Same-level slips, trips, and falls

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1 . ABSTRACT Best Practices in OR Suite Layout and Equipment Choices to Reduce Slips, Trips, and Falls GEORGE BROGMUS, MS, CPE, MErgS; WILLIAM LEONE; LORRAINE BUTLER, RN, BSN, MSA, CNOR; EDWARD HERNANDEZ, RN, BSN Same-level slips, trips, and falls (STFs) are second only to overexertion as a leading cause of workplace injury, accounting for nearly % of all workers compensation costs. In health care facilities in, same-level STFs accounted for % of all lost-time injuries (ie, injuries requiring at least one day away from work). Although STFs occur in many places throughout a hospital, the perioperative suite is of special interest because of the critical nature of the work that occurs there. An STF that disables a worker is expensive in terms of direct and indirect costs, but a disabling fall to a member of an OR team can result in adverse patient consequences as well. A fall in the OR can cause direct patient injury, disrupt the surgical procedure, contribute to surgical errors, or delay the current surgery and future surgeries while other staff members attend to or replace the injured staff member. Controlling same-level STFs is not a matter of improving on a single feature SLIPS, TRIPS, AND FALLS (STFs) account for about % of lost-time injuries for health care personnel. Although the effect that OR layout and equipment choices have on STF risk has not been specifically addressed in the literature, STFs in the perioperative suite are of particular concern because of their potential to cause adverse patient consequences. INCREASED RENOVATION of ORs to include equipment for minimally invasive procedures intensifies the importance of examining best practices in OR layout and equipment choices to reduce the potential for STFs. AORN J (September ) -. AORN, Inc,. of a safety program; rather, it involves conducting a comprehensive evaluation of many elements and making corresponding improvement where needed. This involves consideration of obvious elements, such as slip-resistant floor surfaces, slip-resistant footwear, contaminant control (eg, of liquid spills), and reduction of tripping hazards. It also involves consideration of more subtle, yet potentially critical elements such as floor cleaning methods, room and equipment lighting, room and equipment colors and markings, use of slip-resistant mats, stair and ramp design, incident investigation policies and procedures, training, and use of warning signs or barricades. All of these elements can play a role in preventing perioperative STFs. One aspect of controlling perioperative STFs that has not been addressed specifically in the literature is the potential effect that perioperative suite layout and equipment choices can have on STF accident risks. The increased renovation of ORs to accommodate equipment for more minimally invasive surgery (MIS) procedures makes this a particularly relevant topic. This article examines some of the best practices in OR layout and equipment choices that are likely to help reduce the potential for STFs. There are seven important issues that indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages and then completing the answer sheet and learner evaluation on pages. You also may access this article online at AORN JOURNAL SEPTEMBER, VOL, NO AORN, Inc,

2 Brogmus Leone Butler Hernandez SEPTEMBER, VOL, NO should be considered for reducing STFs in the OR. These include minimizing tripping hazards; maximizing view of the floor and equipment and enhancing floor and equipment lighting; ensuring adequate room space (eg, footprint, shape, volume); controlling contaminants, including the proximity and adequacy of waste containers; ensuring OR team efficiency; minimizing fatigue; and ensuring participative design (ie, designers such as architects, engineers, builders, and hospital administrators collaborate on OR design decisions with perioperative department end users such as surgeons, circulating nurses, and scrub technicians). MINIMIZING TRIPPING HAZARDS The three main sources of tripping hazards are cords and cables, low profile equipment and supplies, and protective and absorptive mats. Excluded from this list is a common tripping hazard in general industry that is or should be unlikely in the OR floor incongruities greater than / inch. Such incongruities include damaged floor surfaces and changes in elevation between different floor materials or rooms (eg, door thresholds). Some older ORs may have door threshold issues, but it is expected that in all but the most run-down ORs, floor surfaces will be in good condition. Cords and cables are necessarily used in surgical environments (Figure ), but these cords and cables should not stretch across walking paths. Even an OR that has articulating ceiling-mounted booms that should help keep cords off the floor and improve ergonomics may have cords lying across a potential walking path and equipment on the floor in that path. The primary control for cords and cables is preplanning. In addition to thoughtful routing of cords and cables, techniques such as securing cords by bundling, taping or braiding, or suspending cords and cables from the ceiling can help minimize problems. Such routing and securing techniques benefit personnel, and ultimately the patient, in addition to reducing STFs. Routing and securing cords benefits personnel by making it easier to check that all necessary cords are properly connected, and it benefits the patient because it is less likely that the patient will be injured or the procedure prolonged because someone trips on a cord. Increased use of telemetry and systems that integrate cables into the OR bed or overhead booms also helps reduce STFs. Any low-profile equipment or supplies can be a potential tripping hazard, including buckets; rolling stools; step stools; support structures for equipment (eg, Mayo stand legs); and boxes of supplies. In addition, even though protective and absorptive mats play an important role, they also can become a tripping hazard. For secure placement, absorptive mats that are designed to be slip-resistant and stay in place should be selected over absorptive materials that are not slip- Figure Cables and cords are used in most surgical procedures; better routing and securing during preparation reduces the risk that OR personnel will trip on these cords and cables. Photograph courtesy of Diana Sullivan and Lorraine Butler, Indianapolis, IN. AORN JOURNAL

