One of the biggest day-to-day challenges for any surgery center is maximizing work space in the OR and perioperative areas. Space is often quite limited in the first place, and keeping supplies in unobtrusive but easy-to-access areas requires forethought and creativity. We consulted with facility managers and other experts to see how they've tackled this problem. We hope you'll find their advice useful to manage the space you have available and perhaps free up some additional room.

Equipment Management
Large, bulky pieces of equipment, such as anesthesia machines and C-arms pose the biggest problems when it comes to equipment storage-they can't be tucked away when they aren't needed and they may end up blocking traffic if they're simply parked in a hallway. The following are some of the ways facilities have handled these concerns:

Create new storage areas
Some facilities have actually created new storage spaces bordering the OR. Says Gail Ponto, RN, CNOR, nurse manager of the Colchester, Vt., outpatient campus of Fletcher Allen Healthcare, "We do orthopedic, eye, ENT, GI, small vascular, hand, and minor general surgery, so having too much equipment is an ongoing problem. We've solved it to some extent by purchasing a trailer and attaching it to the outer core of our OR (we're on the first floor, which makes this solution possible). We used an existing exit door located on the end of the building to hook up the trailer. Inside, we put the least-used equipment in the further end and the equipment we use most frequently in the end closer to the inner core of the OR. The trailer is for equipment only-we don't keep sterile supplies in this area. This system isn't pretty but it's very functional. In fact, we filled the first trailer, so we'll be purchasing another to attach to the existing one. We no longer need to keep equipment in the hallway, which makes it easier to transport patients to and from the ORs."

Purchase less bulky equipment
Notes Gwen Nordberg, MD, of Chicago, Ill., "As technology develops, things tend to get smaller-of course the flip side is that with so many more types of procedures being done, there's a greater array of equipment on hand. But you should be able to purchase universal equipment such as anesthesia machines in more compact sizes." Nowadays, you may also be able to stack many types of equipment (such as monitors) on top of each other or suspend them from the ceiling using booms.

Consider the surgical schedule
Designing your surgical schedule to reflect your equipment needs can ensure that the OR is set up exactly as you need it at the beginning of the day; this keeps the OR free from equipment you won't be using that day and avoids the need to shuttle equipment back and forth. Explains Roxie Lutke, RN, CNOR, director of the multi-specialty Mercy Surgical and Diagnostic Center in Merced, California, "We manipulate our surgery schedules so that we only use certain pieces of equipment on a given day and then change to others. Also, because we do a lot of orthopedic cases, we've set up one room specifically for arthroscopic procedures [and the schedule is set to reflect this], while the other is set up for the more general cases. This way, we move equipment less and it decreases our turnover times. Also, equipment doesn't up sitting in the hallway, waiting to be used for an upcoming case."

There are times, however, when you'll need to transfer equipment quickly from one room to the other, particularly when something malfunctions; to make this easier, Pam Kline, nurse manager for Sacred Heart Hospital in Cumberland, MD, advocates standardizing your basic OR setup. "For example," she says, "We've standardized the camera systems that we use. If a camera goes down, we just get one from another part of the campus."

Supply management
Sterile supplies pose another kind of storage challenge-it's important to have enough disposables on hand, but if you have too much, it can be expensive and time consuming to find exactly what you need and store the excess. Some ideas:

Consider just-in-time delivery of standardized suppliesSays Colleen Kojima, director of surgical services at Straub Clinic and Hospital, Honolulu, Hawaii, "We've saved a lot of space by incorporating a PBDS (Procedure-Based Delivery System) for our disposable supplies." First, Ms. Kojima determined what her most-used supplies were. Her suppliers worked with her to create customized packs, or modules, of these supplies. She then arranged to have the modules delivered to the facility three times per week, based upon utilization and projected upcoming cases. This greatly reduced stock inventory. To set up for a case, her staff simply puts a standard module together with items such as surgical gloves and sutures and specialty items such as implants.

Customize cabinets and supply carts
Says Ms. Kojima, "We've purchased a suture cabinet and placed it in our sub-sterile core for easy access and to keep excess suture packs from cluttering the OR. If it doesn't fit in the cabinet, we don't stock it. We also keep only high-volume items in the cabinet."

Ms. Kline's facility has done something similar. To keep excess disposables and supplies from cluttering the OR, Ms. Kline stocks only the most basic supplies, such as sutures, in cabinets in each room, so they're immediately available. She keeps any specialty items in carts, which can be moved from room to room when needed. She explains, "The specialty carts keep a comprehensive, but limited number, of supplies utilized by a specific service. Inside the ORs, we stock some extras of items used in all procedures- things like sutures, gloves, and sponges. The supplies in the OR are kept for back-up only because these items are already on the case cart."

Take advantage of unused space
You may be able to manage both equipment and supplies more effectively by taking advantage of unused areas. Explains Ms. Kline, "We found a way to prevent less-used equipment from taking up space in the OR while still keeping it accessible by converting a former patient room into an equipment storage area. We keep duplicate items in this room, or items that we wouldn't need in an emergency. We keep a list for staff and the inventory control coordinator, so everyone knows what is kept there. This freed up a tremendous amount of space in the OR."

Ms. Kline also created a supply storage opportunity by converting one of her gowning areas to storage space. "Our ladies' locker room used to be in the OR until we looked at the cover gown issue and determined that there wasn't much difference at all in wearing them only inside the OR or wearing them outside the OR within the confines of the facility. This finding opened the door to allow us to move the locker room and convert the former locker room into much-needed storage space. We maintain the specialty storage carts here, as well as the case carts that are ready for future cases. The locker room is now in a room in close proximity to the OR."

Consider an overhaul
Sometimes, it is necessary to overhaul how all your systems work instead of taking small measures to create space here and there. This is what was done at the Central Maine Medical Center in Lewiston, ME, where Jules McDonald, RN, MBA, BSN, is director of perioperative services. She explains, "We used something called a ?rapidly accelerated operations improvement' system. In a nutshell, this is how it works. First, you map out the patient processes from beginning to end-from the time they first enter the facility, to the time they are prepped for surgery, moved to the OR, taken to recovery, and go home. Then you figure out where the hold-ups are. Your employees, the people who actually perform these tasks, give their input in formulating realistic plans for moving patients through their areas more smoothly. Incorporating the system results in several benefits. At our facility, the frequency of patients moving through the system with no hold-ups and re-work changed from less than one percent of the time to 87percent. There are minimal extra supplies and equipment hanging around, we know where everything is, and we've been able to streamline our paperwork. The system has done far more than just reduce clutter-patients here report far higher standards of service, staff sees quality care and less frustration, and the administration sees much greater savings per case."