devices, . . . ) or due to the properties and conditions of the OR in-

ventory (too wide or too high OR tables, improper OR chairs, . . . ). Others are caused due to work processes, as, for example, excessive exertions while moving a patient from the bed to the OR table (or vice versa), prolonged standing, too little space at the OR table, badly positioned devices, etc. Pains arise especially in the back (more than 80%); but also in the neck, the shoulders and upper arms, as well as in the lower extremities. Thirty-ve percent of the affected surgeons, 59% of the OR nurses and 44% of the OR employees treated themselves due to these pains (e.g., by taking pain medication) or sought professional help (e.g., physiotherapy, massages). 3.2.5. Hazards The surveys participants as well as the OR employees admitted that one or more of the previously noted problems had already lead to potentially hazardous situations some of them frequently. These potential hazards affected either the person itself, a member of the OR team and/or the patient, as shown by the percentages answering yes to these questions in Table 4.

4. Discussion 4.1. Operating rooms 4.1.1. Hospital 1 OR 4 was planned to be a surgical intervention room. As the utilization of the hospital after it was built increased dramatically OR 4 is no longer used as an inter-

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Fig. 7. A mobile cart with permanently installed perfusors, infusion pumps and monitoring is assigned to each patient when entering the OR unit. With a special clamp (see left picture) this cart is mounted to the OR table. Due to the design of the cart and the clamp this cart can only stand next to the left side of the patient.

vention room but as a regular OR. However, the room was never remodeled for its new use. This results in the CSU for anesthesia providing the power and gas supplies for the anesthesia and respiratory devices being mounted in a way that it is hanging next to the patients left side. A mobile cart with permanently installed perfusors, infusion pumps and monitoring is assigned to each patient when entering the OR unit. Due to its structural shape the cart is designed to also be positioned next to the left side of the patients head (see Fig. 7). Therefore, the anesthesia and respiratory devices always stand next to the right side of the patients head and in the ORs 13 the CSUs for anesthesia are mounted next to the right side of the patient accordingly. In OR 4 the cables and tubes are routed from the CSU, hanging next to the left side of the patient, to the devices, positioned next to the right side of the patient, using and infusion stand to hold them up currently. Not only does this evoke the feeling that the room is very small and crowded, but also takes up valuable space. This kind of cable routing and the length of the cables and tubes may cause additional problems, such as an increased wear of the cables and tubes due to the routing via an infusion stand (e.g., by buckling or fraying) which may result in short-circuits and gas leaks, tearing out the connections after getting caught, etc. These problems may be solved in different ways: One possibility would be to relocate the CSU on the

right side of the OR. This could be completed over a weekend and in at worst, some of the pipes for air conditioning and heating running across the new position of the ceiling service unit would need to be relocated. This OR is never used on a weekend and it can be shut down separately not interfering with the other ORs. Another possibility would be to install some additional outlets for gas and electricity in the wall next to the anesthesia and respiratory devices, then the device could be connected to them. A large disadvantage of this solution would be the cables and tubes running from the wall to the device eliminating usage of the passage way between device and wall. A third possibility would be to redesign the infusion and monitoring carts in order to be able to place them next to the right side of the patient. This could be achieved by simple means (time, materials and costs). The biggest disadvantage would be, that the staff would be forced into unfamiliar situations, especially the anesthetists then being forced to work ,right-left-reversed, which could induce errors. The size of the OR is another drawback. Although a size of 44 m2 is sufcient for a regular OR, due to its shape the use of a heart-lung machine in this room is almost impossible. Therefore, the OR schedule is arranged such that in OR 4 only procedures which do not require the use of a heart-lung machine are performed. Accordingly, OR 4 has no hot water compressor or wa-

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Fig. 8. Un-isolated tubes lead from the hot water compressor (located on the corridor in front of the OR) in large loops within the 15 C cold OR to the heart-lung-machine.

