If you had free rein to revamp your OR, no restrictions, what would you do? If you're like most of the readers we surveyed, you'd make it bigger. You'd add more floor space for equipment and more storage space for supplies. You'd make way for the growing number of devices and supplies brought on by the minimally invasive technology boom. As one director of surgical services told us, "The smaller the incision, the larger the room needs to be."

What about your ORs? Wish you could go back in time and move that boom, change the shape of your facility or just make everything bigger? Here is the full wish list from our survey of 167 readers.

Bigger ORs
Forty-nine percent of our panelists say their ORs are too small to accommodate every type of case they perform. Of these dissatisfied panelists, most manage multiple specialties in ORs averaging 367 square feet (range: 120 to 1,500 sq. ft.).

"We can't do some procedures in certain rooms because the equipment won't fit. Other rooms can accommodate the equipment but won't allow passage around the room with enough space to walk between the back table and the wall. There's no work surface for the circulator," says one materials manager working in 400-square-foot ORs.

Lack of counter space is a very common complaint, but the problem runs deeper than inconvenience and hindered maneuverability. Many panelists fear that their small ORs compromise the sterile field. Many times, they say, sterile tables are too close to the unsterile working area or unscrubbed personnel can't stay safely outside of the field.

"When we bring in the C-arm for fluoroscopy or a send for an endoscopy system for a complicated case, there's little room for people to circulate and contamination becomes more frequent," says one medical OR coordinator who functions in a 300-square-foot multispecialty OR.

Many are also concerned about safety hazards. "With the growing number of pieces of equipment required to perform many of the surgeries, and the need to allow space for C-arm use and other factors, there is a near-daily threat to employee safety as we maneuver around the room," says Shelly Young, RN, BHS, MHCA, OR training and education specialist with Sutter Health in Sacramento, Calif., who works in 400-square-foot ORs.

The 49 percent of our panelists who expressed satisfaction with the size of their ORs have an average of 520 square feet, nearly 30 percent more space than those who complained of too-small ORs. Those who express the highest level of satisfaction have ORs closer to 600 square feet.

"Our 528-square-foot ORs are good for most things, but they're a bit small for lap choleys and Lap-Bands. The OR just gets crowded when multiple tables and Mayo stands are used for instruments," says Marlene Sapa, RN, director of the Mid Dakota Surgicenter in Bismarck, N.D., where surgeons perform gynecologic, urologic, pediatric and ENT procedures. Says another panelist, a multispecialty, hospital-based, same-day surgery manager in Cumberland, Md.: "Six-hundred square feet seems to be just right."

More storage
It comes as no surprise that insufficient storage space is another very big problem. Nearly two-thirds (60 percent) of panelists rate their in-OR supply storage as "insufficient" or "very poor/ problematic," and many say their sensitive equipment is relegated to the corridors when not in use - where it interrupts flow, creates inefficiencies and poses a real safety hazard.

"I have yet to work at a hospital that had enough storage space for equipment, which is evidenced by assorted equipment clogging up the hallways - only to be scurried away at times of JCAHO visits," says a Tennessee-based anesthesiologist. This scenario, say panelists, sets the stage for inefficiencies because hallway traffic becomes congested and supplies need to be stored further and further from the OR.

"As we bring more product lines on board, we are having to store more equipment further from the point of use. If we could, we would expand the storage areas to accommodate more disposables for our higher volume cases and more reusable equipment. The closer to point of use, the shorter the turnover times and the shorter the delays," says one director of patient services.

Adds an RN from California: "Our facility is only 10 years old, yet there was not adequate consideration for the amount of storage required for supplies needed as the department grew in caseload, let alone equipment storage. Our choice is either to store the equipment in the hallway, breaking fire codes and creating a general lack of safety when we maneuver gurneys down the hall, or take added time between cases to move equipment in and out of a designated storage room that is too small for the equipment anyway. This [equipment manipulation] poses a danger to employees as they move heavy pieces of equipment around in too small of a space."

In some facilities, equipment is taking up floor space that could otherwise be producing direct revenue. "I'd like to move supplies out of the current storeroom and use that storeroom for the purpose it was designed for - an OR," says Kathy Sulc, RN, OR director at the Plastic Surgery Center in Asheville, N.C. A New York-based director of nursing says she's using the back half of her PACU for storage.

Like the RN from California, many panelists believe their storage problems stem not only from the growth in technology and caseloads, but also from a lack of foresight during facility design. "We missed an opportunity to build it right two years ago," says Thom Clarke, RN, BSN, with the Washoe Medical Center, South Meadows, in Reno, Nev. "We made our sterile supply room and equipment rooms too small. We did not have the input of the people who work in these areas when the important planning decisions for the ORs were still being made on paper. This is an all-too-common problem when new or remodeling construction is done."

