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Review Article

Ergonomical aspects of anaesthetic practice

Address for correspondence: RS Raghavendra Rao

Dr.RS Raghavendra Rao,
Department of
Anaesthesiology,
Victoria Hospital, Fort Road,
Bengaluru, Karnataka, India.
Email:dr.rraors@gmail.com
Access this article online
Website: www.ijaweb.org
DOI: 10.4103/0019-5049.181590
Quick response code
Department of Anaesthesiology, BMCRI, Bengaluru, Karnataka, India
ABSTRACT
Anaesthesiologists service begins as a general physician, goes on as an investigator cum data
analyser leading to the architectural planning of a forthcoming surgical event, but only after
articulately convincing the subject along with his kith and kin. In the era of rapid developments in
the field of medicine which includes relevant developments in anaesthetic care, an adequate work
environment has to be provided to the anaesthesia team so that all anaesthetic procedures can be
carried out safely and efficiently and an optimal workflow can be established in the operating room
environment. Such ecological state demands an updated knowledge and ergonomics to aid him.
Unfortunately, ergonomics is an area of anaesthesia that has received little attention and should be
addressed through more education and training for workplace wellness. Hence, an attempt is made
to discuss few aspects on ergonomics for the interface between anaesthesiologistmachinepatient
systems regarded as humanmachinesystem.

Key words: Anaesthesia, design, ergonomics, layout, performance

INTRODUCTION tools, systems and jobs. The objectives of ergonomists

The anaesthesia workplace can be regarded as a
humanmachinesystem complex, which not only
involves the anaesthesiologist, but also the anaesthesia
technicians and nurse anaesthetists involved in patient
care. In this cockpit, the operator has to handle several
devices.[1] The intensive collection of information
and correlating and analysing them before putting
them into action is really challenging. Not only visual
but also auditory cues have to be integrated in the
actioncontrolloop. It is obvious that in some stressful
and complex situations, a perceptual and cognitive
overloading could occur to the anaesthesiologist and,
therefore, may inhibit an efficient and safe interaction.
The design of the interfaces and the form of information
presentation has a significant impact on these aspects.
This is more pertinent in the present day since the
care of anaesthesiologist extends beyond the four
walls of the operation theatre, involving critical care
and services extended at remote locations.
TERMINOLOGY
Ergonomics is a discipline that investigates and
applies information about human requirements,
characteristics, abilities and limitations to the design,
development, engineering and testing of equipment,
are to improve safety, performance, and wellbeing by
optimising the relationship between people and their
work environment. It is the science of fitting the job
to the worker and the practice of designing equipment
and work tasks to match the capability of the worker.
The terms ergonomics, human factors, human
engineering and usability engineering are often used
interchangeably; however, the term ergonomics is
used exclusively.[2,3]
Ergonomics in a literal sense would mean, scientific
study of a man at work. The neglect of human errors
in such working environment is very common but
often ignored. This thought of ergonomics is mainly
applied in health care industry and some branches and
aspects of the medical field in the last few decades.
The word ergonomics is derived from two Greek
words, i.e.,ergo: Work and nomos: Base or foundation.
It was coined by Murrel in 1949, who led a team of
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of anaesthetic practice. Indian J Anaesth 2016;60:306-11.

