Outpatient Surgical Suite

Author: Pamela Phillips, MD; Chief Editor: Dirk M Elston, MD

Overview
Dermatologists and dermatologic surgeons have played major roles in the development and refinement of many office-based cutaneous surgical procedures. The comprehensive scientific education in the structure and function of the skin that dermatologists receive during formal residency training has directly contributed to these advances. Dermatologists and dermatologic surgeons have pioneered many cutaneous surgical techniques. These specialists been at the forefront in developing new surgical techniques, and they have been leaders in providing safe and effective office-based surgery. The main advantages of office-based surgery compared with hospital-based surgery are patient convenience, surgeon convenience, staff satisfaction, greater economic benefit, and more flexibility. Office-based surgery allows surgeons to consolidate their entire practice in one location and thereby save substantial amounts of time and energy. Because the surgeon has control of the schedule of the facility, competition with other physicians for optimal surgical operating time is eliminated. The staff can be hired and equipment can be purchased to suit each surgeon's particular needs. Lastly, paperwork is generally reduced because the rules and regulations for office-based facilities are more streamlined than those for their hospital counterparts.[1] Patients prefer office-based surgery because the environment is less threatening than that of a hospital or even a facility designed exclusively for surgery. Because the patients are already familiar with the office, they are likely to be more comfortable on the day of surgery than they would be in new surroundings or with new personnel. Patients often view office care as being more personalized than comparable care provided in a larger facility.

Credentialing, Privileges, Accreditation, and Knowledge

Physicians should be able to distinguish the terms certification, credentialing, privileging, and accreditation.[2, 3] Certification means that an eligible physician has completed the required course of graduate study and clinical training and has passed the examination conducted by the respective board. Credentialing involves documentation of the fulfillment of specified criteria. An appropriate body in an organization reviews the documents, and it may interview the applicant. The reviewing body then reports to a governing body, recommending the denial or approval of the requested privileges that allow the physician to perform the specified duties. The term accreditation is typically applied to organizations such as hospitals or other health care facilities. Philosophically, the focus of accreditation is the quality of care provided by the organization, and the accreditation process is designed to verify that an organization meets specified criteria that are assumed to be indicative of high-quality care. In addition to standards for the physical environment, medical records, and ancillary services, the criteria also include standards for the physicians and medical staff.

Physicians who perform office-based surgery should have in-depth knowledge of the skin and subcutaneous tissue, and, depending on the type of surgery performed, he or she should have knowledge of fluid and electrolyte balance, the management of potential complications, and the type of anesthetics used. Physicians should have evidence of the training that they obtained for the particular procedure to be performed. Such training may have been acquired during residency, fellowships, or courses or preceptorships accredited by the Accreditation Council for Graduate Medical Education (ACGME). For procedures such as liposuction, complex closures, use of flaps and grafts, and sclerotherapy, the physician should have documented experience in performing the procedure with an appropriately trained and experienced physician.

Guidelines of Care for Office Surgical Facilities

The American Academy of Dermatology's Committee on Guidelines of Care is charged with developing guidelines of care for dermatologists. The guidelines are intended to promote the continued delivery of high-quality care. In 1992, the committee designed guidelines to help ensure the adequacy of office-based surgical facilities. These guidelines are helpful in creating an environment that minimizes hazards and in dealing with complications in a manner that conforms to the accepted standards of care. The guidelines define 3 classes of facilities.[4, 5]
Class I facilities

A class I facility is a facility in which cutaneous surgical procedures are performed with the aid of only local, regional, or topical anesthesia. Additionally, oral or intramuscular sedatives or analgesics may be administered. The design of the room and building in which these procedures are performed should comply with all state and local fire, safety, sanitation, and building codes for physicians' offices. Adequate hand-washing facilities must be available, and towels should not be shared. Appropriate lighting should sufficiently illuminate the surgical field. Emergency lighting should be available in the event of a power failure. All openings that allow outside air to reach the surgical area should be designed so that insects and animals cannot enter. Equipment in a class I facility should be appropriate for the procedures performed, and it should be in proper working order. In addition to the proper instruments, operating tables, monitors, and emergency equipment and safety devices (eg, approved fire extinguishers) should be available and regularly inspected and tagged. The staff should be familiar with current basic life support procedures, and they should be taught measures to prevent and manage exposure to blood-borne infectious organisms. Other procedural requirements for a class I facility include the proper maintenance of the medical records; the adherence to applicable federal, state, and local regulations; and the development of action plans for use in the event of an emergency.
Class II facilities

Class II facilities are those that offer the additional administration of intravenous sedative or analgesic drugs. Requirements for class II facilities include all those mentioned above for class I facilities and additional ones. More safety and resuscitation equipment is expected. In addition, the physician and staff should be trained in advanced life support. Supplemental oxygen, an

airway suction device, resuscitation equipment, intravenous fluids, and appropriate supplies should be in close proximity. An area should be designated for postoperative recovery.
Class III facilities

Class III facilities are facilities that can use general anesthetics. General anesthesia involves the use of any drug, element, or other material that results in the elimination of all sensations and an altered state of consciousness. In this state, the patient's protective reflexes, including his or her ability to maintain an open airway, can be lost.[6] Class III facilities meet the requirements of federal, state, and local regulations. In addition, a class III facility may meet the standard for outpatient surgical facilities, as established by accrediting organizations. For instance, a physician must monitor and/or supervise the patients. Blood and blood substitutes should be readily available, and a recovery room with dedicated staff must be available.