ter connectors for the heart-lung-machine. Due to the de-centered surgical air supply ceiling in the ORs 1 to 3 surgical procedures in these rooms take only place in the front portions of the rooms. The back parts are almost never used for surgery and therefore serve as a staff walkway through the three ORs. If a heart-lungmachine is used for a surgical procedure it is always placed next to the left side of the patient. The surgeon and the nurse handing the instruments usually stand next to the right side of the patient, with a lot of space behind their backs which can be used as a walk way. These free spaces show, that the 50 m 2 of the rooms are generously spaced and that the 44 m 2 of OR 4 should be sufcient for the use as a regular OR if the correct modications would be made. The air conditioner in the entire OR unit is very loud and two thirds of the employees feel a nasty draft. Also two thirds of the employees consider the room temperature as too cold, which is not very remarkable as the room temperature measured in OR 1 was only 15 C. The warm water tubes for the heart-lung-machine are routed from the hot water compressor, which is located on the corridor in front of the OR, through the wall and then in a 2 m loop laying on the OR oor to the machine (see Fig. 8). These tubes are un-insulated and with a room temperature of only 15 C the water may cool down quickly. As the water used in the heart-lung machine should have a temperature of about 35 C to 37 C, the compressor requires more energy to heat up the water to compensate for the loss of heat due to the cold OR and the un-insulated tubes. Insulating the tubes would help to save energy of extensive heating of the water. An additional change in the room temperature to a few degrees more would not only save energy, but would also help most of the employees to feel more comfortable in their OR.

4.1.2. Hospital 2 The large windows make the OR unit pleasantly bright and friendly. However, in some of the ORs frosted plastic lms were attached to the large windows to screen the OR from view from outside (see Fig. 9). The anesthesia recovery room has a large window row as well. However, this room is not screened from view by frosted plastic lm or similar protection. Due to the architectural layout of the OR unit looking into the room from outside is more difcult, but it still is a possible violation of the patients private sphere and may give the staff a feeling of being watched. The ORs have blinds which are good glare shields and allow for complete darkening of the OR. The side covers of the surgical air supply ceilings in the ORs incur several problems due to the media bar at their lower edge at the height of 1.95m. For tall employees there is the potential hazard of banging their heads on either the bar itself or a device which is connected to it. For short employees the problems are that they can hardly reach the connectors (gas, power, . . . ) to plug in devices or gas tubes. As all ORs in this OR unit have the same layout, they can be used by all the surgical disciplines equally. Only a few of the ORs are permanently assigned to one of the disciplines. The ORs 13 belong to orthopedics, as they are the closest to the orthopedics storage room and the special orthopedics equipment is installed or located in these three ORs. However, if no orthopedic procedure is planned, these ORs can be used by any other discipline as well. Another permanently assigned OR is OR 8. It is assigned to gynecology which is due to the fact, that the neonatal warmth room is right next to this OR. 4.1.3. Hospital 3 The connecting doors between the ORs and the sterile corridor are almost permanently open. This is crit-

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Fig. 9. On some of the windows a frosted plastic lm had to be attached as a view from outside into the room was possible before.

icized by the hospitals hygiene department every time they do their regular routine checks of the OR. After those routine checks the doors stay closed for about a week which is, according to the staff, very impractical and time consuming as the carts holding the singleuse materials for the ORs are located on the sterile corridor. According to the OR management, a study investigating whether the post-surgery infection rate is lower if the doors are closed was not and will not be conducted. Many of the swing doors have foot hooks for opening the doors (see Fig. 10). Therefore the foot (usually with the toes) is hooked into this foot hook and the door is opened by pulling the foot back towards the body. This mode of opening a door is linked to an increased risk of injury, especially as the shoes in the OR usually are open at the heel and might slip off or get stuck. The

foot hooks bear an additional risk as with walking by these doors staff may bump into the hooks and stumble over them. This is especially painful with the squared hooks as found on the connecting doors between ORs and sterile corridor. 4.1.4. Hospital 4 OR 7 which is used as casting room as well as an intervention room for pediatric surgery, has a special ventilation system which can be switched between negative and positive pressure. This makes the room more exible even if a few restrictions still persist. Thus, for example, is does not make sense to use the room as casting room and then use it as an intervention room before it was not thoroughly cleaned. This thorough cleaning is only done in the evenings after all the surgical procedures in all the ORs are nished. Therefore,

