PHYSICAL LAYOUT THE OPERATING ROOM

An operation theatre is the "heart" of any major hospital. An operating theatre, operating room, surgery suite or a surgery centre is a room within a hospital within which surgical and other operations are carried out.

OT are designed and built to carry out investigative, diagnostic, therapeutic and palliative procedures of varying degrees of invasiveness. Many such setups are customized to the requirements based on size of hospital, patient turnover and may be speciality specific.

The aim is to provide the maximum benefit for maximum number of patients arriving to the operation theatre. Both the present as well as future needs should be kept in mind while planning OT.

OT design

Several basic design types are used in surgical services departments, depending on the age of the facility and the physical design of the areas outside the department. All surgery departments are designed with the idea of controlling traffic patterns and quickly providing each operating room (OR) with the necessary supplies during and after each case, while keeping clean and contaminated traffic patterns separate.

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

• Central corridor plan – these plans are two types
  • Racetrack plan - In this design, the front entrance to each OR is from the outer corridor, and supplies are retrieved through a rear entrance to the room leading to the central-core storage and work areas.

    

  • Hotel plan - In this design, the ORs are situated along a central corridor, with separate clean core and soiled work areas. The primary difference in this plan is that all traffic enters and exits the surgery department through a single entrance or a primary entrance and holding area entrance situated along the same corridor.

    

• Peripheral corridor - In this design, the front entrance to each OR is from the peripheral corridor, and supplies are retrieved through a rear entrance from the OR leading to the central-core storage and work areas.

  

• Specialty grouping plan - The "specialty grouping" plan is simply a variation on the hotel or race track plan, in which ORs are grouped by specialty (e.g., neurosurgery, general surgery), each with its own closely associated clean storage areas and, in some cases, each with its own soiled instrument work area.

The design of any surgery department revolves around environmental control, traffic control, and the desire to prevent surgical site infection (SSI). Such factors as the separation of clean and soiled work areas and areas of the department specified as restricted and unrestricted assist in the promotion of this idea. Efficiency is increased with strategic placement of computers, preparation areas, and staff areas.

Different Zones/ Areas

Regardless of the design chosen by the facility, certain principles apply universally. Traffic control follows predetermined traffic patterns that all persons entering the department are expected to follow. The OR department is divided into four zones based on varying degrees of cleanliness, in which the bacteriological count progressively diminishes from the outer to the inner zones (operating area) and is maintained by a differential decreasing positive pressure ventilation gradient from the inner zone to the outer zone.

1. Unrestricted zone or clean area.
2. Semi restricted zone or sub sterile area
3. Restricted zone or sterile area
4. Disposal zone or area

1. Unrestricted/ Clean zone or clean area

• This is the area where hospital personnel, OT personnel, patient's & their attendants can move about in street clothes.
• Connects protective zone to aseptic zone and has other areas also like
  • Stores & cleaner room
  • Equipment store room
  • Maintenance workshop
  • Kitchenette (pantry)
  • Firefighting device room
  • Emergency exits
  • Service room for staff
  • Close circuit TV control area

1. Semi restricted/ Protective zone or sub-sterile area

• After changing from street clothes, with clean gown, cap & OT slipper, the OT team or personnel are, enter in this area. (Operating room attire is required)
• It includes -
  • Change rooms for all medical and paramedical staff with conveniences
  • Transfer bay for patient, material & equipment's
  • Rooms for administrative staff
  • Stores & records
  • Pre & post-operative rooms
  • I.C.U. and P.A.C.U.
  • Sterile stores

1. Restricted/Aseptic zone or sterile area:

• This zone has operation theatres & operation room where operations are done.
• This is a place where staff & patients in street clothes & shoes are not allowed to enter. Scrubbed personnel wear sterile gowns & gloves & get ready for operation procedure. (Operating room attire is required)

1. Disposal zone or area

• Dirty utility area
• Disposal corridor
• OT attire mandatory in this area

Advantages of zoning

• Minimizes risk of hospital infection.
• Minimizes unproductive movement of staff, supplies & patient.
• Increases efficacy of operative team members.
• Ensures smooth workflow.
• Deceases hazards in operating room.
• Ensures proper positioning of equipment's.