306 2016 Indian Journal of Anaesthesia|Published by Wolters KluwerMedknow

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Rao: Anaesthesia and ergonomics
scientists in England during World War II.[4] Those
were mostly designed to war and weapons situations
and slowly started expanding into other fields of social
upkeep. Then, it started progressing as human factor
engineering.[3] The growth has been enormous in the
field of medicine, more so in those concerned with the
intensive care, radiology, anaesthesiology, monitors
and laboratory, etc. Awareness of the importance of
human factor in ergonomics(HFE) in medication safety
and other patient safety domains have significantly
increased. Patient safety leaders call for increasing
involvement of HFE in helping not only to characterise
system factors that contribute to patient safety but also
to inform system design interventions.[5,6] Ergonomics
can be applied as an effective and useful method for
the practice of anaesthesia in a model consisting of
three elements and two interfaces.[7] These can be
depicted with their relations as follows:
Objectives of ergonomics are:(i) To improve safety,
(ii) to improve performance,(iii) upkeep the wellbeing.
Anaesthesiologist(ergonomics)equipment
(bioengineering) patient: Here there are three
elements viz., anaesthesiologist, equipment and
patient. There are two interfaces, ergonomics and
bioengineering. The first interface, ergonomics which
was much neglected in the past is now gaining huge
importance in providing a proper machine/equipment.
The latter interface is concerned with the interaction
between patient and technology.
Ergonomical factors contributing to the workload
for anaesthesiologists include issues associated with
hardware such as clarity and intelligibility of monitors,
range and accuracy of alarms, availability and reliability of
equipment, the degree of automation, and environmental
issues such as lighting, noise, temperature and humidity,
the layout of theatres and anaesthetics.[8]
There are four aspects to be concentrated under
ergonomics in relation to anaesthesia:[9] (1) Equipment
design (2) Workplace layout (3) Environmental
conditions such as lighting and legibility (4) Skill
acquisition, productivity and safety.
EQUIPMENT DESIGN
The equipment, its parts and design needs utmost
research and implementation. The levers and handles
should suit and be at the comfortable position to
operate. It should be thick enough to be securely held
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Page no. 17
and preferably possess feel grip. Its better if they are
made agent specific, as seen in flow control knobs of
anaesthesia machines. They must be positioned such
that movement should not cause interference with
knuckle and prevent excessive movement of the elbow.
There should not be sharp edges or high spots. There
should be proper blocking of static charges and proper
insulation. The evolution of anaesthesia machine to
the present day anaesthesia workstation, not only
resulted in better safety features with visible, audible
and programmable alarms but also a composite,
integrated style with inbuilt monitor, ventilator and
data recording features as well. They are also expected
to have standby power backup option. Hence, the
design is wellplanned such that there is option of
the desired parameters to be chosen and an option
for upgrading easily without replacing the whole
equipment. Another measure is the introduction of
anaesthetic scavenging system that has reduced the
operating room pollution and minimised the risk
of exposure among permanent theatre personnel.
Although the percentage of anaesthetic mishaps that
are primarily due to equipment failure appear to be
relatively small, contribution due to poor equipment
design in the incidence of error or mishap may be
significant.[10]
WORKSPACE LAYOUT
The arrangement and selection of inventory and
furniture should be given proper thought with
improvisation. One of the simplest and most basic
measures to take note of in the operation theatre is to
replace the traditional fixed rotating stool at the head
end of the operating table for anaesthesiologist. This to
be replaced with good quality ergonomically designed
height alterable seat with a provision for writing desk.
Achair with castors, height adjustable with proper
backrest and easy accessibility with manoeuvrability
would be desirable. Todays design of operating tables,
anaesthesia machines, monitors and their controls
suggests the ideal build of an anaesthesiologist is
something grotesque. The bulk of the sodalime
canisters on the side of a machine, drawers or other
obstructions under what are meant as a worksurface
and writing surface and the distance to operating table
controls and lights are all instances of engineering
which may be mechanically good but which ignore
the dimensions of the human who is to operate them.
These examples and many more suggest it is worth
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Rao: Anaesthesia and ergonomics
reviewing all aspects of anaesthetic practice to find
more effective ways to arrange equipment and other
facilities optimally. The size of the operating theatre
must allow sufficient room for the nurses and technical
and helping staff to circulate. Preferably, there must
be a separate induction room and one for recovery
with provision to attend to any complications if they
ensue. The field of cognitive engineering and decision
making has grown rapidly in recent decades. It will
cover current research, theory and practice in ways
that not only provide for the sharing of information
across interested parties but also serve to move the
field forward.[11]
Congestion of wires, tubes and lines in an operating
theatre leads to frequent episodes of tipping
over(Spaghetti syndrome). Solutions varying from
a simple colour coded elastomeric bands holding
different sets of tubes and wires,[12] and use of a single
console for multiple set of wires, to use of wireless
technology to connect patient sensors with monitors
have been tried and suggested.[13] Ofek etal. proposed
an integrated self containing built in operating table