3 SEPTEMBER, VOL, NO Brogmus Leone Butler Hernandez resistant. Furthermore, soiled absorptive mats should be removed if they present a tripping or slipping hazard. A mat that is oversaturated with fluids can lose its slip resistant properties. In addition, oversaturated absorptive mats can swell, presenting a tripping hazard. MAXIMIZING THE VIEW A clear view of monitors in the OR is considered a priority by designers, but often little thought is given to a clear view of the floor. Obtaining a completely unobstructed view of all floor surfaces is impossible, but the importance of being able to see floor surfaces should not be ignored. An effort should be made to allow for unobstructed views of walking pathways in the initial design of the perioperative area and in the arrangement of mobile equipment in preparation for a surgical procedure. The more such pathways are obscured by equipment and monitors, the more likely a potential tripping or slipping hazard will go unnoticed. People adjust their gait depending on their perception of the slipperiness of a floor surface so that they are less likely to slip. When visual cues (eg, the reflection from a Figure It is not uncommon for the OR to be darkened during procedures that require significant monitor use. Unfortunately, the contrast between the darkened room and intense task or monitor light can make obstacles on the floor indiscernible, contributing to the risk of falls. Photograph courtesy of Diana Sullivan and Lorraine Butler, Indianapolis, IN. fluid puddle, the shininess of a newly mopped floor) are absent because of visual obstructions, people are not as likely to adjust their gait accordingly. An important point to remember is that an unobstructed view of walking pathways is useless without adequate lighting. Advancements in surgical technology, such as MIS, have increased the use of monitors in the OR. Unfortunately, an easy solution to seeing monitors more clearly has been to dim the general lighting while leaving the surgical site highly illuminated (Figure ). This can have significant negative consequences. Not only does it leave the rest of the OR dimly lit, which can be a factor in STFs, but the high illumination on the surgical site amplifies the difficulty of adapting one s vision to the dimmer room lighting. Adaptation of the eyes from dark to light occurs rapidly, but adaptation from bright light to weak light occurs more slowly and this effect is more pronounced as people age. Although there is evidence that earlier projections may have been overly pessimistic, the average age of nurses is increasing more rapidly than the average age of the general population because fewer younger nurses are entering the workforce. This makes age-related concerns, such as eye adaptation, particularly relevant to the OR environment. General room lighting, especially floor illumination, is critical for seeing and avoiding not only tripping hazards but also fluids on the floor. An OR designed so that general room lighting must be lowered during procedures is poorly designed. Considerable thought must be given to lighting so that ample light and minimal glare is achieved. The choice of a monitor that performs well in the location and lighting of the OR is critical. Monitors vary widely in quality and performance characteristics. The best monitors not only will have AORN JOURNAL