Improved layout
Just 19 percent of our panelists rate their OR layouts as excellent. The remainder would make at least some improvements if they could, namely moving their electrical and gas connections.

"We have too much equipment with cords stretched across a vast area to get to poorly placed electrical outlets, making it very difficult on the circulator and scrubs to move around safely," says Kim Steger, BSN, director of surgical services with Graham Regional Medical Center in Graham, Texas.

Adds Lori Krcatovich, BSN, CRNFA, with Holland Hospital in Holland, Mich.: "There aren't a lot of options for placement of the anesthesia machines. They require a lot of hook-up. We have columns, not like the new booms, that pretty much tell us where to go. There are too many other devices that need to be plugged in. We need more cordless options, especially the OR table." Maureen O. Lamson, RN, nurse administrator with the Annapolis ENT Surgery Center in Annapolis, Md., says her OR needs an additional suction outlet on a third wall to allow more flexibility for positioning the microscope and video carts.

Poor placement of phone lines is another commonly cited problem. "The nurses' writing area is located away from the phone, and there is no phone near the anesthesia provider," says Ann Geier, RN, MS, CNOR, CASC, vice president of operations with ASCOA in Norwell, Mass.

Several other panelists wish for a functional sterile core. The complaint of this Wisconsin-based surgical services coordinator mimics that of numerous panelists: "The supply room is on the opposite side of the OR rooms. We end up stocking our rooms with duplicate supplies to minimize running to the supply room." Adds Eileen Beltramba, RN, administrator with the Eye Institute of Essex Surgery Center in Belleville, N.J.: "Our layout problem has more to do with the location of pre- and post-op areas than the OR itself. If we had one door in from pre-op and one door out to post-op or a separate door out to the dirty utility area, that would improve work flow."

Rod Carbonell, BSN, administrator and clinical director with Integrity Clinical Management Solutions in Paducah, Ky., agrees with Ms. Beltramba's views. "I don't want my surgeons to have to backtrack more steps than necessary," he says. "I do not want my surgeons to even leave the OR suite. Keeping the surgeon close to the suites not only encourages quicker turnaround times, but also keeps them aware of the efforts involved in running the schedule."

His ideal OR design includes a main back hallway flexible enough to serve supply, equipment, disposal and processing functions.

"This lets a facility function with a very clean and quiet corridor for entering the ORs while the action takes place behind the scenes," says Mr. Carbonell. "Another key is to have a design that puts pre-op and PACU physically close to each other. This allows staff to work in both areas as the day begins and winds down. This model has the potential to significantly reduce staffing costs while building a stronger team environment."

But you need to consider privacy issues so this layout does not become problematic.

"Our pre-op holding area is too small and not well located. [It] holds two stretchers (for four ORs), so extra patients end up in the hallway, and there are only two monitors," says the Tennessee.-based anesthesiologist. "It's near the ORs but is directly between the ORs and PACU, so a patient in pre-op holding can see other patients who are leaving the OR on their way to PACU. Not ideal."

Expansion potential
Many panelists, particularly those who host multiple specialties, also wish for greater potential to expand into new technologies. Sixty-nine percent feel technological expansion will be essential or important in the years to come. Just as many panelists say their ORs will become obsolete because they're not designed to let them adopt technologies like centralized digital controls, communications or imaging without major renovations like power and data cables and ceiling mount installations.

"Everything seems to be going into digital technology. Our surrounding hospitals have digital X-rays that are accessed through the Internet, yet we need to ask for hard copies since we don't have the technology in all our OR suites," says one panelist. Says another: "We are videoconferencing from our ORs to conference rooms and to centers outside of our hospital. These are very exciting times yet in five years, all of this will be old news."

You need to prepare for the rapid pace of medical progress in order to be competitive in the future. Says the director of marketing for an office-based surgical practice in New York: "Technolo-gy will move forward whether you want it to or not. If you're not thinking ahead, playing catch-up is going to be very expensive down the road."

Final advice
When the time does come for you to re-do your OR, involve every member of the surgical team from day one. Even the highest-tech OR won't function smoothly if insufficient space and storage and inefficient workflow hold you back.

"This never seems to be taken into consideration," says one panelist. "Bring in the people who are working day-in and day-out in the ORs. Not the hospital administrators. Not the surgeons, who walk in after everything is ready. But the nurses, the scrubs and the instrument room and central supply personnel. These people know the barriers to efficiency, they understand the flow. They're the ones running from one end of a long hallway to the other trying to get a piece of equipment or a supply. They're the ones trying to jump over cords and squeeze by the sterile field to get to the phone."

Adds another: "Most ASCs are built with attention to the money-making areas. But to keep the flow moving as smoothly as possible, the support areas deserve as much attention. A happy, comfortable staff will be much more productive."