Summary
The wishes of surgeons for their operating rooms (ORs) are similar in principle to those of other workers for their work place - to be able to do their work accurately, productively, safely, and with satisfaction.
To determine these wishes 40 Australian surgeons were asked what changes they would like in their operating rooms. From their responses there were 349 separate comments defined. Each comment was labeled with a keyword which was used to sort them into categories using a spreadsheet. Within each category labels were modified as appropriate and sorting was repeated several times until the groupings appeared stable. Feedback was sought from participants after circulating the collated results by email.
Not surprisingly, there were problems in many areas - equipment, lighting and OR planning. Altogether there were 36 different categories of comment, with half of them having six or fewer respondents.
The analysis clarified the problems of surgeons, and yielded some that were not expected. The results provide a useful tool for informing equipment designers and administrators of necessary changes. Further research with a larger number of subjects, and perhaps a prompt list, may yield additional significant information.
Keywords: Operating rooms, design, equipment, surgeons
Introduction
This study was carried out to determine what surgeons actually want for the design and operation of operating theatres. The original editorial request was for ergonomic requirements desired by surgeons. In common English usage, "requirement" has two meanings, what people should have or what they would like to have correspond to the difference between top-down (authoritarian, expert) and bottom-up (democratic) planning. Expert information is already available in the design literature and ergonomic hand books [1] but both approaches need to be considered.
Surgeons have always had special needs. Early in the history of surgery
Hippocrates [2] wrote
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Hippocrates: “the father of medicine” Cos, Greece 460 – 377 BC |
Today we expect technology to provide the answers for the very problems it creates, but experience shows this does not always happen. New structures can lead to unexpected and unwanted results, especially if there is no practical testing of the engineering or if human factors are ignored. The accumulation of small changes - "technology creep" - which introduces more equipment and staff over time, is eventually like the proverbial straw that broke the camel's back - the OR become unwieldy. But failure to plan for change is hardly restricted to ORs
There are many standard textbooks on ergonomics with recommendations for working posture, lighting levels, information design and management structures [1]. Many problems in this survey reflect either failures to implement accepted knowledge, or rules that need to be updated or modified for the OR environment.
Publications on OR design and function exist [5] as well as on special aspects such as safety [6] and the special needs of anaesthetists [7]. A Medline search yields many hundreds of results on searching for operating, planning, and theatre or room, though it is hard to find papers dealing with the range of problems that surgeons complain of. What is not available is a view of what surgeons actually want.
Method
In this study 40 Australian surgeons known personally to the author were asked by phone or in person to respond to the question: "What changes would you like in the Operating Rooms (ORs) in which you work?". They were drawn from Adelaide (34) and Sydney (6), and worked at teaching, public or private hospitals ranging in size from 30 to 1000 patients. Notes were made, transcribed to computer, and separated into distinct comments. Each comment was labeled with a descriptive keyword for the topic, for example lighting, pedals, anaesthetist, operating tables and so on. A numerical code was added for each surgeon, to show if particular topics were favoured by some surgeons rather than evenly spread.
The comments were sorted by their keywords in a Microsoft Excel® spreadsheet so that groupings emerged. Keywords were modified to collate nearly similar group topics or to subdivide others, so that comments on similar topics were put together. Some comments were re-labeled in this process, and extra keywords inserted where they related to more than one topic. A summary of the comments for each topic were then summarized.
Results
Between them the 40 surgeons provided 349 comments, individual surgeons contributing between one and 36 comments, with a median of eight comments. Some individuals focused on particular problems, and some problems seemed to relate to particular hospitals. During the sorting process there emerged 36 categories, the largest, equipment, contained 50 comments and several only one or two. The other leading areas were lighting, cables and tubes on the floor and video and computers, but there was no sharp cut-off in number between these and the remaining ones. For each category the number of comments is shown in parentheses after the heading.
1. Equipment (50)
This was the largest category with 50 comments. Where they related to one type of item such as operating tables and lights they were given a separate grouping.
