The Academy of Architecture for Health recently held a Webinar-based roundtable discussion on the topic of design for surgical environments. Of interest was a discussion of suggested workflow practices and design concepts for contemporary invasive environments for patient care.

Five well-respected subject-matter experts supported the discussions with healthcare designers across the country. A summary of their discussion follows: 

1. What do we believe today is the area of greatest concern for infection control in the surgical environment? The people, tools, and supplies working within the immediate surgical field (8’ x 8’ around the table) are the primary concerns, but how these factors arrive to the operating room are of equal importance. A carefully orchestrated workflow is key to minimizing the risk of contamination in this cleanest of patient care environments. Anything that moves in and out of operating rooms, as well as the surgical suite as a whole, should be subject to rigorous control. Moisture in this environment must be aggressively controlled by limiting sources. 
2. Which workflow design is potentially best to address and manage this concern, operationally and spatially? A one-way flow of supplies into the operating room, then of soiled goods and trash out of the operating room, is preferred. The shared use of a corridor for staff and patient access into the OR is acceptable, but this same corridor should not be used for delivery of sterile supplies into the OR. Sterile supplies and instruments should have a separate, dedicated pathway from central sterile supply into the operating room without encountering staff or patient traffic, whether in scrubs or not. 
3. Of the two prevalent configurations of surgery design–double-loaded corridors with sub-sterile rooms vs. perimeter corridor with clean core–talk about the pros and cons in light of infection-control objectives. The concept of the double-loaded, most popular in ambulatory care surgery settings, does not provide optimal opportunity to prevent contamination or infection transfer. It inherently allows, in fact assures, the mixed use of the shared corridor for people, patients, sterile materials and bio-hazardous waste. 

Sub-sterile rooms, meaning support spaces with a flash sterilizer and sink, should be eliminated from use in surgical suites.

Flash sterilization has lost validity, as it does not assure that the best possible contamination or infection control measures are applied. Its second negative is that it introduces moisture sources into the sterile environment. Furthermore, the traditional sharing of such a room between ORs to lower equipment cost inherently creates the opportunity for cross-contamination between procedure rooms.

These rooms should be eliminated in favor of some form of the clean core concept, with a soiled utility/clean-up room separated from the operating rooms and clean core. This room should be accessible to all ORs by the external corridor, not through the core. Proper re-processing (using appropriate sterilizing cycles) must be enforced by design. 

1. What activities and/or equipment are acceptable in the sub-sterile room or the clean core? What is not? Only instruments, supplies, and non-moisture-based reprocessing units (e.g., Sterad) should be within the core. Sub-sterile rooms, unless as specific equipment or supply rooms dedicated to one OR, should be avoided. Surgical equipment should not be placed within the clean core, as it tends to move between operating rooms and thus increases risk of contamination if moved in and out of the core or even out into the external redline corridor. Wipe-down cleaning by staff, although mandatory, does not render the equipment suitable for holding in the clean core with sterile surgical supplies. 
2. What is allowable and not allowable regarding staff flow outside of the surgical environment as well as into and out of changing areas relative to the redline zone? Although some requirements for changing have eased (i.e., shoe covers), the traditional concept of changing still must be enforced by design. Access to changing rooms from an external quasi-public or staff corridor must be provided, and then direct access into the redline zone of the operating suite from those changing areas is necessary. Any staff or surgeons leaving the changing area (or other restricted area such as surgery offices or lounge areas) should have convenient resources to put on a cover gown before leaving the restricted environment for any reason. Unfortunately, this practice is not always respected by surgeons or staff or enforced by OR managers, but the design must facilitate the opportunity for this rigorous practice. This restricted access must be provided for interventional radiology environments as well. 

Subject matter experts included: Ramona Conner, MSN, RN, Manager, Standards & Recommended Practices for the Association of Operating Room Nurses; Debra Garner, RN,former OR nurse and Vice President–Medical Technology, HKS Inc.; George Tingwald, MD, AIA, ACHA, surgeon and architect, Director of Medical Planning, Stanford University Medical Center; and Tom Harvey, FAIA, MPH, FACHA, Senior Vice President–HKS Healthcare Group and leader of the Center for Advanced Design Research & Evaluation.

Tom Harvey, FAIA, FACHA, MPH, LEED AP, is Senior Vice President/Clinical Planning Specialist, HKS and President, Center for Advanced Design Research & Evaluation (CADRE). .