4 Brogmus Leone Butler Hernandez SEPTEMBER, VOL, NO Resources to Help Prevent Perioperative Slips, Trips, and Falls Helpful guidelines on general principles for OR design can be found at OR Design and Construction and from the American Institute of Architects. Tools to aid in design are readily available and should be used by teams undertaking an OR design project. These include checklists and three-dimensional design software. Additional practical advice for shiftworkers can be found in the National Institute of Occupational Safety and Health (NIOSH) publication, Plain Language About Shiftwork.. Design and construction process. OR Design and Construction. _process.htm. Accessed July,.. The next generation of operating rooms. American Institute of Architects. print.cfm?pagename=aah_jrnl OR. Accessed July,.. Patkin M. A checklist for components of operating room suites. Minim Invasive Ther Allied Technol. ;():-.. Virtual OR. N Formation Design. mationdesign.com/portfolio/portfolio.html. Accessed July,.. Rosa RR, Colligan MJ. Plain Language About Shiftwork. DHHS (NIOSH) Publication No. -. National Institute for Occupational Safety and Health. Accessed July,. high resolution, but will be compatible with the software and/or electronics delivering the video signal. They will have a high contrast ratio and a surface material that will minimize the effects of reflected light. Positioning of the monitors also is critical. Perioperative personnel should be aware of how small changes in the orientation of a monitor (eg, tilt, angle) can create or eliminate glare. The American Institute of Architects (AIA) recommends that OR lighting be designed to provide a wide range of lighting levels. They suggest that this can be achieved using a ring of fluorescent lights around the diffusers and an outer ring of dimmable down-lights. The fluorescent lights can have one set of white lights and another of green lights that have separate switches. The green lights reduce glare for comfortable viewing of monitors during MIS procedures. The technical aspects of achieving optimal lighting can be quite complex, but in the final analysis, facility administrators must ensure that lighting is adequate so that any slip or trip hazard can be seen. Although it is appropriate to ensure that the surgical site is well illuminated, general room lighting should not be so dim that visual adjustment is needed to clearly see the floor and potential hazards. Surgeons, nurses, and surgical technologists have more flexibility in positioning monitors if general room lighting is indirect or diffused. If general room lighting must be lowered, consideration should be given to providing lighting systems that are designed to focus light only on the floor. Individual low-level lighting systems can be integrated and controlled by automated or voice-activated switching systems. Proximity controlled equipment lighting or high-visibility markings on projecting equipment edges also can be added. ENSURING ADEQUATE SPACE Considerations for adequate space include not only square footage needs, but also that equipment and supplies are arranged such that smooth transitions between and minimal protrusions into traffic areas are ensured. Space considerations for ORs being built today must anticipate some of the trends toward integrating services as well as incorporating technologies that will be available in the future. Although the needs in ORs vary according to the procedures performed, there is a good argument to be made for making the layout of ORs consistent so that efficiency is improved. For example, a consistent OR layout will have clean-up supplies on the same shelf, communication equipment in the same location, and the information monitor on the same boom. This also will reduce wasted time and, potentially, patient-threatening errors. Gordon provides a review of current trends in perioperative suite design with detailed descriptions of what has been successful at new facilities. AORN JOURNAL

5 SEPTEMBER, VOL, NO Brogmus Leone Butler Hernandez Following are additional recommended OR design features. Door placement in relation to the OR bed should be such that aseptic and sterile work zones are maintained for surgeons and OR staff members. A modular, structural, ceiling system should be constructed that has multiple mounting locations, each able to hold various support arms, and a center mounting location reserved for a ceiling-mounted robotic arm. The equipment boom should be placed on the sterile core side of the room away from the OR door. A seated workstation should be placed facing the OR bed and adjacent to the door between the OR and the sterile core. Adequate expansion space should be provided for future robotic systems. A vertical, downdraft, high-efficiency, particulate air filtered-curtain system should be installed to reduce airborne impurities. The key priorities for reducing STFs are the same as those for good OR design. Unobstructed access to the patient this relates to the area primarily around the OR bed so that physicians and perioperative staff members can provide hands-on care during the procedure with unobstructed floor paths. Clear pathways for the circulating nurse the pathways for the circulating nurse extend beyond the OR bed to points of access, such as storage shelves, wall-mounted equipment, and communication devices. Although the practice of ergonomics had some of its early roots in the perioperative area, few recent studies have been conducted using ergonomic analysis techniques in the OR, and many of the studies that do use such techniques (eg, link or flow analysis) focus on the tasks of the anesthesia care provider and not the overall OR layout; none have focused on STF risk. - In the absence of formal analyses that specify appropriate guidelines, providing OR workers with a formal step in their procedures to clear pathways is critical. Appropriate square footage if the OR square footage is too small, cramped spaces, restricted walking paths, and increased tripping hazards can contribute to STF risk. Although a size of to square meters (ie, to square feet) has been suggested by some,, considerations for robotic equipment, consolidation of multiple services in one room, and future technologies that may require more space suggest that these are only minimum guidelines. If the OR square footage is too large, however, the need to quickly traverse long distances to obtain supplies or equipment can cause perioperative personnel to run, which may increase the possibility of STFs. General room shape and volume like most rooms, the OR s shape and volume traditionally have been dictated by its specific functions and the surrounding building structure, but to minimize the risk of STFs, the OR s shape and volume also should be addressed. A room s shape and volume influence how people navigate within and through it. Rounded corners, walls shaped to transition to doors, and even floor material patterns provide additional visual guides for better flow. The volume of OR space, as with the volume of all spaces that people inhabit, subconsciously can affect the overall comfort level of staff members. If the volume is too large, staff members may feel isolated; if too small, they may feel enclosed. These stresses can incrementally add to the risk of STFs. In addition, volume can affect efficient movement in the OR. Larger volume rooms take longer to traverse but are less likely to result in staff members crossing paths, which decreases the risk of STFs. Smaller volume rooms do not require as much time to traverse but are more likely to result in staff members crossing paths, which increases the risk of STFs. Although these considerations may add to construction costs, the benefits of improved efficiency and reduced STF risk could be substantial. Figures and are examples of improved OR designs. CONTAMINANT CONTROL In some respects, contaminant control is the most important aspect of preventing STFs in the OR. Liquids on the floor can turn an otherwise slip-resistant surface into a sliding arena. The best way to control contaminants is at their AORN JOURNAL

