For the fourth time in my career, I'm knee-deep in outfitting new orthopedic ORs for our hospital's outpatient department. Here are 8 tips that have helped me through the process of designing ORs to optimize flow and choosing equipment that will fit the needs of several surgeons. Some decisions — where to put the boom and the gas? — can't be undone, so careful planning is essential.

1. Get everyone's opinion. Include anyone who's going to be working in the ORs in initial discussions for planning new ORs. While surgeons will be able to tell you how they'd like the room arranged, nurses and techs will be able to tell you what works, what doesn't and what gets in the way in a busy OR. With everyone's input, you'll be able to tailor your new rooms to how procedures are done in your facility. As a result of discussions with staff in previous construction projects, we had the booms installed slightly to one side of the room to create more space on the side of the room with the most traffic flow. Staff also recommended that we add more storage cabinets for extra sterile supplies (gloves and drapes) needed during a procedure.

2. Standardize your ORs. Equipping and stocking ORs in identical fashion decreases the amount of time staff spends searching for items and can help maintain efficiency. One of the challenges of standardizing your ORs is making sure that each room is equipped for the variety of procedures you perform. All of our ORs are equipped with:

• OR tables. Our tables are designed to carry up to 500 lbs. Depending on the prevalence of obesity in your community, you may want to consider heavyweight tables that can support patients up to 1,000 lbs. A table's padding should be able to accommodate patients of various weights without causing skin breakdown. Also consider the stability of the table in all its configurations for the various patient positions that accompany orthopedic procedures. Assess the OR table's ease of use, such as how easy it is to push the table in and out of the OR. If you're going to use C-arms for intraoperative imaging, the padding and attachments for the extremities should be radiolucent. Consider the type of orthopedic procedures you'll be performing and the amount of intraoperative imaging that will be used for these procedures. Base your OR table needs on this factor as well because several OR tables with various configurations allow for optimal intraoperative imaging.
• Electrocautery devices. Because of the high risk of burns, safety is the most important factor to consider when purchasing a cautery device. In our case, standardization helps because no matter which OR a team is using, everyone will be familiar with the machine and how to operate it safely. We've also standardized the disposable electrode pads and pencils that we use throughout our institution to further simplify the process.
• OR booms. When choosing booms, it's important to have a good idea of which equipment you plan to mount on the boom and what you want the boom to do. Service is another other important factor. Will you have quick access to repair technicians? This is important because booms can freeze up and make it hard to maneuver in the OR or move patients on and off the OR table. Several vendors supply OR booms. I recommend you get in contact with other facilities that have purchased the specific boom you're considering and ask what they like and dislike about the booms they've chosen.
• Closed-system suction. Our fluid waste management system features closed-system mobile units with suction canisters that we use for more than 1 case and move from room to room. After using these for a few years, we've found that having 1 mobile unit per OR is most effective. You decrease turnover time and reduce the amount of disposable suction tubing that you use throughout the day.
• C-arms. Talk with your surgeons and X-ray techs to make sure you get a C-arm appropriate for the types of procedures you do. If you do a lot of hand and foot procedures, a mini C-arm might be best. If you do spine procedures, you'll need a larger C-arm. Also, make sure that your C-arms are compatible with your OR tables so that you can easily manipulate the C-arm around the patient.
• High-def monitors. As part of our digital OR system, each room has 2 monitors that can be used to see the image generated by the arthroscopic camera as well as radiographic images and information from the patient's electronic medical record. During spine cases, the image that the surgeon sees through the scope can be sent to the monitor on the boom so that the surgical tech can follow the procedure and anticipate which instruments and supplies will be needed next. In our new ORs, we plan to mount a 42-inch monitor on the wall that will let our spine surgeons view CT and MRI images from the operating field, which keeps them from having to leave the sterile field to view these images.

3. Go digital from the beginning. If you're not using electronic medical records now, you will be within a few years. Opening new ORs is a good time to make the switch. Each of our new rooms will have 2 computers, 1 for the nurses and 1 for the physicians. The nurses' computer, used for charting, will be mounted on a moveable arm that will let the nurse work at the computer and see the sterile field at the same time. The physicians' computer, along with the OR boom communication system, will have dictation software so that the physician can wear a headset and dictate from the OR sterile field if desired.

