Six Highlights of AORN’s Design and Maintenance Guideline

New practice recommendations can help advanced planning, cost-conscious design and sustainable maintenance strategies.

In a setting where every square foot of real estate matters, ASC leaders must always consider the best options for thoughtful use of space — for present and future needs.

As AORN Senior Perioperative Practice Specialist Mary Alice Miner, PhD, RN, CNOR, puts it: “OR leaders may be interested in keeping upfront costs down to facilitate the creation and upkeep of ASCs, however, it behooves them to look into the future of each facility.”

For all aspects of new projects, AORN’s new Guideline for Design and Maintenance of the Surgical Suite, which Dr. Miner authored, will help ASC teams explore these questions with evidence-based guidance and tools.

Six practice updates to review

The guideline continues to emphasize the importance of careful design of perioperative spaces for the inpatient and outpatient settings. Updates reflect a more singular focus on surgical suite design and maintenance for similar practices between outpatient and inpatient settings for non-regulatory recommendations such as basic environmental parameters, convening an interdisciplinary team, planning design projects and space requirements for specific surgical care activities such as those in a hybrid OR. ASC-specific additions also include several studies and models added to help improve effective ASC planning, Dr. Miner notes.

To help ASC teams with an efficient review of the updated guideline, Dr. Miner and Erin Kyle, DNP, RN, CNOR, NEA-BC, editor-in-chief of AORN’s Guidelines for Perioperative Practice, shared a preview of ASC-relevant literature and practice changes to help outpatient surgery teams (emphasis on teams) with practice implementation.

ADDITIONAL HELP

Tools for Safe OR Design

ASC teams exploring updates in AORN’s Design and Maintenance guideline can look to updated implementation tools released with the guideline, such as an updated policy/procedure template and a revised gap analysis to understand areas for improvement. Access the guideline and implementation tools at: aornguidelines.org

Additionally, here are two ASC-specific tools Dr. Miner suggests ASCs review to support safe and effective OR design:

• The Safe OR Design Tool is human-centered and allows for interaction with design components in an OR environment through a 3D model.

Access the tool at: osmag.net/Clemson

• The Infection Control Risk Assessment Matrix tool can be used to determine the level of infection prevention strategies needed for a specific construction project dependent on the level of construction and patient risk involved.

You can access the risk assessment matrix at: osmag.net/infectionmatrix

— Carina Stanton

#1: Combine expertise

Despite being heavily directed toward the surgical suite design team, the guideline now outlines a stronger emphasis on how a perioperative RN should be included to bridge the gap between the non-clinical team members and staff working in and around construction or renovation projects, as discussed in Recommendation 1. One important scenario for clinical input is to “facilitate a safe, efficient and low infection risk working environment when construction occurs adjacent to functioning patient care areas,” says Dr. Miner.

#2: Recognize space requirements

For planning purposes, Dr. Miner points out, it’s important that ASCs recognize differences in their function and requirements, such as the minimum surgical suite space requirements in Table 2 in the revised guideline. For example, the minimum space requirements for an operating room in an outpatient facility can be smaller than an inpatient OR. However, a major change in the update is a requirement that ASC space requirements for hybrid OR equipment and sterile processing areas be the same dimensions as inpatient spaces.

#3: Model design plans

Several ASC-specific studies cited in the guideline can help ASC design teams dial in efficiency and costs associated with layout design, as discussed in Recommendation 3. For example, one study looked at two different layouts for their surgical suite — either “center-stage” where all patient rooms center around one staff workroom and patient entrances or “onstage-offstage” where patient and staff entrances lead into separate corridors. “What’s interesting is that both had positive and negatives, and the authors concluded that creating functional zones was necessary for both to stimulate workflow and teamwork as well as patient-centeredness,” says Dr. Miner. She also notes a separate study conducted in a pediatric ambulatory center, where integrated facility design was established by creating mockups and simulations for faculty, staff and patient family feedback. “After receiving feedback, the researchers evaluated anticipated workflow and actual costs with a full-scale mockup for operational testing, which led to significant savings compared to traditional design planning methods.”

Another note for those planning an ASC renovation or new construction is to review the latest CMS requirements outlined in their ASC State Operations Manual (see Recommendation 2), because there could be different requirements for ASCs that receive reimbursement.

#4: Educate on the parameters

Because the air in the OR touches everything, including the sterile field and the surgical wound, perioperative nurses must be familiar with issues relevant to air quality and movement in the operating room, according to Dr. Kyle. Basic air quality parameters include heating, ventilation and air conditioning (HVAC) system design and function; the number of air changes a system is set to; humidity range parameters and what the temperature and humidity levels are in the OR when procedures are performed in the room; and airflow direction in the OR. “When HVAC controls are not well controlled within established parameters, consequences can be catastrophic — especially in the case of surgical site infections in procedures involving implants such as total joint replacements and revisions,” says Dr. Kyle.

That’s why ASC staff nurses should carefully review Recommendations 13 and 14 in the guideline update, because these sections cover new information for safely maintaining environmental settings in any surgical suite, Dr. Miner says. She also points to new guidance from the Facility Guidelines Institute (FGI) guidelines, which AORN holds as the gold standard for all healthcare facilities construction guidance for those performing surgical care, including ASCs. This includes the latest HVAC parameters from the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Standard 170, which are discussed in Recommendation 3 and outlined in Table 5 in the guideline update.

These are recommended for daily practice so teams know how to respond quickly when disruptions in environmental conditions occur due to power outages, natural disasters, or construction. “Nurses responsible for updating and upholding policies and procedures related to utility and HVAC disruptions need to be clear on appropriate settings to quickly identify when settings are off so they can alert leadership,” says Dr. Miner.

#5: Understand air management

With COVID-19 changing perioperative practice in many ways, measures to prevent the spread of airborne illnesses are being developed and implemented on multiple levels, including air quality management, says Dr. Kyle. For example, the federal government has issued new guidance for construction of new federal buildings to include more stringent air quality controls, including the use of minimum efficiency reporting value (MERV) 13 filters. “We expect that these enhanced air quality control recommendations will likely influence updates to ASHRAE 170,” says Dr. Kyle. “AORN is involved in ASHRAE 170 and FGI guidelines updates, and we will advocate air quality controls and solutions that make sense and can be implemented in the perioperative setting.”

#6: Consider sustainability

Managing energy usage to protect the environment is worth considering for sustainability and for cost savings, especially for ASCs with tighter expense margins. One evidence-based approach is using a time-based control system for ambient illuminance lighting in the preoperative and postoperative spaces, as described in Recommendation 3.

A ventilation setback strategy during the planning phase that is incorporated into the HVAC system could also reduce energy costs by reducing the number of air exchanges during periods when an OR is unoccupied, says Dr. Miner, stressing that such a strategy must not affect pressure gradients in the perioperative setting. Depending on the HVAC system and other challenges, including the outside atmosphere, a ventilation setback strategy may not be feasible. “OR leaders and the design team, especially personnel in charge of the HVAC system, should have policies and procedures and the ability to pause the ventilation setback strategy if there is any question of whether the pressure gradient will be maintained or concern about the ability of the HVAC system to return to the intended parameters before setting up for an invasive procedure or operation,” she says. OSM