6 Brogmus Leone Butler Hernandez SEPTEMBER, VOL, NO Figure Cardiac procedures often require more extensive equipment than other types of procedures, but a well-designed OR can accommodate this additional equipment with minimal on-floor obstructions. Photograph courtesy of Stryker Corp, Kalamazoo, MI. Figure Another cardiac OR with in-suite imaging and robotic instrumentation incorporates a design that maximizes ceiling-mounted monitors and equipment and thus minimizes floor obstructions. Photograph courtesy of Stryker Corp, Kalamazoo, MI. source so that they never reach the floor. For example, a dripless, brush-free, gel solution for surgical hand scrubs (Figure ) can help to prevent wet floors by minimizing water splashes. Gel-based skin preps are viscous in nature and less likely to run or pool at the surgical site as liquid prep solutions tend to do. They work rapidly and effectively, and application of gelbased skin preps is controlled, reducing the incidence of pooling under patients and thereby reducing the risk of skin irritation. Furthermore, dripping and pooling of prep solution on the bed and floor is minimized, which provides for a quicker postprocedure clean-up and, ultimately, eliminates another cause of STFs. Manufacturer recommendations must be followed because some gel products are flammable. Fluid pooling on the floors poses a set of risks. Not only does it present an infectioncontrol challenge, but it also can lead to slips and falls, which can be a major liability source for health care facilities. Fluid solidifiers usually are composed of a granulated substance that can be sprinkled onto a spill or poured into a container with fluid. Fluid solidifiers absorb liquid and solidify the fluid into gel. This serves as a means of encapsulation that halts the activity of fluid spills that can result in slips and falls. The fluid then can be disposed of easily. Adding a fluid solidifier to the liquid medical waste container or onto a fluid spill on the floor serves as an excellent means of fluid control and reduces the risk of slips and falls. AORN JOURNAL

7 SEPTEMBER, VOL, NO Brogmus Leone Butler Hernandez Figure Dripless brush-free gel scrub solution minimizes water splashes and thus the risk of falls. An additional feature here is an absorptive floor mat. Photograph courtesy of James Collins, PhD, NIOSH Division of Safety Research, Morgantown, WV. Effective contaminant control includes having adequate waste containers for the procedure and readily available additional waste control supplies, including absorptive products. Waste containers need to be large enough to handle the anticipated volume. To prevent contamination, it is important that the height of the waste container remain below the surgical table but be as high as possible to minimize the distance that the waste has to be moved and so that it does not present a tripping hazard. Team members should determine who will accomplish which critical clean-up duties before the beginning of the procedure. It should not be assumed that each member of the perioperative team knows what will be his or her clean-up responsibilities. For example, if a substance is spilled on the floor, one of the team members should know that it is his or her responsibility to clean up the spill and what specific tools and materials should be used for each kind of substance that could potentially spill. When floors are cleaned after a procedure, the following best practices should be enforced. Areas to be cleaned must be cleared of all personnel except cleaning personnel. Areas to be cleaned must be cordoned off or doors should be blocked (Figures and ). Cleaning must proceed from the most critical clean zones to the least without the need to cross over areas already cleaned. Various supplies and equipment (eg, wet vacuums, two-compartment buckets, mops) can be used. Areas must be dry mopped and allowed to dry completely before the cordon is removed. Effective contaminant control does not end in the OR; it also extends to the decontamination area. This includes ensuring that carts containing liquids do not drip when instruments are transported from the OR to the decontamination area. It also includes using similar dripless carts that allow dripless transport from cleaning areas to drying equipment (Figure ). Whatever the practice, strict policies and procedures must be written in accordance with national standards and best practices and approved by the facility infection control officer. Manufacturer recommendations also must be followed. OR TEAM PLANNING AND EFFICIENCY Without adequate perioperative team planning, risk to the patient increases, and the time the procedure takes and the risk to OR personnel increase as well. Good planning also reduces unnecessary traffic in and out of the OR, thus reducing the chance that someone will slip or trip and reducing the potential for airborne contamination. Reducing procedure-flow disruptions decreases the likelihood of compensating behaviors, such as rushing to make up for the disruption. These behaviors reflect stress, and therefore, can contribute to errors. Reduced rushing and stress can reduce the risk of slips and falls. Fraind et al examined IV medication and fluid administration processes in the OR and identified several inefficient or error-prone tasks, including workspace organization and the routing of IV lines. They noted that The conduits for drug and fluid administration (eg, intravenous tubing, stopcocks) are a source of task inefficiency and an occupational hazard. It was common for anesthesia providers to AORN JOURNAL