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Fig. 10. Many of the swing doors have foot hooks for opening the doors. Some of them are rounded (as e.g. at the connecting doors between washing rooms and Ors) others are squared (as e.g. at the connecting doors between ORs and sterile corridor).

Fig. 11. A glance into the 14 m2 small OR 7 during a pediatric intervention.

the use of OR 7 follows the strict rule, that it is used as pediatric intervention room one morning a week and as casting room the rest of the time. However, this solution illustrates a problem, too. This is the fact, that during the time the room is used as pediatric intervention room, the OR unit has no casting room. Additionally, the use as a pediatric intervention room has several disadvantages. First, with its room size of only 14 m 2 (width: 2.6 m; length: 5.4 m) the room is extremely small for an OR. To use this room as an OR does only work out if combined with the use of the smaller pediatric OR tables, a diminished number of devices and the minimum number of staff. Therefore this room is only used for minor interventions (see Fig. 11). Second, there is the problem that the faucet for the casting rooms mobile sink still works even if the sink is not placed underneath it. This may cause water running on the oor, creating a puddle and making the

oor extremely slippery and dangerous. Thus, even if the mobile sink is placed underneath the faucet this problem is still present if the drain of the sink and the drain in the wall are not properly lined up. Currently this problem is solved by slipping a surgical glove over the faucet and the handle lever to prevent inadvertent operation of the faucet. Additionally, signs on the mobile sink and at the wall remind of the diligence to line up the drains properly (see Figs 12 and 13). The wide-span OR (ORs 4/5) is used exclusively by orthopedics. As it is often very loud during an orthopedic surgery, due to the use of drills, trephines, saws, hammers and chisels, which this may affect concentration for the procedure at the neighboring table. Separating the two OR tables optically using a mobile dividing wall (see Fig. 14) does not change this, as no acoustic separation between the two OR tables is given. Since both tables have a surgical air supply ceiling with

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Fig. 12. While the room is used as pediatric intervention room the mobile sink is removed from the room. Therefore the drain in the wall (black box underneath the faucet) is built in a special way. The glove prevents inadvertent operation of the faucet by keeping it shut.

Fig. 13. Signs on the mobile sink as well as at the wall remind of the diligence to properly line up the drains (Please take care, that the drain of the mobile casting sink is properly lined up with the drain in the wall. Thanks!!!!). If they are not lined up water will run onto the OR oor.

side covers, it is also not possible to suspend the ceiling with sound-absorbent elements. Due to the architecture of the operating area, it is not possible to divide the room with an additional wall. Then either the patient would require additional maneuvering through the current door and a new door in the new wall between OR 4 and OR 5 (see green arrow in Fig. 15), or a new entrance door through the current storage space must be added, which would eliminate storage and also requires extra patient maneuvering (see red arrow in Fig. 15). It could be taken into consideration to assign this widespan OR to another less noisy discipline. However, orthopedics is probably the discipline which is best in handling a noisy environment. In addition, other then this wide-span OR, only OR 6 has laminar airow and is therefore according to DIN 1946-4 suitable for large implant and prosthesis procedures [6], not ORs 13.