Surgeons complained that equipment in general was not replaced as improved versions became available or until it became unusable. Equipment was too bulky especially monitors (see below), image intensifiers, and anaesthetic equipment. Laparoscopic equipment was too complex to use easily, especially for newer nursing staff. The monitor and other equipment on the stack needed to be connected properly before the start of the operation; this was a problem at night time. A second diathermy machine was needed at times. Bean bags were necessary for laparoscopic splenectomy.
Surgeons wanted "plug-and-play" components like those for computers, or a bioengineer in the OR, or their own copy of shorter and more usable instruction manuals. There was lack of standardisation between different brands.
Specific complaints: Re-usable trocars and needleholders were hard to take apart and re-assemble for unaccustomed staff. Trocar seals leaked, faulty diathermy leads and cameras during surgery were replaced with other faulty ones. The camera of cystoscopes was too bulky and heavy, with all the weight at the back end. Gravity pulled them out of the urethra and they seemed to need a third hand. Endoscopes should be autoclavable.
Notes: In the past, some surgeons associated
themselves with particular instrument makers, for example Moynihan with
Thackray . When Americans visiting the great
Moynihan wanted the same cholecystectomy forcpes
he used, they got Thackray to make them, launching this great company. The
The emergence of microsurgery in the 1970s had instrument design driven more by surgeons than manufacturers following habit. It drove surgeons back to direct contact with manufacturers for the new designs and standards needed. Laparoscopic surgery in the 1990s strengthened the links of manufacturers to individual surgeons as firms sought greater market share.This trend became even stronger with laparoscopic surgery in the 1990s as firms sought greater market share. However the problems that some surgeons have in this area are still to be solved, and with most other types of equipment there is insufficient usable feedback to manufacturers. Many problems are due to poor inspection or maintenance, the result of inadequate training or supervision, for which management is responsible.
2. Lighting (32)
Several of the respondents described lighting as their biggest bugbear. The light would wander or was hard to position because it was heavy and the handle too small. It was hard to focus and cast shadows. If the main light was moved the satellite would also move. Older surgeons needed better lighting, and an old light blew bulbs often. Two surgeons wanted electric or voice control of light position. Headlights were needed for deep cavities but were uncomfortable, hard to direct or not bright enough. One colorectal surgeon specified fibreoptic xenon-lit retractors and endo-anal lighting.
Notes: A dry white pack to reflect light in the pelvis has been suggested but feedback from one surgeon was that glare then became a problem. Magnifying spectacles to show more detail may compensate for poor lighting.
3. Cables and tubing (25)
What was a minor nuisance a generation ago has become a major impediment and a safety hazard as tubes and cables have multiplied in number. They tangle, obstruct movable equipment, and occasionally trip people, causing injuries. Three surgeons from the one surgical centre all complained of tangling of diathermy leads, and for two of them it was the only complaint mentioned.
Notes: Ceiling mounted booms for power, suction, communication and other cables now prevent this problem in many ORs, though they can have their own problems such as insufficient range of movement. A cheap solution as a short-term measure is a series of hooks from the ceiling to allow removal from the floor. Where they still exist on floors they create clutter and cleaning problems. Possible solutions are self-coiling diathermy leads like some telephone cords (if this does not create induction problems), or use of the new wireless technology for signal transfer, or battery-powered equipment. The weight of some cables makes it harder to control some instruments accurately and safely.
4. Computers, video, communications, cameras (24)
Surgeons want computers for recording operation notes, to access records or just to use during down-time between cases. Even an area for writing was lacking according to one comment. Also wanted was video equipment for recording operations, video-conferencing, seeking advice or supervising a trainee from an office. It would be helpful to be able to email an x-ray, for example a hand fracture, during the procedure. In a Stryker system a camera can be located in the light handle, but on some lights a bracket can easily be attached using one of the existing screws to hold various devices (provided they do not unbalance the light). The camera can be controlled by a remote clicker (of the type available for the Canon Powershot digital camera) and placed in a sterile plastic bag for the operator to control. Photos are now a routine during arthroscopy, with copies for the clinical record and the patient.
Surgeons want computers
to
- record operation
notes,
- access records o
- use during down-time between cases.
Even an area for writing was lacking according
to one comment.
Also wanted was video equipment for
- recording operations,
- video-conferencing,
- seeking advice or
- supervising a trainee from an office.
e.g. email an x-ray of a hand fracture,
during the procedure.