8 Brogmus Leone Butler Hernandez SEPTEMBER, VOL, NO struggle with intravenous tubing organization. In complex cases, they were also frequently observed to navigate (sometimes unsuccessfully) around intravenous tubing and intravenous poles, and occasionally acted unsafely when hanging intravenous fluids onto IV poles. (p) Wiegmann et al examined surgical flow disruptions and their effect on surgical errors. They found that failures in teamwork and in communication were the strongest predictors of surgical errors. Einav et al, conducted an intervention study to examine the effects of an expanded preoperative briefing protocol on critical events and found that when briefings occurred, there were more than % fewer critical events (ie, information and equipment events combined). These studies reveal that critical events and errors can reduce risk to patients and OR personnel alike if better planning and preoperative briefings occur; time is spent thinking about the layout of equipment, tubes, and cords; and surgical flow disruptions are reduced. MINIMIZING FATIGUE Fatigue can lead not only to surgical errors, but also to accidents and injuries. In the perioperative setting, fatigue primarily is related to sleep and work scheduling but also can be related to the degree that comfort has been incorporated into the design of OR features and equipment. Seated workstations should have comfortable chairs with adequate adjustments, and users should be well-informed regarding how to accomplish proper adjustment. Employees can benefit from standing workstations with padded leaning rests and comfortable shoes or mats. Equipment controls should be within comfortable reach of the operator and should be voice-activated whenever possible, such as voice-activated lights or voice-activated OR beds. - The way work is scheduled can have a significant effect on productivity and safety. The relationship is a complex one because it is not simply a matter of how many hours a person is working, but also includes how frequently during the work day the Figure Wet floor cones are equipped with a plastic chain for cordoning off areas. They also have a flashing light at the top to garner more attention. Photograph courtesy of James Collins, PhD, NIOSH Division of Safety Research, Morgantown, WV. Figure The closed for cleaning sign has a spring-loaded door bar to make it more difficult to circumvent than a simple sign alone. Photograph courtesy of James Collins, PhD, NIOSH Division of Safety Research, Morgantown, WV. person takes breaks from work. when the person is working (eg, daytime, afternoon, night); and how many days (ie, shifts) in a row the person works. Data also suggest that even the day of the week may have an effect on injury risk, especially in AORN JOURNAL

9 SEPTEMBER, VOL, NO Brogmus Leone Butler Hernandez Figure Wet instruments are placed on a cart rather than carried by hand to the drying area; the water collects on the cart rather than dripping on the floor, which would create a slipping hazard. In addition, the instrument holder slides directly off the cart into the drying area. Photograph courtesy of James Collins, PhD, NIOSH Division of Safety Research, Morgantown, WV. the health care industry. Recent research suggests that sufficient, good-quality studies exist to create a formula to estimate the effect of these factors on injury risk., The health care industry is notorious for long and irregular work hours and, despite compelling research, seems strangely ignorant of the detrimental effects of poor work scheduling, especially on interns. - How can scheduling be used to an OR s advantage? In general, elective surgical procedures are scheduled during the daylight hours, which has a distinct advantage. Late afternoon, night, and evening procedures most often deal with the more critical, high-risk, emergent, and complex patients and, consequently, require additional interventions. A good night s rest before each shift is paramount. This can be a challenge with longer shift schedules or for personnel who have worked the previous night shift. As often as is possible, personnel should be scheduled for critical surgical procedural work toward the beginning of their shift. Ample rest breaks between procedures may help to mitigate the risk of injuries., Days off are equally important. Work should be limited to five or six consecutive shifts in a row, followed by at least two rest days off in a row; at least one of these days should be Saturday or Sunday to allow for family or social opportunities on the weekends when the general population is not working. PARTICIPATIVE DESIGN Ergonomists advocate that employees participate in workplace redesign projects to improve the overall success of the design because of the unique insights possessed only by those who do the job daily. Nowhere is this more important than in OR design. Architects, designers, and hospital administrators have valuable insight and experience, but the most elegant and efficient designs arise when OR team members contribute to the OR design. This inevitably involves the use of mock-up spaces so that the designs can be examined hands-on in three dimensions. The relatively few hours spent by participants in discussion and thinking time will be worth many hours in improved efficiencies, not to mention improved quality of patient care. WELL-DESIGNED ORS Well-designed ORs should include several key features. No cords or tubes should be positioned across walking paths (eg, utility booms replace carts). Equipment (eg, fiberoptic light sources, drill and shaver power sources) should remain off the floor and be accessible from mobile utility booms. Enhanced OR lights are critical and should be used so that general lighting is able to correspond to the lighting level needed at the surgical site. Large, flat-screen monitors for endoscopic procedures and other monitoring information should be placed for comfortable viewing without obscuring the visual field of walking paths. A voice-activated OR bed should be used for positioning the patient during surgery. AORN JOURNAL

