RIPCHORD – Realizing Improved Patient Care through Human-Centered Operating Room DesignMapping and Graphically Analyzing Tasks as a Means to Understand and Inform Operating Room Design for Improved Safety Outcomes and Operational Efficiency

James H. Abernathy, III, MD, MPH, FASEAssoc. Professor, Dept. of Anesthesia and Perioperative Medicine, The Medical University of South Carolina

Scott Shappell, PhDProfessor and Chair, Dept. of Human Factors and Systems, Embry-Riddle Aeronautical University

David Allison FAIA, ACHA Alumni Distinguished Professor and Director of Architecture + Health, Clemson University

Representing the RIPCHORD research team including Scott Reeves MD/MBA, Gary Palmer, Gregory Swinton and Joel Greenstein PhD

Presentation Overview The Healthcare Problem

Safety & Outcomes Efficiency

The Problem Context

The Architectural Problem

The Pilot Study

Graphic Methodology

Findings

Discussion

The Healthcare Problem

Improving Safety, Outcomes and Operational Efficiency in the OR.

Little understanding of the role the design of the OR in these issues

Lack of Human Factors research that links measures of safety to the physical design of the OR

The Problem Context

IoM Report on Safety, 199944,000 to 98,000 people die each year from medical accidents Cost of errors equals $17 billion to $29 billion 20% = Surgical errors 16% = Medication errors

16 % of inpatients harmed by human error 7 % of surgical admissions have a human error

12.3 % of cardiac surgical cases suffer from a preventable error

87% of litigated surgical cases had a communication failure between providers

160 interruptions in flow per case

In CT surgery 17.4 teamwork breakdowns per hour

Disruptions have been correlated with surgical errors (r = 0.67)

“If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer's”

Marty Makary, MD – Johns Hopkins General Surgeon WSJ – September 2012

Medical Errors kill enough people each week to fill 4 jumbo

jets

Problem Context

Never Events in the OR

A Complex Milieu Intense life and death event Complex procedures Lots of equipment Many players

Surgeons Nurses Anesthesiologists Perfusionists Residents/Students Transient Observers

Functional/Spatial Stages

1. Pre-Op: Room set up Nurses set up and prepare sterile

tables. Frequent trips to sterile core

Anesthesia personnel check machines, prepare medications and equipment

Perfusionists prime and prepare the cardiopulmonary bypass machine

Functional/Spatial Stages

2. Pre-Op: Patient arrival Patient brought in by anesthesia

team

Patient is greeted by OR team – Perfusionists, Nurses, Surgeons, Anesthesiologists

Induction of Anesthesia occurs which includes insertion of invasive monitors

Functional/Spatial Stages

3. Pre-Op: Patient Preparation After induction of anesthesia

Anesthesia team: TEE performed

OR Team: Patient is positioned for the operation

Surgeons: Vein harvest site is identified

Functional/Spatial Stages

4. Pre-Op: Timeout Structured conversation to

ensure

right patient,

right operation

Ensure OR team is on same page

Functional/Spatial Stages

5. Pre-Op: Patient Prep Patient is washed with

chlorhexidine

Patient is wrapped and draped with sterile drapes

Anesthesia drape goes up

Functional/Spatial Stages

6. Operative Phase: Incision OR nurse moves surgical

instrument tables close to the patient

Surgeons make incision in patient chest

Anesthesiologist continue to monitor and treat patient vital signs

Perfusionists continue preparing bypass machine

Functional/Spatial Stages

7. Operative Phase: Chest Open Patient’s chest is opened by

surgery fellow

Left Internal mammary artery is harvested

Vein harvested from patient’s leg by attending surgeon

Functional/Spatial Stages

8. Operative: Bypass begun Anesthesia confirms adequate

anticoagulation and appropriate physiologic state for bypass

Perfusion moves equipment into place near patient and prepares lines

Surgery team inserts cannulas and as a group, patient is transitioned onto cardiopulmonary bypass

Functional/Spatial Stages

9. Operative Phase: Bypass Ends Patient separated from

cardiopulmonary bypass

Surgeons remove cannulas and bleeding stopped.

Scrub Nurse begins inventory of surgical materials/instruments

Heart-lung machine shut down and disconnected “teardown” begun by perfusionists

Functional/Spatial Stages

10. Operative: Chest Closed Surgeons close chest

Scrub Nurse completes inventory of surgical materials and instruments

Anesthesia continues hemodynamic and hematologic management.