In a Stryker system
a camera can be located in the light handle, but on some lights a bracket
can easily be attached using one of the existing screws to hold various
devices (provided they do not unbalance the light).
The camera can be controlled
by a remote clicker (of the type available for the Canon Powershot digital camera) and placed in a sterile plastic
bag for the operator to control. Photos are now a routine during arthroscopy,
with copies for the clinical record and the patient.
5. Staff (20)
Eight respondents stressed the importance of having the same scrub nurse. Others mentioned lack of problems when staff were familiar with the endoscopic equipment and the surgeon, and the advantages of an experienced, trained and loyal OR team.
Two mentioned the importance of dedicated technicians to ensure complex systems were working properly (already mentioned at the start, in the first category on equipment). To position patients in the prone position needed two big strong orderlies.
Staff who had not been adequately trained made in complex surgery less safe, for example major upper abdominal cancers surgery, even in a major teaching hospital. Instrument lists were not kept up to date (which should be easy with a computer) or not followed, reflecting poor supervision.
One surgeon had no problem locating a diathermy pedal with his foot because it was always placed just where he would use it. This was at a small hospital where the staff knew his work habits well.
Notes: Some surgeons pay for their personal OR staff. In the United States there is a profession of surgical assistant, immigrant doctors not licensed to practice medicine, who assist at regular surgery and carry mobile phones to be called to assist in emergency cases.
6. Pedals (19)
Most surgeons who made comments on foot pedals complained of difficulty feeling them with their feet and being distracted from the surgery while trying to find them. Pedals would slide out of position, and this was a worry if they were standing on a platform. One surgeon said bipolar diathermy pedals seemed made for pygmies and another cited a popular brand as being unergonomic. A covering box was useful for locating the foot over the pedal. A few surgeons used controls on the handpiece to save problems with pedals.
Notes: Manufacturers may not be sufficiently aware of this. Part of the problem is loose rigid boots which make it hard to locate the pedal and apply pressure sensitively. Some microsurgeons, who may have to operate microscope controls with eight different foot pedals, operate in sterile canvas overshoes over socks. Many problems apparently due to equipment design can be dealt with by some other change.
7. Tables (17)
The trouble with operating tables is that they do not wear out, and replacing them is expensive. Four surgeons wanted electrical controls. Others mentioned difficulty moving a table, or unwanted movement, and two wanted the surgeon to be able to control tilt, in one case because the anaesthetist was unwilling. During a right hemicolectomy it was necessary to have both head down and then head up postures. A tall nurse had insufficient knee room. If traction was used to elevate the sternum for exposure, the head-piece bent upwards instead. Controls for configuring the table confused staff unused to them. Better-designed stirrups for leg support were wanted by two surgeons. Another complained that patients could slide if the table was tilted, on one occasion ending up in his lap.
Notes: Tables do not go low enough for laparoscopic procedures [8] This results in a tiring "chicken-wing posture" of the operator, with lack of arm support from the trunk to steady the upper arm . Operating tables made in Australia by the Denyer company had a pedal far under the top end of the table, awkward for a short-legged person to reach. The story is told that the owner-designer of the company was very tall, and positioned the pedal to suit his own dimensions. An expensive electrically controlled table had a flimsy plastic panel with labels indicating positions of the control lever. It broke quickly. A telescopic extension for the foot pedal needed sticky tape to stop it sliding.
Some problems occur because staff or the surgeon have not taken the time to become familiar with how the table works, or the lack of a simple laminated instruction card attached to the table.
Many bad features of tables could be avoided by choosing another brand, probably at greater cost. As with other equipment, problems might not show themselves until the table had been in use for some time, though the policy of some retailers is to offer a trial of a table (doubtless with some pressure to purchase it). One of the problems is lack of information comparing equipment from different companies, though ECRI [9] of the United States, the world's outstanding bioengineering group, offers such reports on a subscription basis which are taken up by major hospitals.
8. Planning and design (16)
Two surgeons described recently built ORs in major hospitals as disasters. They lacking anaesthetic bays and doors were badly placed so they hampered movement of patient trolleys both in and out. Light switches should be placed by the entrance to the OR. These and other controls should be clearly labelled so staff new to the OR would not have a problem.