10 Brogmus Leone Butler Hernandez SEPTEMBER, VOL, NO Robotic instruments for MIS (eg, three-dimensional, endoscopic, robotic technology) should be anticipated, including the latest features for comfort and ergonomic design. Short paths to obtain instruments and supplies and to access waste receptacles should be ensured. Waste receptacle systems and contaminant clean-up materials should be ample and placed in strategic locations. Mandated planning briefings should be coordinated and include clean-up duty assignments and equipment and tube arrangement and routing. Attendance at familiarization sessions for each OR s equipment layout should be mandatory for all staff members. All OR personnel should be well-rested for each procedure and receive scheduled time off and breaks during the work shift. Traditional approaches for controlling STFs (eg, slip-resistant floors, contaminant control, reduction of tripping hazards, slip-resistant footwear) are important in nearly all environments, including the OR. Best practices in OR suite layout, design, and operation also can help reduce the risk of STFs. The beauty of these best practices is that they also can positively affect efficiencies and patient care. REFERENCES. The Liberty Mutual workplace safety index. Liberty Mutual. /omapps/contentserver?cid=& pagename=cminternet%fdocument%fshow Doc&c=Document. Accessed July,.. Occupational injuries and illnesses and fatal injuries profiles tool: case and demographic numbers. US Department of Labor. Bureau of Labor Statistics. Page. Accessed July,.. Maynard W, Brogmus G. Staying a step ahead. Occupational Health and Safety. publishing.com/stevens/ohspub.nsf/ddbfb becdbc/ecbbf cca?opendocument. Accessed July,.. Winning features in a new operating room. OR Manager. ;():,.. Ofek E, Pizov R, Bitterman N. From a radial operating theatre to a self-contained operating table. Anaesthesia. ;:-.. Jackson JR, Owsley C, McGwin G. Aging and dark adaptation. Vision Res. ;():-.. Auerbach DI, Buerhaus PI, Staiger DO. Better late than never: workforce supply implications of later entry into nursing. Health Aff (Millwood). ; ():-.. Buerhaus PI, Staiger DO, Auerbach DI. Implications of an aging registered nurse workforce. JAMA. ;():-.. The next generation of operating rooms. American Institute of Architects. /nwsltr_print.cfm?pagename=aah_jrnl OR. Accessed July,.. Greene J. Lines blurring between OR, imaging. OR Manager. ;():-.. Beney DR. William Beaumont Hospital opens advanced new operating rooms. OR Manager. /pdf/beaumontcasestudy.pdf. Accessed July,.. Gordon D. Trends in surgery suite design. Part. Healthcare Design. ;():-.. Berguer R. Surgery and ergonomics. Arch Surg. September ;:-.. Albayrak A, Kazemier G, Meijer DW, Bonjer HJ. Current state of ergonomics of operating rooms of Dutch hospitals in the endoscopic era. Minim Invasive Ther Allied Technol. ;():-.. Cendán JC, Good M. Interdisciplinary work flow assessment and redesign decreases operating room turnover time and allows for additional caseload. Arch Surg. ;():-.. Fraind DB, Slagle JM, Tubbesing VA, Hughes SA, Weinger MB. Reengineering intravenous drug and fluid administration processes in the operating room. Step one: task analysis of existing processes. Anesthesiology. ;():-.. Held J, Krueger H. Work and teamwork transparency: an ergonomic assessment in operating room facilities. Presented at: International Ergonomics Association/Human Factors and Ergonomics Society Congress; July -August, ; San Diego, CA.. McDonald JS, Dzwonczyk R. A time and motion study of the anaesthetist s intraoperative time. Br J Anaesth. ;():-.. McDonald JS, Dzwonczyk R, Gupta B, Dahl MA. Second time study of the anaesthetist s intraoperative period. Br J Anaesth. ;():-.. Leedal JM, Smith AF. Methodological approaches to anaesthetists workload in the operating theatre. Br J Anaesth. ;():-.. Sandberg WS, Daily B, Egan M, et al. Deliberate perioperative systems design improves operating room throughput. Anesthesiology. ;():-.. Rostenberg B. The innovative edge in health facility design: the impact of emerging medical technology on facility design, operations and staffing. Presented at: The American Institute of Architects National Convention and Design Exposition; June, ; Los Angeles, CA.. Recommended practices for traffic patterns in the perioperative practice setting. Standards, Recommended Practices, and Guidelines. Denver, CO: AORN, Inc; :-. AORN JOURNAL

