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Effects of Operating Room Size on Flow Disruptions in Robotic-Assisted Surgery
Event Type
Oral Presentations
TimeWednesday, April 1411:00am - 11:20am EDT
LocationHospital Environments
DescriptionIntroduction
Surgical procedures have become more complex, integrating advanced technology, state-of-the-art equipment, and in some cases, more team members. Many operating rooms (ORs) were not designed to meet the ever-adapting environment meant to be constrained within them. This may be particularly true with respect to robotic assisted surgery (RAS) which places greater demands on the surgical team to accommodate, manage and work around a large surgical robot, one or two surgeon consoles and a tower. Challenges associated with OR size may present as constrained movement, disorganization, sterility violations, visual constraints, physical contact between devices or people, or even damage and injury.

One approach to studying environmental disruptions associated with OR size is to observe and document flow disruptions (FDs) or deviations in the natural progression of a task, thereby compromising the safety and efficiency of that task. The focus of our study was to investigate FDs – specific to the environment, that occur in the OR during RAS to investigate the systemic challenges associated with room size.

Methods
Robotic surgery observations were conducted by trained human factors observers at two sites in the United States. Site one is an 886-bed non-profit hospital in Southern California and site two is a 700-bed non-profit, academic medical center in South Carolina. Data was collected between July 2019 and December 2020 (17 months).

Data Collection: General, urologic, and gynecologic robotic-assisted procedures that were conducted using the da Vinci Si or Xi robot were chosen for observation for this study. Each procedure was divided into five phases: 1) wheels-in to insufflation; 2) insufflation to surgeon on console; 3) surgeon on console to surgeon off console; 4) surgeon off console to skin closure; and 5) skin closure to wheels out. FDs were captured in the form of a narrative during all five phases of each observed robotic procedure using a data collection tool created by the research team. This study focused only on those FDs that were related to the environment and included observed deviations related to wires and cords, lighting, temperature, narrow or tight spaces, architectural design, and placement and movement of equipment (e.g., trashcans, chairs, trays, etc.) Additionally, the square footage of each OR in which a case was observed was recorded for further analysis.

Data Analysis: To account for the variance in procedure type and duration, the rate of environment FDs per hour was calculated and used for the analysis. A multiple regression analysis was then conducted using IBM SPSS (version 24) statistical software to determine the effect of room size and hospital site on the number of environmental flow disruptions by and across all phases.

Results
A total of 54 observations were conducted (28 at site 1 and 26 at site 2). Site 1 observations took place across six different rooms: 385.6 sq. ft (n=4), 466.9 sq. ft (n=7), 610.6 sq. ft (n=12 across two ORs), 611.3 sq. ft. (n=1), and 611.9 sq. ft (n=4). Site 2 observations took place across two different rooms 533 sq. ft. (n=15) and 691 sq. ft. (n=11).

Phase 1: A multiple regression demonstrated a significant effect of room size (t = 2.052, df = 52, p = .045) and site (t = -5.312, df = 52, p = .000) on the rate of environmental FDs occurring during phase 1 (R2 = .357). The analysis demonstrated that for every 100 square foot increase in room size, the rate of environmental FDs increased by 1.6 per hour, with site 1 experiencing 7.5 FDs more per hour than site 2.

Phase 2: A multiple regression demonstrated a significant effect of room size (t = -2.457, df = 52, p = .017) and site (t = -3.854, df = 52, p = .000) on the rate of environmental FDs occurring during phase 2 (R2 = .372). In contrast to phase 1, for every 100 square foot decrease in room size the rate of environmental FDs increased by 1.8 per hour, with site 1 experiencing 4.9 more FDs per hour from a baseline of 17.7 FDs per hour.

The multiple regressions did not demonstrate significant effects of room size on environmental FDs for phase 3, 4, 5, and across all five phases.

Discussion
Significant effects of room size and hospital site on the rate of environmental FDs were found for phase 1 (wheels in to insufflation). More specifically, as room size increased, the rate of environmental FDs also increased during phase 1. Furthermore, significant effects of room size and hospital site on the rate of environmental flow disruptions were also found for phase 2 (docking), however as room size decreased, the rate of environmental flow disruptions increased during phase 2.

The difference in activity between the two phases could serve as an explanation as to why there is an increased rate of environmental FDs in larger ORs during phase 1 but in smaller ORs during phase 2. For example, activities taking place in phase 1 include procedure set up and preparation which involves organizing the room and setting up equipment needed for the procedure. Larger ORs may require more movement of equipment around the OR, removal or storage of unnecessary equipment, increased issues with wires and cords as they are more spread out, and overall increased movement by the OR team as compared to smaller ORs. Alternatively, activities taking place in phase 2 include preparation for robot docking. Such preparation involves clearing pathways for the robot by rearranging the placement of trash cans, chairs, tables, trays, etc. In smaller ORs, available surface area is already limited and when introducing new technology that requires the use of larger equipment into the room, challenges arise with regards to available space to successfully maneuver equipment around the room. FDs in this phase can include equipment collision, personnel in the OR having to move out of the way for equipment placement, and personnel running into equipment due to a lack of space.

Furthermore, the rate of environmental FDs was higher at site 1 than at site 2 for both phases 1 and 2. These differences may be contributed to training OR teams for RAS, OR set up, and pre-procedure preparation.

Findings from this study bring to light the challenges involved in introducing new technology into ORs that are not designed for its accommodation. Although new technology provides greater benefits towards patient safety, it is important to consider the needs of the technology with respect to OR size and set up before it is integrated into the OR for use.

Funding Sources:
This project was funded under grant number HS026491-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (KC, JA, TC). The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of HHS. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report.