4.1.5. Hospital 5 The climate control in the ORs causes a nasty draft. With less the 18 C (which are only exceeded after the climate control is turned off) it is unpleasantly cold in the OR for everyone who is forced into a static working posture like anesthetists and nurses. Unfortunately none of the surgeons, who have a more dynamic working posture, participated in the questionnaire. Therefore, it is unknown how the surgeons feel about the room temperature. For the anesthetist, whose working posture is seated most of the time while watching the anesthesia and the patients vital signs wearing only the short sleeved scrubs, the room temperature is too low. In this hospital the anesthetists remedy this by laying a heating mat around their shoulders (see Fig. 16). As the OR unit is on the ground level and the walking path from the parking lot to the main entrance leads by directly at the outside windows, the blinds of the

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Fig. 14. The two tables of the wide-span OR are optically separated by a mobile dividing wall. An acoustic separation is not given.

Fig. 15. A subsequent separation of the two tables of the wide-span OR by building an additional wall would result in accessing OR 4 through the front area of OR 5, how it is done at the moment, but then through an additional door, or through a newly built access are which would replace one of the storage rooms. Both access ways would be associated with increased maneuvering of the OR table.

outside windows of OR 1 and the sterile corridor are closed permanently. Frosted plastic lms attached to the clear window glass should be considered. This way, it would no longer be possible to look into the OR from the outside and the blinds could remain open.

Thus, the OR would have daylight (even if without a view). But this might bring up another problem when daylight glares the OR team. The blinds between OR 2 and the sterile corridor are permanently closed as well, although this is not necessary. It only prevents

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Fig. 16. As the anesthetists consider the room temperature in the OR as too low and a nasty draft is present, they use the heating mat to stay warm while the surgical procedure is performed.

employees who are on the sterile corridor from looking into the OR. However, employees pass by these windows only on very rare occasions, only if they need to get instruments, implants or devices for OR 1 from the storage room or the shelves on the sterile corridor, or if an employee changes between the ORs using the sterile corridor (and not the washing room). For the employee changing between the ORs the look into the OR would not matter at all, as he or she is about to enter OR 2 or just left it. 4.2. Device operation 4.2.1. Device situation in the hospitals As the different anesthesia and respiratory devices in hospital 1 are from the same manufacturer, their operational concept is similar. However, they vary widely in the range of their features. This is volitional as now for anesthesia induction a smaller, easier to operate device can be used, which offers all features necessary for inducing anesthesia without confusing the anesthetic staff with additional features only needed in long and complicates surgical procedures. Hospital 3, the University hospital, uses a large variety of different anesthesia devices. Even if most of them are manufactured by the same company and, therefore, have similar operational concepts, they vary widely in their range of features and their operation. The hospital tries to justify this fact with being a teaching hospital and trying to train their employees to be exible. However, according to the own statements of the anesthetic

staff, problems occur in the operation of this variety of devices and the manuals were not read by everyone. The University hospital employs two medical technicians who solely are responsible for these anesthesia devices. According to them, about 50% of their service is due to operator errors alone. Also, the large number of different devices leads to problems. In hospital 3 about ten devices, which are frequently used, are permanently placed in every OR. In addition, 75 devices are located in the OR unit which can be brought to every OR depending their use. These 75 devices are 55 different devices by type, model and manufacturer. This means that every employee should be able to operate each of these 55 devices (plus the ten in the ORs) safely. 4.2.2. Operating the devices The devices in the OR are typically stand-alone solutions from various manufacturers, which can not be optimally positioned around the surgeon and whose operational concepts are not adjusted to each other. Unfortunately, integrated OR-systems are still rare and do not offer the integration of all the devices used in an OR. In addition, devices with the same mode of operation often have completely different operational concepts. Therefore, it is, for example, almost impossible for an anesthetist to change from a device manufactured by company A to a device manufactured by company B or C without having a related training. According to their own accounts, few read the manuals for all the devices (87 of 741 participants (surgeons,