which manages the entire process of patient flow
and control of supply systems and environmental
conditions. The design utilises the space below the
operating table to store equipments required for
patient safety, provide conduits for compressed gas,
vacuum and drain systems, water for heating and
cooling, communication lines and backup power
supply. The main power supply units, generators,
pumps and central plumbing tubes are to be stored
in a lower intermittent service floor, and pass directly
through the floor into the base of the operating table.
All devices will be connected to electrical sockets
located inside the table, linked to the central electrical
power supply.[14]
ENVIRONMENTAL CONDITIONS: LIGHTING AND
LEGIBILITY
Proper lighting, visibility and legibility(readability)
are the most desirable features in indoor engineering.
In the past only surgical lighting was given
importance. Over the decades, more emphasis is on
the team and theatre as a whole. The light should
be good enough to appreciate colour changes in the
operating field including colour changes in the patient
(cyanosis/pallor). Lighting should be ample enough to
view the monitor display clearly without any glare.
The problems faced with routine top lights to present
day shadow free, nonglare able, nonheat producing
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lights(preferably of 70,000 to 1,20,000 luminous
intensity) are appreciable. The ratio of intensity of
general room lighting to that at the surgical site should
not exceed 1:5, preferably 1:3.[15]
There is provision to adjust these lights directly by
the operating team or independently manually or by
remote. These lights have almost nullified the problem
of glare.
Display of typed material on equipment: Numbers and
letters should both be legible at a distance of 30cm.
The ratio of the height to distance should be 1:200.
There must be a protocol for the style of print and
font which makes them easiest to read and also for
the wording placed on the equipment. Mistakes occur
from parallax, pointers hiding numerals, scales whose
direction of increase contradict the users expectation,
polycarbonate plastic covers which reflect light and
scratch easily; they may better be avoided or modified
to suitable alternatives. Displays should be grouped
according to function, follow a logical sequence from
top to bottom and left to right, and have an obvious
relation in space to the controls which alter them.
Nonurgent information, such as the makers name
and model and serial numbers of equipment, should
not be on the front face. Controls and displays for
maintenance should be shielded while controls which
are critical to life should be handiest and protected
against accidental activation or deactivation.
The design of displays is a large subject on its own,
and entails simple, legible, and standard presentation
of data. Information presented to the anaesthetist may
be of measured quantities or status. Different grades of
system status are best shown by indicator lights coded
green, amber or red, flashing 35times per second
as visible alarms along with audible warnings to be
used. Even lowlevel noise disturbs good working
rhythm and may mask necessary conversation or
audible signals. Distracting chatter, noisy equipment
and inappropriate impromptu lectures may all be
intrusive.
Apart from lighting and vision, there are other
environmental factors which can affect theatre staff
adversely, as well as the patient. Temperature and
humidity obviously need control, and there should
be simple gauges for these in operating theatres,
together with an efficient hospital engineering service
to maintain them in good working conditions. Apart
from impairing efficiency of work, factors in the
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Rao: Anaesthesia and ergonomics
environment can be downright dangerous, but this
very danger has meant earlier recognition and control
of such threats as anaesthetic gas pollution, electric
shock and radiation. Some attention also has to be
paid towards the workload of hospital staff regarding
lack of sleep and efficiency and stress of all kinds has
to be considered in planning the working environment
of operating rooms. Physical problems that may be
encountered include back and neck ailments. Some of
the basic requirements for designing an ergonomically
efficient operating room are listed in Table1.[15]
SKILL ACQUISITION, PRODUCTIVITY, AND SAFETY
Threading a needle is a good example of an illustration
of skill. This is a skillful task where two hands should
remain steady together by abolishing normal hand
tremor until the completion of the task. Such skills are
learnt very fast when regularly practiced. Someone
who has found it difficult to thread a needle will
find this task laborious in his entire lifetime, unless
regularly practiced. Few anaesthetic procedures
have been analysed regarding their elements. In
many skills, it is the accuracy of feel rather than the
accuracy of movement that is important. Abudding
Table 1: Basic requirements for an ergonomically
efficient operating room
1. Induction room and post operative care unit may be
integrated with operating room to minimize anaesthesiologist
movement and fatigue.
2. The size of the operating room can be as per the
requirement but recommended size is 6.5 m x 6.5m x 3.5 m
for easy movement of the staff.
3. The surface/flooring must be slip resistant, strong &
impervious with minimum joints (e.g., mosaic with copper
plates for antistatic effect ) or jointless conductive tiles/
terrazzo, linoleum etc. The recommended minimum
conductivity is 1 m and maximum 10 ms.
4. Walls and ceiling should be aesthetically pleasing
nonporous, fire resistant, water and stain proof, seamless,
nonreflective and easy to clean. Asemi matt surface paint
reduces reflection of light and tiring of eyes of OT personnel.
5. The sliding doors are preferred to the double action leaf type
since they are more user friendly, save space and prevent
air turbulences.
6. Sufficient electric points should be available on the wall to
prevent entangling of wires and also preferably at a height of