Good ideas as well as blunders to avoid could be learned from visits to or experience working at other hospitals. It was important to have nurses contribute, to integrate equipment and anaesthetic systems, and for automation to be less clumsy.
An OR dedicated to laparoscopic surgery would be an advantage, and one like the new Stryker product (seen at another hospital) even better, but it would need an adequate clinical load to justify the cost. The modular designs now available, with a space between the inner and outer walls, served as a corridor for electricians and other technicians to maintain and modify services to the OR, but whether this was worth the cost was hard to say.
Notes: In the past the planning of ORs has been the task of architects unfamiliar with activities within them. Planning committees may have hurried intermittent input from busy surgeons and no input from scrub nurses, cleaners, plumbers or others. As with hospitals a lot could be learned by Post-Occupancy Evaluation ("what would you do differently next time?") and applied as Pre-Occupancy Evaluation but is not [10,11]. Three OR managers who were asked separately from this inquiry all said their main priority in planning an OR in the future would be adequate space for storage. Storage was the first item to be reduced at planning meetings when costs had to be lowered.
Today "Operating Rooms of the Future" are a multi-billion dollar industry for companies like Karl Storz, Stryker, Olympus and others, promoted with the help of sophisticated sales videotapes. Ethicon initiated the concept of this new type of OR at their Cincinnati facility at great expense in the early 1990s but made a big issue of confidentiality which hindered open discussion. They used a top-down approach, and failed to ask users directly what their needs and problems were.
Today at prices approaching a million dollars such ORs are too expensive for wide use despite greater efficiency and fewer staff salaries. However, immediate and important improvements to many ORs could be achieved by addressing the ordinary issues described in the present study.
9. Surgeons (13)
Comments on surgeons referred mainly to their particular specialty and its requirements. They differed in age, experience and doubtless in operating style, personality and other attributes. One said surgeons should be quicker. Another mentioned simplicity and being trained to manage with whatever equipment was provided. If nurses had been surveyed about surgeons there would doubtless have been many more responses.
10. Sterile zones (12)
Most comments about sterile zones came from one widely travelled surgeon who wanted more discipline in observing them. He described a bench used as a barrier on which one sat to change shoes before swivelling over to enter the sterile area, and another instance where patient trolleys were wheeled in over a mat soaked in antiseptic.
Notes: This is a specialized topic on which infection control officers would be the best to advise for planning and running ORs. One device observed was a disposable sticky mat to pick up soil from footwear.
11. Management (11)
Quality of management varied enormously between hospitals. It was described as appalling in public hospitals but excellent in private ones, an observation found in comments on other topics. Quality of equipment varied between them as well. One bitter complaint from three surgeons was lack of flexibility for scheduling cases, for example breast cases which while not urgent should be operated on in three to seven days. A rigid finishing time and pressure to provide service meant little time for teaching and supervising trainees.
12. Monitors (11)
Of four surgeons who made nine comments, each wanted a second monitor and one wanted a third when radiology was combined with the procedure. They wanted monitors to be lighter, less bulky and positioned more easily, especially the urologist who wanted the monitor positioned between the patient's legs, perhaps suspended from the ceiling, instead of to one side where it was partly obscured by the patient's knee. In that position it would also be aligned for better eye-hand co-ordination. It could be. One surgeon mentioned depth perception as a problem and another envisaged goggles to provide this.
Notes: Flat video displays cost five or ten times more than bulky ones. They are a standard feature of the "OR of the Future". Depth perception is determined by almost 20 cues, of which only eight are lost with two dimensional screen displays [12].
The next 18 categories had between two and
seven comments each: Doors
(7) should be wide, open either way, have a kick plate for electrical
opening and separate for entry and exit of patients. Devices to hold doors
open did not work and in one case a broken door had not been fixed for
many weeks. (Such maintenance problems could make a separate category).
Anaesthesia: (5) Six surgeons complained about anaesthetists or their
equipment which intruded on their space. Two specific comments were that
they talked too much or too obtrusively
There were several areas
with only one comment each. One surgeon named a hospital which was outdated, didn't want to change and where the OR needed upgrading
or a bomb. Cleaning would be easier if walls and floor met at a curve.