11 SEPTEMBER, VOL, NO Brogmus Leone Butler Hernandez. Wiegmann DA, ElBardissi AW, Dearani JA, Sundt TM. An empirical investigation of surgical flow disruptions and their relationship to surgical errors. Presented at: The Human Factors and Ergonomics Society th Annual Meeting ; October -, ; Santa Monica, CA.. Einav Y, Gopher D, Donchin Y. Briefing in the operating room a tool for enhancing coordination and enriching shared knowledge bases. Presented at: The Human Factors and Ergonomics Society th Annual Meeting ; October -, ; Santa Monica, CA.. Gerbrands A, Albayrak A, Kazemier G. Ergonomic evaluation of the work area of the scrub nurse. Minim Invasive Ther Allied Technol. ; ():-.. Koneczny S, Matern U. Checklists suitable tools for usability testing. Presented at: The Human Factors and Ergonomics Society th Annual Meeting; September -, ; Santa Monica, CA.. Kranenburg L, Gossot D. Ergonomic problems encountered during video-assisted thoracic surgery. Minim Invasive Ther Allied Technol. ; ():-.. van Veelen MA, Nederlof EA, Goossens RH, Schot CJ, Jakimowicz JJ. Ergonomic problems encountered by the medical team related to products used for minimally invasive surgery. Surg Endosc. ;():-.. van Veelen MA, Snijders CJ, van Leeuwen E, Goossens RH, Kazemier G. Improvement of foot pedals used during surgery based on new ergonomic guidelines. Surg Endosc. ;():-.. van Veelen MA, Jakimowicz JJ, Kazemier G. Improved physical ergonomics of laparoscopic surgery. Minim Invasive Ther Allied Technol. ;():-.. Wauben LSGL, van Veelen MA, Gossot D, Goossens RH. Application of ergonomic guidelines during minimally invasive surgery: a questionnaire survey of surgeons. Surgical Endoscopy. ;():-.. Brogmus GE. Day of the week lost time occupational injury trends in the US by gender and industry and their implications for work scheduling. Ergonomics. ;():-.. Folkard S, Lombardi DA. Modeling the impact of the components of long work hours on injuries and accidents. Am J Ind Med. ;():-.. Spencer MB, Robertson KA, Folkard S, et al. Research Report the development of a fatigue/ risk index for shiftworkers. Health and Safety Executive. Accessed July,.. Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. ;():-.. Barger LK, Cade BE, Ayas NT. Extended work shifts and the risk of motor vehicle crashes among interns. N Eng J Med. ;():-.. Barger LK, Ayas NT, Cade BE. Impact of extendedduration shifts on medical errors, adverse events, and attentional failures. Public Libr Sci. ;():-. get-document&doi=./journal.pmed.. Accessed July,.. Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns compliance with accreditation council for graduate medical education work-hour limits. JAMA. ;():-.. Tucker P, Folkard S, Macdonald I. Rest breaks and accident risk. Lancet. ;():.. Tucker P, Lombardi D, Smith L, Folkard S. The impact of rest breaks on temporal trends in injury risk. Chronobiology Int. ;():-.. Wilson JR, Corlett EN, eds. Evaluation of Human Work: A Practical Ergonomics Methodology. London, England: CRC Press;.. Rubel Z. Visualization and mock-ups for OR design and construction. Presented at: The OR Manager Conference; May -, ; Austin, TX. George Brogmus, MS, CPE, MErgS, is the technical director of ergonomics at Liberty Mutual Insurance Group, Burbank, CA. Mr Brogmus has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. William Leone is a consulting architect, Lake Elsinore, CA. Mr Leone has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Lorraine Butler, RN, BSN, MSA, CNOR, is an administrative director at Methodist Hospital, Clarion Health Partners, Indianapolis, IN. Ms Butler has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Edward Hernandez, RN, BSN, is the OR nurse manager at James A. Haley Veterans Hospital, Tampa, FL. Mr Hernandez has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. AORN JOURNAL

