Shopping for OR equipment can be a bewildering task, especially with so many different options on the market today. Here are a few pieces of advice condensed from past Outpatient Surgery Magazine articles about buying:
If you will be administering general anesthesia, you'll need a hospital-grade machine.
Machines with standing as opposed to hanging bellows are preferable because they collapse immediately if there's a leak. Most new machines have standing bellows, but some refurbished machines may not.
Insist on a fail-safe mechanism that automatically changes nitrous oxide flow along with oxygen. The machine ought to have an oxygen sensor to measure the percentage of oxygen delivered and gauges that tell you when oxygen is running low. There should also be back-up gas cylinders.
If you will be doing adult and pediatric cases, get a machine with two vaporizer ports.
If you'll be doing general anesthesia without muscle relaxation, you may be able to use a machine without ventilators.
Refurbished machines can be excellent buys, but have a biomedical engineer check out the machine before buying.
The ideal surgical light provides intense, uniform illumination that is as close to pure white as possible. The light field should be adjustable to reduce glare. It should be able to project light from many different angles via a reflector system so that the light can go "around" items like instruments and hands. And it needs to be as cool as possible, since heat can dry tissue and make the surgery team uncomfortable. Lights have improved; they are brighter, cooler, truer and more focusable. There are also many nice new features. Most can automatically switch to a backup bulb if the main one dies. Some are particularly easy to maneuver and adjust. Sealed heads keep dust and cleaning liquids out. Some lights can also accommodate cameras.
Most surgery centers will need a universal generator that can produce both monopolar and bipolar power and a variety of cutting and coagulation levels. Even universal generators do not work for all procedures, however. Be sure to ask the maker which procedures the unit is recommended for.
The controls should be as simple as possible to prevent confusion. Monitoring of the active and return electrode is a nice feature but not imperative. Consider a unit with both hand and foot controls if a lot of surgeons will be using the unit, since preferences vary. Start slow with the electrodes; most centers can get by with a spatula, a pencil handpiece, a bipolar forceps and a ball.
Vital signs monitors
Like many other electronic items, monitors are getting better, smaller and cheaper.
Many monitors now incorporate signal filter technology that reduces false positives during pulse oximetry, an important feature if you do a lot of pediatric cases. One company is developing a sensor that goes on the forehead rather than on the finger. For small procedures, one company has a battery-operated stand-alone pulse oximeter that is about the size of a small cellular phone and clips on the finger.
Most facilities need one monitor with 12-lead EKG for higher risk cases. The rest can be five-lead models.
Your monitor should be able to do capnography-that is, measure end-tidal CO2. Two years ago the American Society of Anesthesiology recommended this monitoring function for all general anesthesia. Now many feel it is necessary for conscious sedation as well. Volatile agent analysis is nice, but probably not necessary for most ASCs.
Monitor screens are now colorful and customizable so that you can more easily read them from across the room.
It might not hurt to choose a monitor that can port data to a medical records system, but few ASCs use this function now.
If you purchase a refurbished monitor, insist on a warranty of at least six months.
Many outpatient surgery centers use awareness monitoring to help titrate anesthesia levels and bring patients to consciousness more quickly. Proponents say these devices help speed recovery and reduce drug costs. Detractors complain about the lag in the display of data; the machines have to sample the patient's brain waves over periods of time before providing a readout. The disposable sensors also add to case costs.
These have undergone a revolution in recent years and now offer more positioning options, better fluoroscopy compatibility and patient comfort.
If possible, buy an electric table. Even though they cost $3,000 to $4,000 more, surgical nurses greatly prefer them and they may actually save you money because less staff is required to operate them. Make sure the table comes with a battery backup and a control backup, and a manual footpump when all else fails.
Most tables claim they can support 400 lbs., but not every table will do so in articulated positions. Check to make sure. If you have multiple ORs, consider buying one table that can support more than 400 lbs. for morbidly obese patients.
If you will be using a C-arm with your table, be sure the table top is fully radiolucent and, if possible, has a wide top. There should also be a built-in channel underneath the tabletop or a raised tabletop to allow placement of a cassette. Several tables feature exceptional maneuverability of the tabletop to provide maximum C-arm access. Some rotate on the pedestal, some slide back and forth, and some do both.
Many nifty table accessories are available these days. Be sure to figure in the costs of these when doing price comparisons, as some manufacturers underprice the table and overprice the options.
Refurbished tables can often be excellent buys for ASCs, but do as much due diligence as possible before buying. Get a full disclosure of the service history on the table, and ask the refurbisher for a detailed description of what it does to all its tables prior to resale. The table should have been rebuilt rather than just cleaned.
When choosing one of these, solicit the help of surgeons, pain management specialists and a radiologist, and be sure to demo several models in your facility without the company representative present.
Centers doing orthopedic and podiatric procedures can get by with a only "mini-C," a small and less expensive C-arm. Users report excellent image quality and ease of use. If you will do pain management, however, you will need a full-body C. These have enough anode current to penetrate deep dense tissues so that areas such as the lateral lumbar spine are visible.
On a full body C, get two screens; your pain management specialist will need to visualize needle placement in two planes.
Remember that if you purchase a full-body C, your state may require the walls of the OR to be leaded. Mini-Cs produce negligible radiation.
In general, the larger the C and the greater the distance between the imaging surface and the tube, the better it will accommodate larger patients.
The best C-arms allow maximum freedom of movement as they rotate through both the AP-to-lateral and caudal-to-cephalic arcs. The surgeon should be able to tilt the device to visualize difficult areas without disturbing the patient.
This device is best purchased new. Older models offer poorer image quality and lower power. Make sure the company offers a complete warranty, and strongly consider a service contract.
These devices have undergone a technological renaissance and now offer crisper resolution and better color. Companies are producing scopes specifically for ASCs that cost less.
Optically speaking, all the scopes currently on the market are excellent. In other ways, though, they may not be equal. For example, the oculars on some scopes may not spread as widely as those on others, causing difficulty for surgeons with wide-set eyes.
Surgeons tend to have strong preferences in scopes. Be sure to involve them in the decision. But don't feel it's necessary to spring for "bells and whistles."
Small, non-motorized floor mounted scopes are fine for most ASCs. If your OR will only be used for one specialty, however, consider a ceiling mounted scope.
Go ahead and spring for flat screen monitors. Although at one time these could not compete with traditional cathode ray tubes for image quality due to lag time, they have improved and are now nearly the same quality. They are more manueverable and lighter, meaning that it's easier to attach them to the ceiling. They are slightly more costly, but the benefits are widely thought to make up for the cost.
Also spring for digital image capture. This makes for a higher quality image, easier storage and more flexibility.