A blue colour would be soothing though anaesthetists
complain it makes cyanosis hard to assess. One surgeon had not upgraded
his own operating room because of the cost he would have to pay himself.
One surgeon stopped trying out new ideas in the OR because of legal worries.
He was interested in testing whether oblique lighting from a laparoscopic
port other that one for the telescope would give better depth perception.
This would need laboratory trialling first.
Change rooms were too small. Shoes in the OR should be cleaned of dirt
and blood at the end of each day. Manual water taps were better than automatic
electronic ones which would not work if there were a power failure, and
they are cheaper. Terminology in the OR and teaching were also mentioned.
Discussion
In an ideal world every patient would be operated on in the best-equipped, staffed, managed, most modern and expensive OR. In the real world most Ors are under-resourced and under-funded, and surgeons experience a range of problems which vary widely in number, importance and nature, These reflect the wide differences between hospitals, type of work, resources, management, individual surgeon, and specific ones of the type collected in the study. Such problems are not considered in adequate and timely fashion because surgeons are not asked or their opinions ignored as the hierarchy of hospitals has changed in the last generation.
Surgeons vary greatly in temperament, some requiring detailed adherence to routines and others comfortable with whatever equipment and staff they are allotted. Some are unaware of existing instruments which would help them, notably the Book-Walter retractor for abdominal exposure, and techniques hidden in unfamiliar journals or part of an unpublished tradition. Surgeons are also inventive and energetic. A review of old journals and past catalogues of surgical instruments shows that the surgical knot-pusher is re-invented, usually by a trainee, every decade or two, while many other must-have innovations have disappeared into limbo.
Given the large number of variables and the small size of the sample surveyed in the present study, it is likely that many problems have not been recorded, and the relative importance of the ones presented is not valid. These faults would be corrected in larger studies, in several countries, and narrower ones confined to one hospital, one specialty.
However the present study has shown three results. The first is that this method of survey can work. The second is that many of the problems recorded should have been solved by a combination of good management and common-sense. Third, it reveals some unexpected, valid complaints.
Data of this kind may be powerful in convincing hospital funding authorities and administrators of overdue need for changes. Such arguments can be more effective if backed up by separate cost-benefit data.
There are other possible benefits. The designers of ORs and equipment to be used in them can now have more feedback, in a shorter time, to correct problems in their products. Surgeons can benefit even more if problems they suffer have been solved in other hospitals and these solutions are made known more widely.
Some underlying issues emerge. One of them is training and allocation of staff. To use new technology competently nurses and other staff need appropriate training, now often part of basic training for surgeons as well. In most industries maintenance and OHS issues reflect competence and quality of management, and hospitals and ORs are no exception. In the mood of modern economics and downsizing, industry generally adopts multi-skilling. In a hospital this means that for example neurosurgical emergencies are staffed with nurses competent at abdominal or orthopaedic surgery. The cost of this mismatch is not known, but surgeons are all too familiar with the strain and inefficiency of this situation.
The process of planning new ORs or modifications has been discussed in some detail recently [11] and readers are encouraged to consider this as a prelude to the present paper. Failings in planning occur when architects do not consider all the functions and activities, including access and work flow, and do not consult effectively with all who work in the OR. Administrators and managers are not effective as intermediaries between the designers and surgeons and other staff.
Surprisingly there were no complaints about the time it took to process samples for frozen section or delays waiting for radiographers or other staff, though there was one passing reference to the need for a bioengineer. No mention was made of musculoskeletal complaints, which are common [13] suggesting that a prompt by a check-list would have brought these to light. Likewise, there was only one complaint about crowded change rooms where more could have been expected.
The costs of this study were minimal, apart from several days of the author's time, consisting of telephone calls and computer use. One of the strengths of this study was the 100 per cent approach of those who were contacted by phone. This contrasts starkly with the low response rates to paper questionnaires, typically only a quarter or a fifth. Personal knowledge of the investigator and past work in this area by responders may have contributed to their cooperation.