12 Examination. Best Practices in OR Suite Layout and Equipment Choices to Reduce Slips, Trips, and Falls PURPOSE/GOAL To educate perioperative nurses about instituting best practices to reduce slips, trips, and falls in the perioperative suite. BEHAVIORAL OBJECTIVES After reading and studying the article on reducing slips, trips, and falls (STFs), nurses will be able to. identify the adverse effects of STFs that occur in the work environment,. discuss hazards present in the perioperative environment that could increase the risk of STFs, and. describe solutions that should be considered for reducing STFs in the OR. QUESTIONS. Same-level STFs are second only to overexertion as a leading cause of workplace injury, accounting for nearly of all workers compensation costs. a. % b. % c. % d. %. A fall in the OR can. cause direct patient injury.. contribute to surgical errors.. delay the current surgery and future surgeries.. disrupt the surgical procedure.. require the OR manager to stop all further surgical procedures that day. a. and b.,, and c.,,, and d.,,,, and. Important issues that should be considered for reducing STFs in the OR include. controlling contaminants.. enhancing floor and equipment lighting.. ensuring adequate room space.. ensuring OR team efficiency.. maximizing the view of the floor and equipment.. minimizing fatigue.. minimizing tripping hazards. a.,, and b.,, and c.,,,,, and d.,,,,,, and. The primary control for cords and cables is a. bundling, taping, or braiding them. b. preplanning. c. suspending them from the ceiling. d. thoughtful routing.. reduce glare for comfortable viewing of monitors during minimally invasive surgical procedures. a. Green fluorescent lights b. White fluorescent lights c. Dimmable down-lights. Recommended OR design features include. a modular, structural, ceiling system with multiple mounting locations.. a seated workstation facing the OR bed and adjacent to the door between the OR and the sterile core.. a vertical, downdraft, high-efficiency particulate air filtered-curtain system.. adequate expansion space for future robotic systems. AORN, Inc, SEPTEMBER, VOL, NO AORN JOURNAL

13 SEPTEMBER, VOL, NO Examination. a door placed such that aseptic and sterile work zones are maintained.. an equipment boom on the sterile core side of the room away from the OR door. a.,, and b.,, and c.,,, and d.,,,,, and. The key priorities for reducing STFs include. appropriate room shape and volume.. appropriate square footage.. clear pathways for the circulating nurse.. use of telemetry and minimally invasive equipment.. unobstructed access to the patient. a.,, and b.,, and c.,,, and d.,,,, and. When floors are cleaned after a procedure, the areas to be cleaned must be cordoned off or doors blocked. a. true b. false. Effective teamwork can help prevent STFs because OR team planning reduces. unnecessary OR traffic, decreasing the chances that someone will slip or trip.. procedure-flow disruptions, decreasing the likelihood of compensating behaviors such as rushing.. stress, which can contribute to errors. a. and b. and c.,, and. Work should be limited to four or five consecutive shifts in a row, followed by at least one rest day off on a Friday or Saturday. a. true b. false The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP. Check with your state board of nursing for acceptance of this activity for relicensure. AORN JOURNAL

14 Answer Sheet. Best Practices in OR Suite Layout and Equipment Choices to Reduce Slips, Trips, and Falls Event # Session # Please fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to: AORN Customer Service c/o AORN Journal Continuing Education S Parker Rd, Suite Denver, CO - or fax with credit card information to () -. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit. Signature. Record your AORN member identification number in the appropriate section below. (See your member card.). Completely darken the spaces that indicate your answers to examination questions through. Use blue or black ink only.. Our accrediting body requires that we verify the time you needed to complete this. continuing education contact hour (-minute) program.. Enclose fee if information is mailed. ID Number Session Number Mark only one answer per question. A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E AORN (ID) # Name Address City State Zip Phone number RN license # State Fee enclosed or bill the credit card indicated MC Visa American Express Discover Card # Expiration date Signature (for credit card authorization) Fee: Members $. Nonmembers $ Program offered September The deadline for this program is September, AORN, Inc, A score of % correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion. SEPTEMBER, VOL NO AORN JOURNAL

15 . Learner Evaluation Best Practices in OR Suite Layout and Equipment Choices to Reduce Slips, Trips, and Falls This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of to. PURPOSE/GOAL To educate perioperative nurses about instituting best practices to reduce slips, trips, and falls (STFs) in the perioperative suite. OBJECTIVES To what extent were the following objectives of this continuing education program achieved?. Identify the adverse effects of STFs that occur in the work environment.. Discuss hazards present in the perioperative environment that could increase the risk of STFs.. Describe solutions that should be considered for reducing STFs in the OR. CONTENT To what extent. did this article increase your knowledge of the subject matter?. was the content clear and organized?. did this article facilitate learning?. were your individual objectives met?. did the objectives relate to the overall purpose/goal? TEST QUESTIONS/ANSWERS To what extent. were they reflective of the content?. were they easy to understand?. did they address important points? LEARNER INPUT. Will you be able to use the information from this article in your work setting? a. yes b. no. I learned of this article via a. the Journal I receive as an AORN member. b. a Journal I obtained elsewhere. Session Number c. the AORN Journal web site.. What factor most affects whether you take an AORN Journal continuing education examination? a. need for continuing education contact hours b. price c. subject matter relevant to current position d. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): Author names and addresses: A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E AORN JOURNAL SEPTEMBER, VOL NO AORN, Inc,

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