Electronic medical records facilitate accuracy of patient information between our physician's office electronic medical record and the hospital's electronic medical record. The physician's office first enters a patient's information into the system used by the physician's office when the case is scheduled. Then our facility's schedulers import the surgery order into our EMR system, which creates our surgery schedule. From this, a physician preference card or supply and instrumentation pull list is generated in order for support staff to gather the necessary supplies per surgeon, per procedure, per patient. During the procedure, the nurse documents the care the patient receives throughout the surgery as well as the supplies and medications used.

Additionally, the entire OR team has access to the patient's full EMR. This is helpful when complications arise and the surgical team needs to look up the patient's health and medication history. Other areas of the facility can also look up documentation regarding the patient's surgical procedure to assist with the care the patient receives in PACU, the inpatient unit or within the post-operative/discharge unit. Our EMR contains surgeon- and procedure-specific post-op education and discharge instructions that are generated for the patient before discharge. We developed these documents through the collaboration of our nursing staff and a surgeon.

4. Evaluate before you trial. When a surgeon wants to invest in something new for the facility, the device has to go through our technology committee of 4 surgeons (sports, spine and total joint specialists), our chief executive, our chief financial officer and me, the head of surgical services.

The committee verifies that the device has been approved by the FDA and then reads the relevant peer-reviewed literature. We take into consideration the price of the new technology and the per-case cost information provided by the vendor. The physician requesting the equipment also attends the committee meeting to speak on behalf of the product and to sell us on why he needs to add the new technology.

The system works as a check-and-balance process before purchasing any major equipment, especially if the item is outside of the approved capital budget request. The committee weighs the possible patient safety benefits and the efficiency of the device against the cost and any disposables it may require. If the committee approves the device for a trial, we schedule a trial of 6 cases with the requesting surgeon and the product's vendor. After the trial is complete, the requesting surgeon will then present the product to the committee to discuss any new findings he discovered during the trial. Sometimes the surgeon withdraws his request after the trial has been completed because the product didn't meet his expectations.

Evaluating a device on paper before you bring it into the facility for a trial decreases the number of devices that unexpectedly arrive in the ORs for trials at the request of physicians. Unscheduled trials can slow down your patient flow and disrupt your schedule because the surgeon may be learning to use a device and may take longer to finish his cases that day. When trials are planned well in advance, you can schedule your cases accordingly and take comfort in knowing the product has been evaluated from a safety, cost-benefit and efficiency standpoint.

5. Stock from the preference cards. If you're opening a new facility, use the preference cards of the surgeons who'll be operating there. To begin with, look at the most common procedures that your surgeons perform and stock accordingly. Then look at your schedule for the first few weeks and make sure that you have everything you'll need for all the cases planned.

6. Keep updating staff. Things change often with a building project, so it's important to keep everyone in the loop during the construction phase. Before you move in, some of your staff may be afraid of the unknown and what the new facility will mean for them. Giving regular progress reports, news of changes in plans and helping them visualize the new ORs will help reduce the fear of the unknown.

7. Run mock patients through the process. Before you open new ORs, practice with a few mock patients. Our EMR software lets us create test patients for which we gather all relevant data. Begin with the patient walking through the front door and have the patient fill out all the documentation needed for a common procedure. Send the patient to the waiting room and then the pre-op area for an interview with the anesthesia provider. From there, the patient goes into the OR. Everyone walks through the procedure, including charting. The patient ends up in PACU and is finally discharged. If you're going to do this exercise, do it a few days before your first real case. This will allow everyone a few days to think about the process and what needs tweaking. On your first day, everyone will be familiar with the process and will be more at ease taking care of your facility's first patients.

8. Don't worry. Finally, don't be afraid to make mistakes. When you open your new rooms, it's guaranteed you'll run into challenges and things that need tweaking. This is part of the process. After the first day, things will only get better.