Sub areas

• Nurses station or counter - Nurses station is an area where nurses and other health care staff sit behind when not working directly with patients and can perform some of their duties. The station has a counter that can be approached by visitors and patients who wish to receive attention from the nurses. It should be spacious enough to allow two or more personnel to work together.
• Pre-operative check area (reception) - It is the area where OT nursing personnel receive patients. Here patients and his records are checked.
• Holding area - This area is planned for IV line insertion, preparation, catheter / gastric tube insertion, connection of monitors, & shall have O2 and suction lines. Facility for CPR should be available in this area.
• Induction/Anaesthetic room - It should have all facilities as in OT, but there is controversy as to its need. It should provide space for anaesthetic trolleys and equipment and should be located with direct access to circulation corridors and ready access to the operating room. It will also allow cleaning, testing and storing of anaesthesia equipment. It should have sufficient power outlets and medical gas panels for testing of equipment.
• Post anaesthetic care units (PACU)/Post–operative or recovery room – Room where patients are kept & cared until they are out of anaesthesia & until their vital signs become stable. These should contain a medication station, hand washing station, nurse station, storage space for stretchers, supplies and monitors / equipment and gas, suction outlets and ventilator.
• Staff room – Men and women change dress from street cloth to OT attire; lockers and lavatory are essential; rest room etc. are desirable.
• Sanitary facility for staff- One washbasin and one western closet (WC) should be provided for 8-10 persons. Showers and their number is a matter of local decision. Inclusion of toilet facilities in changing rooms is not acceptable; they should be located in an adjacent space.
• Offices – for staff nurse and anaesthesia staff- The office should allow access to both unrestricted and semi-restricted areas as frequent communication with public is needed.
• Rest rooms- Pleasant and quiet rest for staff should be arranged either as one large room for all grades of staff or as separate rooms; both have merits. Comfortable chairs, one writing table, a book case etc., may be arranged.
• Laboratory – Small laboratory with refrigerator for pathologist to be arranged.
• Seminar room- Since staff cannot leave an OT easily, it is better to have a seminar room within the OT. Intra-departmental discussions, teaching and training sessions for staff (with audio-visual aids) may be conducted here.
• Store room-
  • These rooms should have steel cabinets & separate for specific items.
  • These cabinets should be spacious enough to accommodate various items such as sterile linens, sterile trays, sterile drums with sponges, dressings, cotton swabs, bandages, sterile rubber sheets, catheters, sutures, syringes, infusion & transfusion sets.
  • A separate store room is needed for unsterile, clean articles such as linen, OT dress items, stainless steel equipment's
  • The cabinets of store rooms should be made up of such materials which can be cleaned & washed without being damaged.
  • There should be bigger store room for equipment's such as monitoring devices, suction apparatus, O₂ cylinder, trolleys, wheel chairs, stretchers, defibrillator, pace makers, bed urinals, OT slippers etc.
• Scrub room- This is planned to be built within the restricted area. This should be spacious. Sometime s two or three operation theatres can share one scrub facility. Scrub area should have deep & wide shink to avoid splash of water on the surrounding area. There should be facilities for running water. The taps should be such that they could be opened or closed by foot pedals or they have long handles that can be operate by elbows.
• Waiting room – Patient's attendants or family member's waiting room with attached toilet & drinking water facility.
• Visitor's gallery - Gallery from where the visitors can see the operative procedures being performed.
• Utility Room - This is also called clean up room where instruments, articles, gloves are received following surgical procedures. Here all these are cleaned, washed & wiped dry & then wrapped, stored & sent for sterilization.
• Disposal or sluice room - This room receives all soiled linen & dressing. Here all disposable items are separated according to biochemical waste management code & then packed in leak proof containers. The soiled linens are sent to the laundry. The OT set up should be such that it should be possible to dispose off soiled items without taking them through sub-sterile or sterile areas.

OPRETING ROOM

NUMBER & SIZE

• The number & size can be as per the requirement.
• The standard OT should be rectangular or square in shape and similar in design.
• It should be 20×20×10 feet in size so it provides a floor space of 400 Sq. feet approx.
• It should be spacious enough to allow free movement of personnel, trolleys, stretchers, wheel chairs, monitoring devices, portable x-ray machines etc.
• Cardiac or neurosurgery OT should be bigger in size of 20x30x10 feet with 600 sq. feet floor space.
• OT for endoscopy or minor surgery can be of small size of 18x18x10 feet with a floor space of 324 sq. feet.

DOORS

• Main door to the OT suite has to be of adequate width (1.2 to 1.5 m).
• The doors of each OT should be spring loaded flap type, but sliding doors are preferred as no air currents are generated.
• All fittings in OT should be flush type and made of steel.

SURFACE / FLOORING

• The surface / flooring must be slip resistant, strong with minimum joints.
• It should be easily washable, free as possible joints, seams so that they do not permits adherence of bacteria or dust particles containing microorganism.
• It should be able to withstand repeated washing with germicidal agents.
• It should be able to absorb sound.
• The colour of the flooring should be such that if a needle is dropped on the floor it is visible.

WALLS

• The walls, ceiling & floor surfaces should be made of hard fire resistant, smooth, non-porous material.
• It should be light in colour (light blue or green) and washable paint should be ideal.
• Colour of paint should allow reflection of light and yet soothing to eyes.
• Adequate electric points should be available on the wall at < 1.5 m height from the floor.

