RIPCHORD – Realizing Improved Patient
Care through Human-Centered Operating
Room Design
Mapping and Graphically Analyzing Tasks as a Means to Understand and Inform Operating
Room Design for Improved Safety Outcomes and Operational Efficiency
James H. Abernathy, III, MD, MPH, FASE
Assoc. Professor, Dept. of Anesthesia and Perioperative Medicine, The Medical University of South
Carolina
Scott Shappell, PhD
Professor and Chair, Dept. of Human Factors and Systems, Embry-Riddle Aeronautical University
David Allison FAIA, ACHA
Alumni Distinguished Professor and Director of Architecture + Health, Clemson University
Representing the RIPCHORD research team including Scott Reeves MD/MBA, Gary Palmer,
Gregory Swinton and Joel Greenstein PhD
Presentation Overview
 The Healthcare Problem
 Safety & Outcomes
 Efficiency
 The Problem Context
 The Architectural Problem
 The Pilot Study
 Graphic Methodology
 Findings
 Discussion
The Healthcare Problem
 Improving Safety, Outcomes and Operational
Efficiency in the OR.
 Little understanding of the role the design of the OR
in these issues
 Lack of Human Factors research that links
measures of safety to the physical design of the OR
The Problem Context
IoM Report on Safety, 1999
 44,000 to 98,000 people die
each year from medical
accidents
 Cost of errors equals $17
billion to $29 billion
 20% = Surgical errors
 16% = Medication errors
Disruptions have been correlated with surgical
errors (r = 0.67)
160 interruptions in flow per case
In CT surgery 17.4 teamwork
breakdowns per hour
87% of litigated surgical cases had a communication
failure between providers
12.3 % of cardiac surgical cases suffer
from a preventable error
7 % of surgical admissions have a human error
16 % of inpatients harmed by human error
“If medical errors were a disease, they would
be the sixth leading cause of death in
America—just behind accidents and ahead of
Alzheimer's”
Marty Makary, MD – Johns Hopkins General Surgeon
WSJ – September 2012
Medical Errors kill enough people
each week to fill 4 jumbo jets
Problem Context
 Never Events in the OR
A Complex Milieu
 Intense life and death event
 Complex procedures
 Lots of equipment
 Many players
 Surgeons
 Nurses
 Anesthesiologists
 Perfusionists
 Residents/Students
 Transient Observers
Functional/Spatial Stages
1. Pre-Op: Room set up
 Nurses set up and prepare
sterile tables. Frequent trips to
sterile core
 Anesthesia personnel check
machines, prepare medications
and equipment
 Perfusionists prime and prepare
the cardiopulmonary bypass
machine
Functional/Spatial Stages
2. Pre-Op: Patient arrival
 Patient brought in by anesthesia
team
 Patient is greeted by OR team –
Perfusionists, Nurses, Surgeons,
Anesthesiologists
 Induction of Anesthesia occurs
which includes insertion of
invasive monitors
Functional/Spatial Stages
3. Pre-Op: Patient Preparation
 After induction of anesthesia
 Anesthesia team: TEE
performed
 OR Team: Patient is positioned
for the operation
 Surgeons: Vein harvest site is
identified
Functional/Spatial Stages
4. Pre-Op: Timeout
 Structured conversation to
ensure
 right patient,
 right operation
 Ensure OR team is on same
page
Functional/Spatial Stages
5. Pre-Op: Patient Prep
 Patient is washed with
chlorhexidine
 Patient is wrapped and draped
with sterile drapes
 Anesthesia drape goes up
Functional/Spatial Stages
6. Operative Phase: Incision
 OR nurse moves surgical
instrument tables close to the
patient
 Surgeons make incision in
patient chest
 Anesthesiologist continue to
monitor and treat patient vital
signs
 Perfusionists continue preparing
bypass machine
Functional/Spatial Stages
7. Operative Phase: Chest Open
 Patient’s chest is opened by
surgery fellow
 Left Internal mammary artery is
harvested
 Vein harvested from patient’s leg
by attending surgeon
Functional/Spatial Stages
8. Operative: Bypass begun
 Anesthesia confirms adequate
anticoagulation and appropriate
physiologic state for bypass
 Perfusion moves equipment into
place near patient and prepares
lines
 Surgery team inserts cannulas
and as a group, patient is
transitioned onto cardiopulmonary
bypass
Functional/Spatial Stages
9. Operative Phase: Bypass Ends
 Patient separated from
cardiopulmonary bypass
 Surgeons remove cannulas and
bleeding stopped.
 Scrub Nurse begins inventory of
surgical materials/instruments
 Heart-lung machine shut down and
disconnected “teardown” begun by
perfusionists
Functional/Spatial Stages
10. Operative: Chest Closed
 Surgeons close chest
 Scrub Nurse completes inventory of
surgical materials and instruments
 Anesthesia continues hemodynamic
and hematologic management.