Perfusion moves heart-lung machine back or out of room

Perfusion boom returned to dormant position along wall

Functional/Spatial Stages

11. Post-Op: Transition

Surgical drapes and wraps removed

Instrument tables pushed back against wall

Anesthesia team prepares patient for transport to ICU

Functional/Spatial Stages

12. Post-Op: Patient Exit

Patient moved onto gurney from table

Patient transported back to recovery or ICU by remaining team members

Functional/Spatial Stages

13. Post-Op: Close out

Scrub and Circulating Nurses clean up remaining equipment and close out procedure

Functional/Spatial Stages

14. Post-Op: Room Turn-over

Environmental Service Staff clean up room

EVS staff sets up room for next procedure

Pilot Study Site: MUSC

The Medical University of SCQuaternary Care Academic Medical Center Ashley River Tower [ART] opened 2008. 10 OR Surgical Suite with clean core2 rooms dedicated to cardiac procedures XX Cardiac procedures annually

RIPCHORD Realizing improved patient care

through human-centered operating room design (RIPCHORD)

Two industrial engineers with expertise in HF workflow disruptions observed 10 cardiac operations from entry into the OR until they left for ICU.

Each disruption was documented on an architectural layout of the OR suite and time stamped during phase of surgery (pre-operative, operative, post-operative).

RIPCHORD

RIPCHORD

Our goal was to develop a standard taxonomy for observing flow disruptions

1080 unique observations

Identified six main categories

Communication

Usability

Physical Layout

Environmental Hazards

General Interruptions

Equipment Failures

RIPCHORD

RIPCHORD

RIPCHORD

RIPCHORD

RIPCHORD

Initial conclusions of RIPCHORD

Layout was the single largest contributor to flow disruptions in the cardiac OR. Interruptions and usability continue to impact surgical flow, but

communication failures occurred less than expected.

Environmental factors and equipment failures were infrequent

As expected, disruptions varied across phase of the operation with layout impacting pre-operative and operative phases

The perfusionist was differentially impacted by layout issues Notably, nurses were most often impacted by interruptions

Historically Little Focus on Physical Environment/Layout

Screened 1400 articles55 studies involving error in cardiac surgery

Tasks Tools Team Patient Provider Organization Physical Environment

15 14 9 4 3 7 0

The Architectural Problem

Most human factors research does not provide useful design related information on:

Physical movement between discrete tasks and work points

Configuration of the physical environment [equipment & room]

Physical barriers, obstacles and points of congestion

Traditional Human Factors Tools

Link AnalysisIndicates functional linkages between activities and work points but not movement path[s] through space.Does not indicate the real and potential physical constraints, and areas of congestionDoes not indicate points of potential risk or hazard.

Broad Architectural Questions

Does the physical configuration of the OR setting [both architectural space and movable equipment] impact clinical safety, outcomes and performance in the OR?

If so, can links between errors or more specifically task interruptions, critical clinical activities and the built environment be established, geographically anchored and visually documented?

Specific Architectural Questions

Where do critical activities and movements occur? Where are the places of highest volume of

movement and activity? Where are the places of potential or actual hazards,

constrained movement or high risk activity? Are there co-relationships between task interruptions

or errors, clinical movement and activities, and spatial elements?

OR Study Site

Room Area: 662 NSF

Room Dimensions: 29 x 24.6 Feet

Room Specs: Surgical Boom

Anesthesia Boom

Perfusion Boom

Movement/Link Analysis Process

Movement Links: Pre-opNursing – Anesthesia – Perfusion – Surgeons Line density = frequencyLine width = physical movement path

There is a significant amount of movement and activity throughout the room by nursing, anesthesia and perfusion personnel in preparation for a procedure.

Movement Links: Operative

Instrument tables and perfusion equipment is moved close to the surgical table.

The circulating nurse, anesthesia and perfusion personnel continue to move about during the operative phase of the procedure.

Movement Links: Post-Op

Surgical instrument tables are moved back to wall

Perfusion equipment is moved back and broken down, tubing is unplugged and discarded

Patient is transferred to a gurney and taken to ICU or Recovery.

Interruptions: Pre-Op Interruptions at the in-swinging

entry door with the perfusion boom, perfusion equipment and personnel.

Anesthesia work area at the head of the table is congested, as there are three or more people working in the center of surrounding anesthesia equipment and supplies in tight quarters.

Interruptions: Operative

The perfusion area is a congested thoroughfare

Perfusion near entry door conflicts w traffic entering room

Access to patient side of equipment is behind surgeon

Anesthesia personnel continue to move about within their constrained workspace.

Interruptions: Post-Op

Conflicts continue at in perfusion area in general

Conflicts continue at the in-swinging entry door during transfer of patient and movement of gurney.

Recommendations Expand anesthesia work

space at head of table

Expand space for perfusion between table and wall and/or eliminate travel through area

Swing entry doors out and/or relocate closer to the footwall of the room.

IMPLICATIONS

Separately, layout and human factors play a critical role in surgical flow and patient safety.

However, when considered together the implications for healthcare architecture are magnified.

To fully understand the complexities of cardiac surgery and implications for surgical flow, a systematic approach to disruptions that include architecture, human factors, personnel, and traditional medicine are required.