I've been involved in a few OR renovation projects, and the main concept I've come to embrace over the course of them is this: Whatever is cutting edge today will be obsolete in about five years. Instead of thinking in terms of specific equipment - the latest HD video camera or a fancy cautery device - you need to think in broad design paradigms that you can then fill in with specific instrumentation. Here's a look at the five elements we at Mt. Sinai Hospital considered so that we could equip our ORs with the future in mind.

Consider patient flow and safety
When you start to plan, step back, look at the whole space you'll be dealing with and think about patient flow in that room. It's the same as if you were renovating your kitchen. You don't just say, "OK, I want a dishwasher and a sink and a refrigerator, and I would like them where they'll look nice."

Instead, you think about where you're going to be doing the dishes, and therefore where the sink needs to be in relation to the dishwasher; you aren't going to want the refrigerator to be between the two - it creates distance between two objects that should be near each other, and increases the likelihood someone will be in your way (standing in front of the refrigerator with the door open, no doubt).

So with an OR, think about where you walk in. Who is going to be bringing the patients in? Where is it appropriate to put the doors? How big are the beds? What equipment will be needed next to the OR table, and what can stay in a corner?

Where you put equipment is not only a workflow issue, it's also a patient safety issue. That's why your OR should permit adequate access to the patient by both the surgery and anesthesia teams, and should facilitate positioning of the patient in order to complete procedures safely and expeditiously. Some tips for reaching these design goals:

• Replace carts with overhead booms. If a patient codes, you can swing booms out of the way quickly to gain access. With a boom-based system, you won't be hindered by power and control cables and wires on the floor.
• Buy versatile operating tables. You want to purchase one that allows for a variety of patient positions (to accommodate varied procedures and body weights) and a variety of accessories. For example, a mayo stand mounted directly to the table will give a surgeon a place other than on the patient's body to temporarily set instruments down. That protects the patient and maintains efficiency for the surgeon.

Think in terms of workflow and safety instead of the specifics of equipment, and everything will fall into place.

Consolidate controls
Now that there's so much equipment needed in ORs, it's best to find ways to centralize it. That is, you don't want the controls scattered throughout the OR - figure out how you can put it all in one place. Not only does it ease motion in and out of the OR, but also it will ease access to the patient and make life easier for the circulating nurse.

Back to the kitchen: The person who does the dishes wants the sink and dishwasher near each other and probably the cabinets, too, so that when the dishwasher's done, putting away glasses and plates is efficiently done.

Think of the many duties the circulating nurse is responsible for in the OR. Over the course of a typical laparoscopic case, the circulator is responsible for charting patient data, turning on and adjusting surgical equipment, retrieving equipment, moving equipment carts, ensuring laparoscopic equipment control units are connected and turned on, adjusting lighting, controlling the insufflator, replacing empty gas tanks, fine-tuning the laparoscopic light source, adjusting video monitors and recording video, to name a few tasks.

You want her to be able to access all these controls without having to run to five different places (just as, if you're putting away dishes, you don't want to have to make 20 trips from the dishwasher to the other side of the room - it's just inefficient). Construct a workstation conducive to efficiency. Here's how:

• Add a small, mobile desk to the workstation that lets the circulator chart and document patient information while facing the surgical team. (When not in use, you can store the desk and stool under the workstation counter.)
• Wire the room so that controls for lights, video signals, video recorders, still-image recorders, printers, overhead boom motors and the sound system are within arm's reach - and put them in order of the frequency of their use.
• Build the monitors into the workstation where they're easily viewable and, again, so that the circulator can face the surgical team. Configure the monitors to show all possible inputs.
• Dedicate one computer to charting and one to multimedia image and video capture, recording and storage.

Follow this model for the anesthesia team as well - with all their equipment controls within reach, a separate recessed light they control and a dedicated video monitor that lets the anesthesia provider see how the procedure is progressing without his leaving the head of the table. Also, give the surgeon some control of the equipment, such as video monitors, that he needs for procedures.

Control information
Everything is digital now: digital documentation, digital still images, digital video and digital communication. You need plenty of networking access and as many electrical outlets as possible wired into the booms. Wireless networking capabilities, such as Bluetooth or the forthcoming wireless USB, are a bonus.