SCRUB STATION

• For sterile hand wash
• Types: Stainless/ Granite/Marble/ Cement
• Gradient of basin forward and downwards
• Gradient towards outlet
• Hot water mixing: automatic or manual
• Non splashing taps; possible to change direction
• Elbow/ Foot or Infra-Red operated taps
• Soap dispenser: Manual/automatic
• to be planned for at least for 2-3 persons in each OT.

VENTILATION, TEMPERATURE & HUMIDITY

• The OT Require Efficient ventilation that will control temperature and humidity in OT and dilute the contamination by microorganisms and anaesthetic agents.
• The ventilation in OT should follow the principles that the direction of airflow should take place from the sterile to the clean zone & form the clean zone to the less clean areas.
• There should be no open window in the OT and sliding doors of the OT should be open from the OT towards the sub sterile zone.
• There should be no interchange air movement between one OT and another.
• There should be no circulating fan or cross ventilation to prevent airborne contamination of the surgical wound.
• An effective ventilation system is necessary to exchange the air. This air is filtered with an efficient air filtering system.
• There are two types of air conditioning systems : recirculating and non recirculating.
• The circulating system takes some or all of the air, adjusts the temperature and circulates air back to the room.
• Non-recirculating systems heat / cool the air as desired and convey it into the operating room with ideally 20-air exchange per hour. Air is then exhausted to outside. Anaesthetic agents in the OT air are also automatically removed. These are thus ideal but are expensive.
• The broad recommendations include:
  • 20-30 air exchanges / hour for recirculated air
  • Only up to 80% recirculation of air to prevent build-up of anaesthetic and other gases
  • Ultraclean laminar airflow – the filtered air delivery must be 90% efficient in removing particles more than 0.5m m.
  • Positive air pressure system in OT: It should ensure a positive pressure of 5 cm H2O from ceiling of OT downwards and outwards, to push out air from OT.
  • Relative humidity of 50-60% to be maintained
  • Temperature between 18o-24oC. Temperature should not be adjusted for the comfort of OT personnel but for the requirement of patient, especially in paediatric, geriatric, burns, neonatal cases etc.

LIGHTING

• The general room illumination the OT is provided by fluorescent lamps (surface ceiling mounted) to produce even illumination of at least 500 Lux at working height, with minimal glare are preferred.
• This contrast should be maintained in corridors and scrub areas, as well as in the room itself, so that the surgeon becomes accustomed to the light before entering the sterile field.
• To minimize eye fatigue, the ratio of intensity of general room lighting to that at the surgical site should not exceed 1:5, preferably 1:3.
• Colour and hue of the lights also should be consistent.
• The surgical or operation light should be an overhead ceiling mounted unit.
• The overhead operating light must:
  • Overhead light should be near daylight in colour and shadow less and give25000-125000 Lux of light (50000 to 100000 Lux at the centre and at least 15000 Lux at the periphery).
  • Give contrast to the depth and relationship of all anatomic structures. The light may be equipped with an intensity control mechanism. The surgeon may ask for more light when needed therefore a reserve light should be available (e.g. a mobile operation light).
  • Provide the diameter light pattern of a focus appropriate for the size of the incision. These are adjusted with controls mounted on the light fixture.
  • Be freely adjustable to any position or angle. Most overhead operating lights are ceiling mounted on mobile fixtures. It can be positioned so that light is directed into a single incision or two concurrent operative sites.
  • Be spark-proof where anaesthetic gases are used.
  • Produce minimum heat to prevent injury to exposed tissues, to ensure the comfort of the sterile team, and to minimize airborne microorganisms.
  • Be easily cleaned. Tracks recessed within the ceiling virtually eliminate dust accumulation. The radiant heat produced by the light should raise the tissue temperature not more than 2^oC.

EMERGENCY SIGNAL

• The OT management committee should consider installing an alarm system in case of a life-threatening emergency.
• The activation of this alarm will save valuable time to mobilize the emergency designate staff and direct them to the site of the emergency.

OTHER FACILITIES OF OR

• Electric generator - OT department should have electric generator to ensure uninterrupted electricity supply in case of electricity failure.
• O₂ supply & suction system - OT should have piped in O₂ supply through central O₂ supply system from a central source. There should also be central suctioning through piped in suction arrangement.
• Music system - Operation theatre can also have a soft music system. Music creates a pleasant environment for patients & staff. Music also provide diversion of the patient's mind. Music can provide relaxation to pts who undergo surgery under local, regional or spinal anaesthesia. It also provide a soothing atmosphere & decreases tension & fatigue of the OT staff.
• Computer terminal - The modern OT construction also provide a surface area for the computer terminal in each OT. These computers are being used to record & maintain patient information.