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OR nurses and OR employees), this equals about 12%). However, diligence demands that every manual is read and understood before rst use. Disregarding this is, at least in Europe, relevant for prosecution [23]. For every device which is present in the OR and therefore likely to be used, each potential user should have had a (personal) introduction into the devices [16,17,19]. This also applies only for about a third (34,5%) of all participants. Thus, the secure interaction between the user and the equipment can be optimized by the operator with selective organizational measures, such as simulations and training. Operators and users need to be aware of their responsibilities. It is absolutely unacceptable that according to their own accounts 70% of the surgeons (in 2004) and 50% of the OR nurses (in 2005) are not able to operate the devices correctly. Surgeons try to excuse the fact, that almost 60% of them do not feel sufciently trained in operating the devices, by stating that nurses are responsible for device operation in the OR and not themselves, and that it therefore is not too severe that they are not able to do it. It is not reassuring that 40% of the OR nurses do not feel sufciently trained in using the devices. Thus, chances are rather high to run into an OR team where nobody feels sufciently trained. Therefore, all groups and institutions involved in product development, testing, operation and use of medical products need to be concerned about improving the safety of use of the medical products. 4.3. Cables, tubes and connectors The fact that only 67% of the participating OR employees (n = 138) state that in their ORs cables and tubes are running over the oor and/or freely suspended through the air creating snares for stumbling, even if the use of the checklist showed that it should be 100%, suggests that the OR employees do not see them as stumbling snares. This may be on the one hand due to getting used to this situation over time, or on the other hand be due to reaching a certain point where they can not see the woods for the trees. Many of the employees do not feel disturbed by this situation. Therefore, only about half of the participants stated that they felt hindered in their work by the way cables and tubes are routed in the OR. However, a large number of the participants need to climb over these cables and tubes during a surgical procedure. This does not only induce the risk of stumbling and eventually hurting oneself, but also bears the potential hazard of disconnecting cables and tubes and therefore endangering the patient

and/or the entire OR team. In an industrial setting this situation would be unacceptable. In industry, these cables need to be xed to the oor with black-yellow or red-white striped adhesive tapes and danger signs need to be applied according to the German Unfal lverhutungsvorschrift (regulation for preventing accidents) [24]. Combining the results from the surveys about the working conditions in the OR and the results from the questionnaire for the OR employees from the OR evaluation with the results from the electrical safety survey leads to the following ndings: More than a third of all participants state that they have difculties to correctly assign the devices connectors, plugs and sockets. This may lead to major problems. In addition, considering the fact that the devices can be plugged into three different power circuits, which even are color-coded, but only 42% of the participants being taught the differences during training and only 45% at their present work place, further problems arise. A regular check occurs only 27% of the time and therefore has very little effect. This shows up in the problems occurring during power blackouts; with 56% of the problems being caused from devices shutting down which shows that they were not plugged into the right sockets. Simple color-coding on a device would be a sufcient hint for assigning this device to its respective power supply. This would minimize the risk of connecting lifesustaining machines to the regular power supply where they would shut down in case of a power blackout, instead of connecting them to uninterruptible power supply where the would stay powered. Many hospitals perform an announced test of their emergency power system regularly, often resulting in all devices, regardless if important or not, being plugged into the sockets for the uninterruptible power supply for the duration of the test and being forgotten to be plugged back after the test into the right sockets. Sometimes this results in the case of a power blackout in unimportant devices, such as a battery charger, being plugged into the uninterruptible power supply and the battery backup being not strong enough for the really important devices. 4.4. Pain Other workplace where this many employees accept uncomfortable and painful working postures are very rare. Only 15% of all participants state, that in the OR they never had to work in uncomfortable or painful working postures. Interestingly, 15 participants (equals 2%) never thought about if their working postures were

