Q&A: OR design may impact surgical duration for TJA
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Key takeaways:
- Results showed design factors, including OR size and clearance size, may impact surgical duration.
- Future studies will examine the impact of individual design components on surgical duration.
Data recently published in HERD: Health Environments Research & Design Journal showed that OR physical environment may impact surgical duration and outcomes for total joint arthroplasty.
With a scarcity of literature on how physical environment and architectural design of ORs impact surgical procedures, Xiaobo Quan, M.Arch, PhD, associate professor of architecture at the University of Kansas School of Architecture and Design, performed a quasi-experimental study that compared surgical duration and workflow disruptions in TJA procedures between two ORs with different architectural designs at the same hospital.
In the study, one of the rooms was bigger, equipped with wider clearances on both sides of the operating table, had a wider door positioned on the sidewall, more storage and a larger clearance between the circulator workstation and the sterile field, creating a superior OR design. Quan told Healio that the improved design resulted in a significantly shorter surgical duration for the same type of surgery performed by the same surgeon. The average surgical duration was 96 minutes for total hip arthroplasty vs. 107 minutes in the comparator room, while the average duration for total knee arthroplasty was 85 minutes vs. 93 minutes, respectively.
To find out more about the study results and implications, Healio spoke with Quan about how OR design can impact the surgical duration of TJA.
Healio: What was the impetus behind this study?
Quan: During the recent years, I did literature reviews on how the built environment impacts health care outcomes. One study showed how the built environment may impact physicians’ ability to complete certain simulated tasks. They found that noise and music have an impact on [completion of tasks].
Recently, I read other studies about how work disruptions contribute to longer surgery duration. The study showed for every disruption observed, it oftentimes took about a minute to resolve and caused an increase in surgery duration. In a typical surgery, those disruptions would cause more than a 20% increase in surgery duration.
I believe surgery duration is an important outcome here because surgery time is precious. The OR is expensive to build, maintain and operate. I made the connection that if the physical environment has an impact on workflow disruptions and workflow disruptions have an impact on surgery duration, why not examine the connection between the physical environment and the surgery duration? According to previous studies, there should be a connection, but nobody had studied it.
In the hospital in the study, it happened to have two rooms that were constructed at the same time but designed differently, where one doctor performed the same type of surgery in two rooms, and the team members rotated between the two. So, it was a natural experiment.
I focused on single-side knee and hip replacement surgeries. Unlike some other unique orthopedic surgeries, these are more standard and are performed frequently. I picked these surgeries because many surgeons have a lot of experience performing them and any time savings on these surgeries may lead to an annual reduction in surgical time.
Healio: How may the design of the OR change surgical outcomes?
Quan: The [Facility Guidelines Institute] FGI Guidelines for Design and Construction of Health Care Facilities were created by groups like the [American Institute of Architects] AIA and others to specify how big the OR should be, as well as the size of the clearance around the surgical table. In the OR, the surgical table is typically in the middle. One thing that is critical is the size of the clearance between the sterile zone and the other workstations and supply storage.
There are several setup changes during a surgery. They move patients in, move patients on the table, do preparation and then do the surgery. When patients wake up, the team needs to bring the bed in. There are a lot of changes during that time and the adequate size of the clearance will make workflow disruptions, like the physical blockage of certain walking paths, less likely. If you have a tight space, no matter how you move equipment around or position it, you will get to the point where it is too crowded, and the circulator or other staff may not be able to move through. Sometimes the doctor may want to walk around the table to the other side for some reason but does not want to break the sterile field. At that time the circulator needs to come in to move things around. This takes some time to work.
The disruptions that I studied are environment related. I categorized those by looking into the previous literature focusing on workflow disruption, which had identified several environment-related disruptions.
Healio: From an architectural perspective, what changes would you recommend when designing a new OR?
Quan: For every surgery, we need to figure out an ideal setup. It should be customized. I observed a huge difference between knee and hip replacement surgeries and between different surgeons.
One thing I want to emphasize is that I controlled both the surgical type and the surgeon. Those two things impact surgical duration a lot. My study is the first to make the direct connection between the physical environment and the surgery duration while controlling these two major factors.
In terms of the recommendation for the design, we need to first look at the typical workflow for a particular surgery type at a particular facility and design the room around these operations with certain scenarios in mind. What will happen while moving the patient to the table? What will happen during the surgery? Every OR has a different setup that will serve a different process.
I am also planning a study looking at how different factors impact surgery duration. For instance, the room size and shape could be more important than the door location and the amount of storage inside the room for certain scenarios.
Healio: What can studies like this accomplish for orthopedics and OR design?
Quan: This study highlights the importance of the physical environment. A lot of time the physical environment is only considered as a cost center. The decision-makers on the capital investment may not think that the investment may relate to cost savings on the operation side. The health care operation counts toward 70% or 80% of health care expenses, whereas capital investment is a small amount.
Say you saved 5 minutes per surgery. If we consider that you have five surgeries a day, then that will be 25 minutes. If you consider there are five staff members in there, including the surgeon, that will add up to about a 2-hour savings in staff time. And that is only for one OR on one day. If we have 10 ORs and staff members are paid hourly, that is a huge savings for a health care organization.
The better designed room in the study does not represent the best possible design and can be further improved. If we have more improvements, like a newer building or a new OR, that will further reduce surgery duration. Eventually, with the further improvement, the savings in the surgery may help increase the utilization of the OR. Instead of doing 500 surgeries per year, now you can do 600 in an OR. For a health care facility, that is a win, and for patients, that is also a significant win because longer surgery duration has been found to be related to postoperative complications, like infections and bleeding. Longer surgery also contributes to the cancellation and delay of subsequent surgeries. This is a major issue, especially for elective surgeries where patient satisfaction is important. If you make people wait, they get frustrated and anxious. It is related to patient experiences, patient outcomes and cost.
Reference:
Xiaobo Q, et al. HERD. 2024;doi:10.1177/19375867241254529.
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