When equipment booms perform as intended, they bring hazardous cables up off the floor, obviate the need to search for equipment between cases, help preserve sensitive equipment and improve OR ergonomics. But when they don't perform, booms can cause staff injuries, hinder efficiency and frustrate the surgical team - while costing a lot of money. The only way to prevent the latter scenario is to create a painstakingly thorough plan before you buy. This is the clear message from the 60 OR and facility managers who responded to our recent boom survey. Here's their long list of factors to consider:

See for yourself. See your boom in operation and use it when possible before you buy. "Don't rely on the showroom demonstration. Get the list of satisfied customers as well as those who have had difficulty," says Nancy Gondringer, CRNA, MA, director of surgical services with the Lincoln, Neb.-based St. Elizabeth Regional Medical Center. "And don't make the mistake of visiting a facility when the OR is empty. See how they set up their boom and watch them use it." Ray Hasel, MD, FRCPC, DABA, chief of anesthesiology and pain management with Lakeshore General Hospital in Pointe Claire, Quebec, recommends going a step further. Don't just see your boom in operation, he says, operate under it. "Get observer status and do procedures at three different facilities," he says.

Position the boom wisely. Since the boom needs to be integrated into the function of the OR, say our panelists, consider traffic flow, procedure types, sterile field requirements and other equipment needs before finalizing boom placement. Says one clinical educator: "Do every kind of procedure in the room before you pick final placement."

Keep ceilings high. Several panelists lowered their ceilings well into the construction process because they needed more above-ceiling space to accommodate cables, ductwork and structural supports. Others have retrofitted booms into existing ORs with too-low ceilings. The result, they say, is that the boom interferes with surgery and causes shoulder and head injuries. Says one manager: "A retrofit on too low a ceiling is worse than not having a boom at all."

Get sufficient arm reach. Forty percent of our panelists who report boom problems cite insufficient arm reach as their top concern. Figure out exactly how much arm reach you'll need for every procedure, they advise, even for those you don't yet perform but plan to add. "Our boom doesn't reach far enough," complains one clinical educator. "We have to manipulate the patient's bed after the patient is anesthetized."

Maximize maneuverability. Difficult maneuverability is another top concern of our panelists who report boom problems. Booms that are hard to move, won't go where you need them or can't be nestled out of the way when not in use won't improve efficiencies. Our panelists recommend three ways to maximize boom maneuverability:

• Consider booms with three points of articulation in the arm.
• Evaluate one- and two-boom layouts. Single booms may not meet all your needs, no matter how good the arm reach, but a second boom creates more devilish details to consider. If two booms aren't precisely positioned, sufficiently articulated and properly sized to your OR, they'll cause interference. "Two large and cumbersome booms were installed on either side of the patient, making it difficult to get other equipment in and out of the rooms," says one clinical nurse manager. "And they always seemed to be in the way. We removed them after five years."
• Be sure you can nestle your boom out of the way when not in use. Says one panelist: "Some booms don't go 360', and we can't get them out of the way during some procedures."

Make your plan tangible. Our panelists recommend using the virtual reality software and erector sets that some vendors offer. One panelist even used Lego blocks to bring her boom design to life. This, along with the site visits, will help the whole team visualize the boom setup and can be invaluable in helping you evaluate boom placement, arm reach and maneuverability.

Think domino effect. Moving things around even an inch or two can spell functional problems later, and our managers recommend revisiting your plan with each and every alteration. One panelist, who installed two booms in her orthopedic ORs along with independently hanging surgical lights, now plans to remove them for this very reason. "We changed the position of our lights during installation, but we didn't foresee how that change, although very slight, would interfere with boom placement," she says. "We thought we had it all worked out until we started doing shoulders, which increase the demand for maneuverability because they are left or right procedures. The bottom line is any time anybody makes any changes, reassess your whole plan."