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uncomfortable or painful. The other 83% experienced, at least occasionally, pains caused by their working posture. This reveals the culture developed over the years in the OR: the patients and their well-being take precedence within the OR and the staffs personal interests are left behind. The list of reasons for an uncomfortable or painful working posture is long [15]. Many of the reasons could be avoided, if the underlying problems were eliminated by appropriate actions. A large number of these problems require the help of the medical technical industry for their solution. A smaller, but not less important number demand the (simultaneous) restructuring of work processes. Pain often occurs, for example, when transferring the patient from the bed onto the OR table or vice versa. This task can be performed in different ways. On the one hand it can be done using an automated transferring aid or on the other hand it can be performed using muscle power. Transferring the patient using muscle power is fast, but may cause pain and injury in back, shoulders, arms and neck. In contrast, transferring the patient using the automated transferring aid does not cause pain, but requires more time. Thus, it is important to adapt the work processes in the OR accordingly to allow the time for the employees to actually use the automated transferring aid and that they consider it as a valuable aid supporting their work and not hindering it. The medical technical industry is, for example, required for the modication of OR tables. OR tables cause various problems potentially associated with pain. An OR table which is too high even if it set to its lowest level (e.g. in minimally invasive surgery), forces the surgeon to either use a step stool (which is associated with further problems and potential hazards) or to work with elevated arms which may cause pains in arms, shoulders, neck and back. If the table is too wide (e.g. in thoracic surgery if the patient is placed on his/her side), the surgeons have to (or must) bend over the table, potentially causing pains in back, neck and lower extremities. The clamps which are used to mount the accessories to the OR table may not only hinder the optimal position at the OR table, but also cause pains due to pressure points or forced working postures. Since the list is long, a large potential exists to solve these problems. Through suitable modications of the existing systems and/or through the development of new systems the OR could become a mostly pain-free workplace, if the work processes within the OR simultaneously are restructured.

4.5. Hazards Nearly every problem in the OR sooner or later causes a potentially hazardous situation for the OR team and/or the patient. Many of them, however, could be prevented prior to a hazardous event. Sufcient training in operation of the devices as well as a modication of the operational concept by manufacturers could dramatically decrease the potential of hazards for operating the devices. Due to the implementation of media bars and wireless transmission, cables could be widely banished from the OR, and, therefore, the risk of hazards evoked from cable routing could be minimized. Intuitive labeling on connectors would prevent risks due to false assignment of connections. Modications of medical technical equipment and work processes could prevent working postures which are painful for the staff which evoke potential hazards. Notication, education and training via simulations could reduce the potential hazards associated with power blackouts within the OR.

5. Conclusion The surveys, the querying of the OR employees, and the evaluation of the OR units using the checklist pointed out various problems requiring sufcient solutions, as these problems cause disturbances in the ORs work processes, violations of the patients private spheres and discomfort or even potential risks for the OR employees and the patients. Optimization of the OR units may be achieved via various short-term, mid-term and long-term solutions: 5.1. Short-term solutions There are several short-term solutions. Particularly relevant for safety are the organizational actions such as training of employees. But also a reduction of the number of different devices can increase safety. For all the problems, however, short-term solutions are only improving immediate measures, but not permanent best-practices solutions. 5.2. Mid-term solutions For other problems a remedy can be found in midterm solutions. Compared to the short-term solutions these solutions are associated with a greater effort; therefore, deliver more extensive remedies. These mid-

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term solutions, for example, include the evaluation of potential modication measures for the entire OR unit to ease problematic areas as well as the modication of the devices and the improvement of usability by the manufacturers 5.3. Long-term solutions Most of the problems in an OR unit, however, require long-term solutions, even if an improvement can be achieved by short- or mid-term solutions. Those solutions oftentimes are vision of the future, as the respective technology is not yet sufciently developed and tested. Thus, in the near future their implementation should be possible; therefore, all potential possibilities for a long-term solution need to be taken into consideration. These long-term solutions include, for example, the automation of storage and ordering systems in the OR using RFID technology or a wireless OR. The optimization of oor plans for new hospital buildings and OR units plays an important role. There is no one-size-ts-all solution for OR units. Individual solutions need to be found for every OR unit that will be built considering all the potential users and their special needs early in the planning phase. Mistakes which were made in previous designs need to be taken into consideration to learn from them and their effects and to avoid making them all over again. Thus, with high diligence optimized oor plans can be developed which are able to support the work processes in the best possible way.

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