Surgical Suite
The design and layout of an operating suite are extremely important. The suite must provide an atmosphere that enables efficient state-of-the-art care. The setting should be pleasant and comfortable for both the patient and the surgical staff.[7] The design of the surgical facility must be individualized to the office and the type of surgery to be performed. The scope and number of procedures to be performed at the facility should be anticipated. Overplanning and overbuilding to allow for future expansion is wise. Review as many different existing plans as possible prior to building an office-based surgical suite. Also, visit existing facilities during the preplanning process to evaluate the strengths and weaknesses of the various designs. The size of the facility depends on the needs of the individual surgeon, and it is governed by factors such as the number of operating rooms and recovery beds; the necessary storage areas; and the space for sterile supplies, bathrooms, hallways, and offices. Construction requirements are largely based on the federal fire-safety codes, which are different for newly constructed and previously constructed buildings. In addition, any local fire and building codes must be met. These codes may vary from state to state.

Operating Room
An operating room size of 14 X 16 ft is adequate, whereas a room size of 14 X 20 ft is ideal. This larger size provides adequate space for an operating table and surgical sink, and it allows a full complement of staff to move about unencumbered. The extra space is particularly important in the event of an emergency situation when additional personnel and equipment are needed. In considering the size of the operating room, the space occupied by items such as cabinets, the thickness of the walls, the structural supports, and the plumbing and air conditioning fixtures should be considered. The free floor space is the most practical concern. The walls and floors should be durable. A suspended ceiling with standard acoustic tile can be used, although nonporous ceiling tiles are easier to clean and may be more sanitary.

Surgical Equipment
Operating table

The installation of high-quality surgical tables is strongly recommended. In a busy surgical practice, such tables make the patient more comfortable and provide easy access for the surgeon. In addition, the adjustability and overall dimensions of the table are important parameters to consider. Powered tables with foot-operated or fingertip controls are the most desirable. Adjustments in back and foot elevation are essential for the patient's comfort. The tilt positioning of the table is important, because it enables the physician to change the angle of the table. This feature not only enhances the patient's comfort but also enables the staff to place the patient in the Trendelenburg position if needed. Surgical tables are manufactured in various dimensions. A wide table more easily accommodates heavy patients, whereas a narrow table occupies less space and provides the surgeon with better access. The size of the headrest varies and is a consideration for comfort and access. Finally, armrests are another option that may help the staff in comfortably performing certain procedures.
Operating room lights

Optimal illumination in the surgical field is essential, especially during precise surgical procedures. A wide range of surgical lights are available and should be closely matched to the needs of the procedures to be performed. Specific considerations include the intensity of the light, the size of the illuminated field, the production of heat and shadows, and the maneuverability of the lamps. A common model consists of a single lamp placed in the center of a concave reflective shell. More expensive, larger designs provide multiple lamps in a concave reflective shell, each aligned at a slightly different angle to widen the illuminated area and minimize shadows. The diameter, shape, and composition of the concave reflective surface determine the focus depth, as well as the shadows and glare produced. More expensive models are equipped with a focusing adjustment to help sharpen the intensity of the illumination. In addition to field size and illumination, maneuverability is a vital consideration. Ceilingmounted track lighting provides the greatest range of motion, with as much as 360 flexibility, and it fully illuminates the head and feet. Ceiling-mounted fixed units are most commonly used. They should be situated over the table to illuminate the largest field possible. All lights should be equipped with handles to allow the staff to position them during the procedure. These handles should be capable of being sterilized. Sterile, disposable handle covers are available from most manufacturers.
Mayo stand

The Mayo stand is universally required. It allows for easy convenient access to equipment and supplies and its height is adjustable. A table unit with 4-6 wheels is most maneuverable and stable, and it can be moved during the procedure.
Waste containers

Well-equipped surgical suites should include kick-bucket waste containers. These waste containers are made of stainless steel with rubber baskets. The containers are mounted on wheels

and have a protective hard rubber and steel rim that the staff can use to move the bucket with their feet during the procedure.
Monitoring equipment

Monitoring equipment should be available so that the staff can determine the patient's pulse, blood pressure, electrical cardiac activity, and blood oxygen saturation (ie, pulse oximetric level). A means for determining the patient's temperature should also be available. These data should be recorded by attending personnel or by means of automatic recording devices.
Sterilization equipment

A variety of small, steam autoclaves are available for use in office surgical suites. If many procedures and thus the use of numerous surgical instruments are anticipated, a second unit should be available. If space allows, a built-in hospital-type steam autoclave may make the sterilization of bulky items more convenient.
Medical gases and suction devices

Oxygen, nitrous oxide, nitrogen, and compressed air are the gases that are usually available at an ambulatory surgical suite. Suction devices should be considered with these gases because the equipment for both are installed together.
Recovery area

Space dedicated as the recovery area can vary depending on the anticipated caseload. All postoperative patients can be moved to one area where one nurse can easily monitor them. Adequately trained personnel must be in the immediate vicinity of the recovering patients until the patients are fully awake and alert.
Emergency equipment

A major consideration in an office operating room should be the management of emergencies. Adequate equipment must be immediately available. The following are essential:

Stethoscope Blood pressure cuff Thermometer Cardiac monitor and pulse oximeter Defibrillator Laryngoscope with endotracheal tubes of various sizes Ventilation (Ambu) bag with airways of various types and sizes Oxygen tank Bags of intravenous fluid with adequate supplies for emergency administration Drugs for emergency treatment Availability of transportation from the operating room to an emergency facility

All staff should be trained in the use of all emergency equipment. The staff should also be trained in pediatric and adult basic and advanced life support.

Bathroom facility

Bathrooms should be near the operating room and recovery area. Building codes require that the bathrooms be accessible to individuals with physical disabilities. Emergency alarms should be placed in the bathrooms within easy reach for the patients.