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.
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