 Perfusion moves heart-lung machine
back or out of room
 Perfusion boom returned to dormant
position along wall
Functional/Spatial Stages
11. Post-Op: Transition
 Surgical drapes and wraps
removed
 Instrument tables pushed back
against wall
 Anesthesia team prepares
patient for transport to ICU
Functional/Spatial Stages
12. Post-Op: Patient Exit
 Patient moved onto gurney from
table
 Patient transported back to
recovery or ICU by remaining
team members
Functional/Spatial Stages
13. Post-Op: Close out
 Scrub and Circulating Nurses
clean up remaining equipment
and close out procedure
Functional/Spatial Stages
14. Post-Op: Room Turn-over
 Environmental Service Staff
clean up room
 EVS staff sets up room for next
procedure
Pilot Study Site: MUSC
The Medical University of SC
 Quaternary Care Academic
Medical Center
 Ashley River Tower [ART]
opened 2008.
 10 OR Surgical Suite with
clean core
 2 rooms dedicated to cardiac
procedures
 XX Cardiac procedures
annually
RIPCHORD
 Realizing improved patient care
through human-centered operating
room design (RIPCHORD)
 Two industrial engineers with
expertise in HF workflow disruptions
observed 10 cardiac operations from
entry into the OR until they left for
ICU.
 Each disruption was documented on
an architectural layout of the OR suite
and time stamped during phase of
surgery (pre-operative, operative,
post-operative).
RIPCHORD
RIPCHORD
 Our goal was to develop a
standard taxonomy for observing
flow disruptions
 1080 unique observations
 Identified six main categories
 Communication
 Usability
 Physical Layout
 Environmental Hazards
 General Interruptions
 Equipment Failures
RIPCHORD
RIPCHORD
RIPCHORD
RIPCHORD
RIPCHORD
Initial conclusions of RIPCHORD
 Layout was the single largest contributor to flow disruptions in
the cardiac OR.
 Interruptions and usability continue to impact surgical flow, but
communication failures occurred less than expected.
 Environmental factors and equipment failures were infrequent
 As expected, disruptions varied across phase of the operation
with layout impacting pre-operative and operative phases
 The perfusionist was differentially impacted by layout issues
 Notably, nurses were most often impacted by interruptions
Historically Little Focus on Physical Environment/Layout
Screened 1400 articles
55 studies involving error in cardiac surgery
Tasks
Tools
Team
Patient
Provider
Organization
Physical
Environment
15
14
9
4
3
7
0
The Architectural Problem
 Most human factors research does not provide useful
design related information on:
 Physical movement between discrete tasks and work points
 Configuration of the physical environment [equipment & room]
 Physical barriers, obstacles and points of congestion
Traditional Human Factors Tools
Link Analysis
 Indicates functional linkages
between activities and work
points but not movement path[s]
through space.
 Does not indicate the real and
potential physical constraints,
and areas of congestion
 Does not indicate points of
potential risk or hazard.
Broad Architectural Questions
 Does the physical configuration of the OR setting
[both architectural space and movable equipment]
impact clinical safety, outcomes and performance in
the OR?
 If so, can links between errors or more specifically
task interruptions, critical clinical activities and the
built environment be established, geographically
anchored and visually documented?
Specific Architectural Questions
 Where do critical activities and movements occur?
 Where are the places of highest volume of
movement and activity?
 Where are the places of potential or actual hazards,
constrained movement or high risk activity?
 Are there co-relationships between task interruptions
or errors, clinical movement and activities, and
spatial elements?
OR Study Site
 Room Area:
 662 NSF
 Room Dimensions:
 29 x 24.6 Feet
 Room Specs:
 Surgical Boom
 Anesthesia Boom
 Perfusion Boom
Movement/Link Analysis Process
Movement Links: Pre-op
Nursing – Anesthesia – Perfusion – Surgeons
Line density = frequency
Line width = physical movement path
There is a significant amount
of movement and activity
throughout the room by nursing,
anesthesia and perfusion
personnel in preparation for a
procedure.
Movement Links: Operative
 Instrument tables and
perfusion equipment is
moved close to the surgical
table.
 The circulating nurse,
anesthesia and perfusion
personnel continue to move
about during the operative
phase of the procedure.
Movement Links: Post-Op
 Surgical instrument tables
are moved back to wall
 Perfusion equipment is
moved back and broken
down, tubing is unplugged
and discarded
 Patient is transferred to a
gurney and taken to ICU or
Recovery.
Interruptions: Pre-Op
 Interruptions at the in-swinging
entry door with the perfusion
boom, perfusion equipment
and personnel.
 Anesthesia work area at the
head of the table is congested,
as there are three or more
people working in the center of
surrounding anesthesia
equipment and supplies in tight
quarters.
Interruptions: Operative
 The perfusion area is a
congested thoroughfare
 Perfusion near entry door
conflicts w traffic entering room
 Access to patient side of
equipment is behind surgeon
 Anesthesia personnel continue
to move about within their
constrained workspace.
Interruptions: Post-Op
 Conflicts continue at in
perfusion area in general
 Conflicts continue at the inswinging entry door during
transfer of patient and
movement of gurney.
Recommendations
 Expand anesthesia
work space at head of
table
 Expand space for
perfusion between table
and wall and/or
eliminate travel through
area
 Swing entry doors out
and/or relocate closer to
the footwall of the room.
IMPLICATIONS
 Separately, layout and human factors play a critical role in
surgical flow and patient safety.
 However, when considered together the implications for
healthcare architecture are magnified.
 To fully understand the complexities of cardiac surgery and
implications for surgical flow, a systematic approach to
disruptions that include architecture, human factors, personnel,
and traditional medicine are required.