Our ORs have multiple video inputs with a centralized video signal routing system. The router is mounted above the circulating nurse's workstation and can be configured for up to 16 inputs and 16 outputs. Inputs include endoscopic cameras, video sources (including hand-held and ceiling-mounted cameras), C-arm and ultrasound. These can be routed to one or more outputs, such as monitors, digital and cassette video recorders, and a video-capture board in the dedicated multimedia computer.

As video technology evolves, much of the cabling will remain the same - that way all you'll have to worry about is replacing recorders and printing devices and other components that can be readily updated.

Protect your staff
Just as important as keeping patients safe is keeping your staff safe as well. Several equipment and design considerations will help you accomplish this goal:

• Mount equipment on booms...This gets cords and cables off the floor, so you have fewer tripping hazards, and keeps the nursing staff from having to push heavy equipment and carts - a back-saver in itself - over those cords.
• ...but not too much. You don't want staff pushing 500-pound equipment booms; that's a recipe for injury. We planned for total equipment weight of 200 pounds per boom, with capacity of 250 pounds to anticipate future equipment additions.
• Pick the right booms. You also don't want anyone whacking his head on a boom. The fix for this is very simple: Buy booms that extend down to just a few feet off the floor. If the boom ends at your knees, you'll be OK, but if it's at shoulder level, someone is going to walk head-first into it.
• Purchase ergonomic tables. A table with a good range of vertical motion will accommodate shorter and taller surgeons, so they perform a procedure with the patient at a height comfortable to them. Usually, this means with arms by his sides, elbows flexed at 90' and wrists in a neutral position (think the proper way to type). As I mentioned before, a table that's compatible with lots of accessories is a good idea - that Mayo stand might do well to function as a no-hands passing zone, for instance.
• Incorporate flat-panel monitors. These are making OR design easier. First, you can mount them on a much lighter and cheaper boom that doesn't require as much architectural infrastructure. More importantly, you can hang it where surgeons, anesthesia providers and nurses can see it, even if that position is directly over the patient's head. No one has to crane or strain to view the monitor, and the anesthesia team retains adequate access to the patient's airway.

An eye toward tomorrow
Keep flexibility, expandability and modularity in mind. During the building stage, plan for flexibility in the future. Reinforce the entire ceiling and have steel ceiling mounts for booms built in - in a variety of places. Who knows? You might need to move booms in the future and allow for several different mounting points.

If you have a choice, make your ORs as large as possible. (That's a tough task here in New York City, where space is at a premium everywhere.) But you can certainly count on having more equipment than less in the future. Rather than cramping, allow for that expansion.

On the technology side, in the five years since our initial OR renovation, we've made many changes; several things we thought were essential a few years ago, like CRT video displays, have changed substantially. The actual video signal is still the same as what we used five years ago, but that will probably change in the very near future with the advent of HDTV. Once that happens, or if we go into digital video signals, we're going to need to update all the wiring as well.

You have to plan that everything is going to change, and the keys to that are avoiding proprietary connectors and using modular design. For example, keep all your video recorders connected through a patch panel or in a separate video closet. That way, you can just pull out an old unit and put in a new one when you need to update. Equip your booms the same way - you want to be able to pop in a new piece of equipment when you need it.

More lessons learned
There are surprises every step of the way both during and after the building of your ORs. Take these parting lessons from me, so the chances will be less that you'll encounter any surprises:

• Count on obsolescence and anticipate change. Equipment is constantly becoming more high-tech, and you never know when your facility might change a contract that mandates a sea-change in your equipment.
• Don't be a guinea pig. Make sure the people designing your OR and installing your equipment have substantial experience doing so. We had one contractor come in who basically said, "This is really exciting, I've never been in an OR before." That sent shivers down my spine because I've seen plenty of instances where a contractor didn't have OR experience, and things didn't work out as planned.
• Get a great service plan. Even if everything works perfectly the first day, that doesn't mean it will on day two. Maintenance and service are every bit as important as the original installation. Ideally, you'll have someone whose job it is to maintain the equipment; the more technology you bring into an environment like an OR, the more critical it is to have someone fix the problems when they happen.