Know your equipment and gas line needs. About 20 percent of our panelists who report problems say they don't have enough shelf space, and another 20 percent say weight is an issue. To prevent both problems, define exactly what equipment you need to house in the boom and whether the boom can hold it. The old-style TV-like endoscopic monitors, for example, can be too big and heavy for modern booms, and placing gases through the boom adds substantial weight to the whole construct. "Our equipment is so heavy that the booms had to be reconfigured from a strictly hydraulic system to a combination of hydraulics and electricity," says Donna F. Holt, RN, administrator of the Strand GI Endoscopy Center in Myrtle Beach, S.C. "Now they drift occasionally, initially requiring service to the tune of nearly $900 per visit, although now I just tighten the set screws myself."

Lack of equipment planning can also lead to equipment incompatibilities. One panelist purchased a lighter, digital flat-screen video monitor to house in the boom but didn't realize until later that it is incompatible with the facility's older-style analog video equipment.

Know your connections. Determine exactly what connections you need on your boom, including the number of gas, electric, video and suction connections. These features (and others) might come a la carte. One panelist's booms came with electrical outlets only, and she ended up retrofitting the other connections at a cost of $2,000 to $3,000 per OR. "Find out if the wires for your video equipment are included," she warns. "The costs are not all-inclusive and things are extra. Be sure you understand all of the costs to install, repair and maintain the boom."

Ensure vendor compatibility. If your video equipment and boom vendors can work together, you'll save yourself some headaches. For example, check to see if your video vendor can send cables to the boom company so the wiring can be pre-installed, says Marlene Brunswick, RN, director of nursing with the Findlay (Ohio) Surgery Center.

Ensure sufficient cable space. Several panelists purchased booms with conduits that were too narrow to house all of their cables, and some experienced cable damage and shearing as a result. "The narrow structural tubing of the arms made it nearly impossible to pull in the number of cables we required," says Bruce Duncan, BSc, PEng, MPA, coordinator of biomedical engineering with the Vancouver Island Health Authority in Victoria, B.C. "Don't opt for thin, elegant-looking tubing for the arms."

Customize. Knowing your needs up front will help prevent retrofitting later. After receiving her new booms, Ms. Holt had to have special $1,000 devices made for hanging her endoscopes. "We had to remove stainless steel bars, send them to a metal shop to have holes drilled and purchase acrylic scope holders separately," she says. "The acrylic cracked and we had to replace them every few months." Adds Kathleen Brooks, PA, regional director of perioperative services with Bassett Healthcare in Cooperstown, N.Y.: "One of the boom vendors was reluctant to configure the boom the way I wanted it because he had never done it that way before. Now, it works great."

Think about the future. "If I were to pass on a tip, it would be to plan to add a boom, even if it's only one room at a time," advises Ms. Brunswick. "It will prove over time if it is worth adding it to other rooms and if your volume of video cases warrants it." Many of our panelists also recommend building in as much extra shelf space and flexibility as you can to accommodate future needs - including room for additional cables.

Boom satisfaction
A full 43 percent of our OR managers rate the boom purchasing decision as "difficult" or "very difficult." The way to ensure success, they say, is to know exactly why you need a boom in the first place, get intimately involved in every detail and refrain from over-relying on outside expertise. The comment of this ASC medical director reflects the feelings of several panelists: "We were convinced [to buy] by representatives and a very few hospitals that had installed them but used them for too little time to accurately assess the disadvantages of the system." Some panelists, like Ms. Holt of Strand GI Endoscopy, now regret the decision to invest in a boom in the first place. "Even if properly customized from the beginning, the high overall cost of $150,000 per boom far outweighs their usefulness for our purposes," she says.

Then there are those like Ms. Brunswick who are thrilled with their booms and can easily tick off the benefits:

• efficiency of moving the boom out of the way when you're not using it and the ability to immediately have it ready;
• never having to plug or unplug equipment and move slave monitor cables from one side of the room to another is a room turnover time saver;
• not having to change CO2 tanks mid-procedure; and
• no longer having to worry about wheels from portable towers moving from room to room through irrigation fluids on the floor, which can be an infection control problem.