Include infection prevention in your hybrid OR design

If a hybrid operating room is likely to be part of your hospital’s future, a critical part of the planning is to decide where it will be located. Variables such as available space, funding, and type of procedures to be performed will drive the decision, but a common component of all hybrid OR projects—whether new constructions or renovations—is infection prevention.

“Infection prevention needs to be a part of the design process, not just the department that you contact when you need to have an ICRA [infection control risk assessment] form completed,” says Heather Hohenberger, BSN, RN, CIC, CNOR. As the quality improvement coordinator, perioperative services at Indiana University (IU) Health, Hohenberger is trying to raise awareness about the importance of infection prevention when designing hybrid ORs.

In January 2012, she was involved in assessing the hybrid room that opened in 2010 within the cardiac catheter lab space at Riley Hospital for Children, a freestanding pediatric academic center that is part of the IU Health system. Her observations and recommendations led to elimination of surgical site infections (SSIs) among hybrid patients as well as changes in workflow and staff training.

“Infection prevention provides the guiding principle for what barriers need to be in place for a demolition, renovation, or any type of construction process to decrease the risk of infection from the dust and debris,” she explains.

These efforts protect not only existing patients but also future patients. “If Infection Prevention staff aren’t involved from the onset, the potential for rework increases,” she notes.

Cath lab conversion

Riley Hospital has 14 ORs located in a section of the hospital that was built in the mid-1980s, where pediatric neurosurgery, cardiovascular, orthopedic, general, gastrointestinal, genitourinary, and ENT procedures are performed. Little space and block time were available among those ORs and the cath lab equipment was becoming outdated, so the decision was made to open a hybrid room within the cath lab space.

Cardiologists approached hospital leaders, and once approval was granted, a biplane was purchased for fixed angiography and a control room and equipment room were built. Monitors for fluoroscopy, patient data monitors, an injector, a sterile back table, a Mayo stand, anesthesia equipment, and mechanical ventilation equipment were needed along with diagnostic tools for cardiac procedures.

A new exterior wall was built to allow space for the additional equipment, Hohenberger says.

Design and construction teams met weekly with the end users, equipment manufacturers, and contractors. Infection prevention staff, however, weren’t consulted as a part of the design process until after initial demolition, when questions about air exchanges and room ventilation raised concerns about converting to open procedures.

A hybrid room, especially if it’s built in an interventional radiology (IR) or cardiac cath lab space, must have a minimum of 15 air exchanges per hour, Hohenberger says. A Class A operating room has 15 air exchanges per hour, and class B and C rooms must have a minimum of 20 per hour. The architect—and likewise the end users (nurses, cardiologists, and hospital leadership)—may be unaware of the differences in infection prevention requirements between diagnostic and open surgical procedures.

“If conversion to an open procedure is needed, the room must be designed to provide the required number of air exchanges for that procedure,” Hohenberger emphasizes. “If you’re renovating an old cardiac cath lab space, you need to know how many air exchanges exist because you may need to increase that number.”

Staff training

When a hybrid OR is located in a cath lab or IR area, staff must be trained in the infection prevention measures that are second nature to OR staff.

“Infection prevention efforts start when a patient comes into the room, not when a diagnostic procedure changes to a surgical procedure,” Hohenberger says. This mindset reflects a fundamental difference between OR staff and those who work in other departments.

“If you’re in a cath lab space, make sure staff know it’s not just a diagnostic procedure, it’s a surgical intervention. Little things like wearing a surgical mask while walking from the control room to the procedural space and thinking about sterility in the entire environment—not just the table but the whole field—are important,” she notes. “We shouldn’t just assume that people know this.”

Among the topics that should be covered during training are:

• operative attire
• hand antisepsis
• setting up the sterile field
• patient skin prep
• draping techniques
• traffic patterns
• surgical conscience

At Riley, there wasn’t a designated educator for the cath lab/hybrid room staff when the new room opened in 2010. Later on, concern about the occurrence of SSIs among patients treated in the hybrid room prompted cardiology and the medical director of infection prevention to request observation of the procedures performed within the space. In January 2012, Hohenberger observed the hybrid staff and recommended some changes. Since then, there have been no SSIs from that area.

What changed? Hohenberger says they needed to “go back to the basics” of infection prevention. An OR educator was brought in to provide orientation checklists such as how to perform a proper hand scrub.

Because the room location and nature of the procedures differ among hospitals, there is neither a consistent staffing matrix nor workflow, Hohenberger points out. Workflow is specific to each facility, and the location and surgical specialty utilizing the hybrid room dictate the staffing needs.

“If the hybrid room is in the OR space, there will be a circulator and a scrub nurse trained specifically for that room, but in a cardiac cath lab space, there may be a team that’s available by page to come as needed—for example, a cardiac cath RN acting in a circulator role, or another RN scrub helping to pass instruments to the operating or diagnostic team,” she explains. Anesthesiologists and physicians are the only consistent staff.

Lessons learned

Efforts to raise awareness about infection prevention efforts among hybrid room staff fostered a sense of collaboration and understanding between the hybrid and OR teams. “By building a relationship with the OR staff, hybrid staff were able to see that they weren’t alone—there’s a larger group of people who understand the kinds of issues they have while providing patient care,” Hohenberger says.

“If you’re looking to open a hybrid room, opening it within the OR is the best option because it eliminates so many factors that could eventually cause problems,” she adds. “Each facility is different, and for some it may be necessary to open the hybrid room within a cath lab or IR space, so it’s important to understand the infection prevention practices that need to be in play at the very beginning of the process.”

What’s ahead

A new wing is being built at Riley that will house the OR, preoperative and postoperative areas, and the postanesthesia care unit. The new space will have 17 ORs and 2 hybrid rooms for the cardiac team. “We’re also moving 2 rooms for interventional radiology into the new OR space,” Hohenberger says. “We’ve learned that the best way to make it function is to move the hybrid room into the OR space. We’ll still have the hybrid room team, which will function out of the new OR, and we’ll still have the 17 ORs.”

The space was specifically designed to place the 2 hybrid rooms just south of the 2 cardiovascular rooms, she says. The proximity of the cardiovascular team and the cross training that is planned will ensure prompt response in case an open procedure is needed.

The decision to build the 2 new hybrid rooms within the OR space was significant. In the future, the hybrid room in the cath lab space probably won’t continue to be used for hybrid cases within that space, Hohenberger says. Staff will move into the new hybrid OR space, so it’s unclear what will become of the old hybrid space.

—Elizabeth Wood