BK - It seems counter-intuitive to think that there are health and safety issues in such a health-critical environment. How do these issues come about?
SB – I agree it seems illogical, considering that substantial advances in surgical technology over the last 20 years have improved patient outcomes greatly. However, those advances have been designed to improve surgical success rates and the course of post-operative recovery, not to address occupational safety. Imaging devices, surgical robots, automated pumps, etc., are very often being used in spaces appropriate to the demands of the 1960s and 1970s.
BK - What are the health and safety issues that you encounter most often in the operating room (OR)?
SB - At a very basic safety level, crowding is the one of the most common issues seen in OR suites. This is not just an inconvenience, as egress pathways from ORs and through corridors of surgical suites are often severely compromised, sometimes to the point where fire codes and Joint Commission standards are violated. Moreover, egress from ORs is especially difficult anyway, considering that in the event of a fire or other emergency, patients may need to be evacuated on stretchers and accompanied by life support equipment. I should note that the risk of fires in ORs is very real because of the use of volatile anesthetics and sterilants in the presence of spark and heat sources, such as eletrocauteries and orthopedic power tools. Managing fire risks and responses in ORs requires a major discussion and is probably better left to a future interview dedicated to that topic.
Air quality is another frequent concern in ORs because of the increasing use of newly developed chemical agents. These include chemotherapeutic drugs, bone cements, topical anticoagulants, and a host of other products. Moreover, new high level sterilants and disinfectants are used to treat working surfaces after surgery to combat ever-increasing strains of resistant bacteria. Some chemicals are used in aerosol form, which makes their vapors more difficult to contain and increases their potential to affect air quality.
BK - How has your hospital dealt with these issues? Which have been the most complex to solve?
SB – We’ve found that each situation has to be managed according to its individual impact and characteristics. For example, we have reviewed our systems for administration of chemotherapeutic drugs to ensure they are contained and that back-up procedures are in place in the event of spills or leaks. We have also conducted air monitoring during administration of these agents to ensure vapors are not being released. We approach the air quality issues posed by disinfection and sterilization between surgeries in two ways. First, we review the volatility and potential health effects of proposed disinfectants and sterilants, and we attempt to find alternatives for those that off-gas potentially irritating or harmful vapors. Alternatives may include using a completely different, less hazardous chemical that is equally effective, or changing the way in which it is applied (e.g., using saturated wipes instead of an aerosol sprayer). When alternatives are not available, we’ve tried to schedule the treatments of OR surfaces to allow maximum air exchange between surgeries.
Oddly enough, the most difficult problem to manage has been crowding. Clinicians obviously want the best for their patients, and today this means having the best equipment available. They also want to be prepared for emergencies, meaning that "crash carts" and other emergency equipment have to be staged nearby. It's difficult to argue that any such items should be moved to comply with fire codes, when the rejoinder from a surgical team is that they need this specialized technology to improve a patient's chances. Our strategy has been to work with clinicians to ensure that only what is really needed is present. Operating rooms are busy places, and to save time, several pieces of equipment are sometimes staged near operating rooms in anticipation of upcoming surgeries. In place of this temporary “storage,” we try to use a "just-in-time" strategy, meaning that equipment is staged in the immediate area just prior to the procedure, and is removed when the procedure is complete. It’s obviously labor intensive to keep moving equipment back and forth. However, our surgical departments acknowledge they have to pay more attention to this basic safety concern -- it's the right thing to do to ensure staff and patient safety in the event of an emergency. And, of course, egress and related concerns are scrutinized closely by The Joint Commission and OSHA.
BK –What do you see on the horizon with regard to managing the OR environment?
SB - The issues I described above will only become more severe with the rapid pace of technological development in medicine. The real answer to dealing with them lies in the design of OR suites. New facilities and those undergoing major renovations must be built specifically to accommodate more equipment and to better manage air quality. Architects and design engineers can no longer use the templates that served them well two or three decades ago. With regard to alleviating clutter, it's not just a matter of creating more storage space -- it means reconsidering traffic flow patterns throughout a suite, not only for patients and staff, but also for expeditious movement of equipment and supplies. Air quality management also has to be built into the design, with careful thought applied to the positioning of local exhausts, canopies, and other containment devices. Patients and staff should be well protected, while at the same time these devices should not interfere with surgical procedures. For dealing with each of these issues and others that may arise, the most useful strategy is to build a mock-up of proposed designs and then solicit input from the actual users. We’re often surprised by the small modifications requested by clinicians that greatly improve their ability to deliver care.
Steve Bloom has approximately 30 years of experience in environmental, respiratory, and air quality issues. Currently a senior scientist at Environmental Health & Engineering, Inc. (EH&E), he also serves as full-time Director of Environmental Affairs at Brigham and Women’s Hospital, where he manages a comprehensive program that addresses air quality, environmental management, safety, and regulatory compliance.