Future research should target specific types of surgery and plan on a sufficient number of subjects to allow stratifying size and type of hospital and other emerging variables. Different countries and regions may show other patterns of complaint according to their culture. A structured check-list for the main types of problem encountered may elicit more information by reminding them of other possible comments, particularly for establishing priorities for response. One suggestion has been that surgeons be asked for their top three concerns. This could be done at the start of the dialogue, and followed up with prompts or a checklist. Studies should also be directed to anaesthetists, nursing staff radiologists and eventually to all others whose work is related to ORs, including orderlies, cleaners, and tradesmen. Some of these may yield uncomfortable comments about surgeons themselves.
Conclusions
Seeking the opinions of surgeons about problems in Operating Rooms provides important information, useful for architects, equipment designers, hospital administrators, and OR managers. More such studies are needed.
Acknowledgements
I thank the 40 surgeons who kindly gave their time and support to this study.
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a preliminary discourse and annotations, by Francis Adams. New York, W
Wood 1886. Available at www.library.adelaide.edu.au/etext/h/h7w/h7w.zip.
On the Surgery
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text with English translation and commentary by M. S. Spink and G. L.
Lewis [Maqalah fi al-`amal bi-al-yad. English & Arabic] Berkeley :
University of California Press, 1973
4 Lythgoe RJ The measurement of visual acuity MRC Special Report Series
No 173 (HMSO, London 1965) quoted in KFH Murrell Ergonomics Ergonomics.
London, Chapman and Hall, 1965
5 Johnson IDA , Hunter AR The Design and Utilization of Operating Theatres
(ed) Edward Arnold 1984.
6 Mainland J. F., Dudley H. A. F. Safety in the operating theatre ed London
Edward Arnold 1976
7 Ehrenwerth J, Dorsch JA.et al. (ed) Operating Room Design Manual. American
Society of Anaesthesiology 1999
8 Matern U : Tables do not go low enough for laparoscopic procedures
9 ECRI 5200 Butler Pike, Plymouth Meeting, PA 19462 USA. www.ecri.org
10 Patkin M. Hospital architecture - an ergonomic debacle. In: Estryn-Behar
M, Gadbois C, Pottier M, editors. Ergonomie a l'hopital, Colloque International
Paris Juillet 1991. Toulouse: Octares Editions, 1992:79-83. p6
11 Patkin M Operating room design for minimally invasive surgery Min Invas
Ther & Allied Technol 2001: 10(3) 129-
12 Patkin M Isabel L Ergonomics, engineering and surgery of
endosurgical dissection. JRCSEd 1995 40: 120-132
13 Berguer R, Smith WD, Chung YH. Performing laparoscopic surgery is significantly
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Michael Patkin
Departments of Surgery, University of Adelaide and Flinders University,
South Australia
This was originally published in MITAT (Minimally Invasive Therapy &
Allied Technologies), Taylor & Francis.
Issue: Volume 12, Number 6 / November 2003, Pages: 256 - 262 ,
and has been modified from there.
Correspondence to mp at mpatkin.org
______
This was an easy paper to write.
I sat in my easy chair and phoned up 40 surgeons I knew.
Fig
1. Arm-chair research
In late 2004 I phoned
forty Australian surgeons I knew personally .I said, "I'm
your fairy godmother. What would you like different in the operating theatre
where you work most often?
This was true arm-chair research, done from the comfort of a reclining chair. (Fig 1)
It was also easy to fund. Costs were:
- 40 phone calls and call-backs
- scribble paper
- time on my home computer
I wrote down their comments
by hand (next time I would use a hands-free microphone and earpiece) and
then copied them into a Microsoft text file. Altogether there were 349
comments.
I labeled each comment
with a keyword which I then used to sort them into categories using a
spreadsheet. I revised the labels, resorted the
comments, and repeated this cycle several times until the groupings looked
stable. I sought feedback from my subjects by email, and in only a couple
of cases I expanded their comment a little.
As you would expect,
these surgeons reported problems in many areas - equipment, lighting and
OR planning. Altogether there were 36 different categories, though half
of them had just six or fewer respondents.
It was easy to see the
main problems surgeons have. It would be great to similar but larger surveys.
This kind of information should be useful for equipment designers, hospital managers architects.
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