less than 1.5 metres from the floor for easy approach.
7. Taps in the scrub room should be knee/elbow operated or
preferably electronically controlled taps activated by infrared
sensor.
8. Central air conditioning should ensure temperature range
of 18-24 C with 5060% humidity levels. Aminimum of 20
air exchanges/h should be ensured. It is preferred to have
100% fresh air.
9. Sound level in OT should be limited to 25-35 db.
10. There should be emergency communication system that can
be activated without the use of hands.
Indian Journal of Anaesthesia|Vol.60|Issue 5|May 2016
Page no. 19
anaesthesiologist may learn the resistance of vein
wall through a run of haematomas. Analogies suggest
learning is quicker with better feedback and if
simulators are used for teaching. Understanding the
forces involved, and the details of the common pattern
of hand posture used by experts are very essential.
The psychological analysis of how skills are acquired
can be carried further, defining stages of learning. The
first of these is the coding of individual movements,
especially hand and body posture. An example of this
is been given earlier in Environmental conditions.
The later stages are arranging coded elements of
movement into a sequence, which eventually becomes
an unconscious act like the subroutine of a computer
programme.
A basic implication of ergonomics for anaesthesia
is to have a fresh look at the requirement of the
infrastructure and the work of the anaesthetist to
define his activities in a logical and detailed way.
The ergonomics of controls and displays has special
relevance as anaesthetic technology became more
complex and advanced. It is even more important to
acquire skills in certain aspects of work, so that they
are carried out by specially trained technicians and
nurses under the supervision of the anaesthesiologists
instead of directly by them. The introduction of
least exposure radiology equipment (Carm mobile
xray unit), use of ultrasound and echocardiogram in
the areas of monitoring has made features noninvasive
and more reliable adding to better patient safety. Use
of ultrasound has grown beyond monitoring purposes
and has largely influenced the practice of regional
anaesthesia. It is found to increase the success rate and
reduce the onset and procedure times for peripheral
nerve blockade compared with traditional nerve
localization techniques. The presumptive mechanism
for these benefits is the ability to accurately inject
local anaesthetic circumferentially around the target
nerve.[16] However, there exists little information
regarding the competencies involved with use of such
practices. Astudy assessing the common inadequacies
during performance of an ultrasoundguided block by
novice in the field has provided important ergonomical
inputs which help in training of novice.[17]
Components of ergonomics
To optimise system performance while maximising
human wellbeing and operational effectiveness,
ergonomics embrace a range of human centered
issues relevant to equipment or systems design and
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Rao: Anaesthesia and ergonomics
training, including[18](i) Body size(anthropometry),
motion, and strength capabilities(biomechanics)
(ii) sensorymotor capabilities vision, hearing,
haptics(force and touch), dexterity(iii) cognitive
processes and memory(including situational
awareness) (iv) training and current knowledge relating
to equipment, systems, and practices(v) training and
current knowledge of medical conditions(including
emergency conditions)(vi) expectations and cultural
stereotypes relating to the operation of equipment
(vii) general health, age, motivation, stress levels,
mental fatigue and performance.
Implications for action
The professional bodies of anaesthesiologists must be
convinced about the validity and significance of the
foregoing analysis and certain practical steps taken, as
below:[9]
The bodies should formally acknowledge
the relevance of ergonomics to anaesthetic
equipment and workplace design and also
towards training and analysis of skills used
They should have an adhoc committee
and designated resource persons to relate
ergonomics to anaesthesia
Ergonomics should be incorporated into
standards for anaesthetic equipment, a protocol
of recommended design for work areas including
operating theatres, recovery and intensive care
areas, routine procedures and for training
Research on ergonomics and anaesthesia should
be encouraged by the suitable choice of projects
for senior trainees and others likely to seek new
areas for investigation
Finally, anaesthesiologist being the end user
should take active part in the design and
modification of infrastructure and equipment
by giving constructive feedback to the
administrative bodies
Automation of monitoring and recordkeeping,
use of services of nonanaesthesia personnel
such as nonphysician technicians may
probably reduce the workload associated with
the anaesthesia related tasks.[8]
SUMMARY
Understanding human limitations early in the
development of medical devices can reduce errors and
avoid performance problems exacerbated by stress
and fatigue. Using ergonomics in a design process
can reduce the costs of procuring and maintaining
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Page no. 20
products. Ergonomics can minimise the incidence
of injury or long term malaise from poor working
environments. An ergonomics task analysis can help
identify key components of surgical skill, ensuring
that students have affordable, appropriate, valid
and reliable training. The way of visualising and
documenting the interaction data with the help of the
iFlow Chart showed assets in communication at the
interdisciplinary debriefing. There seems to be potential
ergonomic benefits associated with recent advances in
the field such as the use of ultrasoundguided regional
anaesthesia. Prospective studies are needed to quantify
the ergonomic or other benefits, to explore additional
applications of this technology in the training and
practice of ultrasoundguided procedure.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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