S7 EP 5: Kasey Irwin, Summer Series

Kasey is the Elective Surgery Coordination Manager at Barossa Hills Fleurieu Local Health Network and ia a PhD Candidate.

If you'd like to learn more about the AHDC, please connect with us on our website www.aushdc.org.au or on LinkedIn at linkedin.com/company/aushdc.

Transcript

[00:00:00] David Cummins: G'day welcome to the AHDC podcast series, Health Design on the Go. I'm your host, David Cummins, and today we are speaking to Kasey Irwin, elected surgery coordinator at Barossa Hills Local Health Network in Adelaide. 

[00:00:26] Kasey has been a nurse for over 12 years and is currently undertaken her PhD in engagement in operational room design with staff. Kasey's very passionate about health and hospital theatres. We look forward to hearing more about her research today in our podcast series on research.

[00:00:41] Welcome, Kasey thank you for your time to be here. 

[00:00:43] Kasey Irwin: Thanks for having me. 

[00:00:44] David Cummins: My sister's a nurse and as with all nurses, they pretty much can do anything but I think a nurse who's a theatre nurse who is doing her PhD is very impressive in itself. What drove you to do a PhD? 

[00:00:55] Kasey Irwin: When I started off in nursing, I was in my third year of nursing and I became really engaged in research.

[00:01:02] Up until that point I was a little bit scared of it and I was just focused on moving into nursing, particularly in the operating room but became interested in research. So throughout my career I've been able to work in a range of different operating rooms across Adelaide and in some country sites as well.

[00:01:17] And have always just been interested in design and it was sort a good time for me to move into that, to do a PhD. 

[00:01:23] And I was particularly focused on operating room design and how we engage with the staff in that operating room to understand how it can improve design processes. 

[00:01:31] David Cummins: So when you talk about operating room, for those that aren't really familiar, are you talking about the operating department or the theatre itself?

[00:01:38] Kasey Irwin: Yeah, so for my research, it's specifically focused on the operating room. My background as a theatre nurse is a scrub scout role, so that's a role that assists the surgeon either being scrubbed, handing instruments and providing that patient care or on the other side of that table providing support to the entire surgical team.

[00:01:57] So my work has been very focused on the operating room specifically and I'm not sure if most people know, but it's about a 55 or 60 square meter space. There are a number of stakeholders that work within that space as well. So I was particularly interested in how everybody moves within that space together to provide patient care because you can't leave those four walls once you have started that surgery. So that was my interest in research in that way. 

[00:02:22] David Cummins: Yeah. And did you differentiate between a maternity theatre, cardiac theatre, trauma theatre, general theatre. Is your research based on theatres as a whole? 

[00:02:31] Yeah, theatres as a whole. I've done some qualitative research so far, so data collection understanding the perspectives of different operating room staff, so that's nurses, surgeons, and these tests, and also the technicians that work within that space and it's not been defined to a particular specialty or type of surgery. 

[00:02:49] But I am doing some quantitative research at the end of this year and I'm hoping to do a larger survey with operating room staff across Australia to really understand are there any differences among cardiac theatres, obs and gynae (Obstetrics and Gynaecology) and those sorts of things. 

[00:03:01] Yeah. Interesting. So where are you with your PhD at the moment and what are your findings showing at the moment? 

[00:03:06] Kasey Irwin: Yeah, so I'm sort of smack bang in the middle. I've done a mixed method study. So I've done my qualitative data collection and I've been moving on to that quantitative.

[00:03:14] Survey shortly, but what we've found so far, and we'll be exploring further is some concepts related to ensuring the engagement is respective and inclusive when designing operating rooms. So what we did initially was talk to, as I mentioned, nurses, surgeons, anesthetists, technicians. But then we also pulled in some architects and some project teams to discuss their perspectives on engaging with operating room staff in that planning process.

[00:03:42] So certainly ensuring engagement and respect came up within both groups. Not only the clinicians, but also their designers. That is either a barrier or something that promotes engagement, is people feeling respected as a part of that process. 

[00:03:55] David Cummins: And maybe I've missed it, but surely part of that respect is of the patient as well.

[00:04:01] Kasey Irwin: It absolutely is. And I think that comes into the next point that we found from those initial interviews is that the staff in the operating room can foresee safety concerns just based on their experience and their understanding of caring for the patients so they can sort of see whether it's on a floor plan or whether it's part of discussions that are happening in different groups about things that might perhaps not work well based on staff safety and patient safety and their experiences of caring for people in that really small space.

[00:04:33] David Cummins: So is your research leaning towards a stronger and bigger design or more efficient design or more efficient patient flows or staff flows? What are your feelings and thoughts or what is your research showing at the moment? 

[00:04:47] Kasey Irwin: Yeah, certainly there's some enhancement I think that could be put into the planning process.

[00:04:52] What we have also found is that staff are impacted by things that might be external to the operating room in providing the care and moving, whether that's through doors that don't perhaps work properly, then that has other implications for infection control and also just delaying care, staff needing to travel long distances to collect items, and then of course, all the internals where equipment's plugged in, where power points are situated, where booms might be within the room.

[00:05:18] So it's really giving staff the opportunity to provide that feedback and identifying and forcing some of those safety concerns to enhance the design for the people working in the space. 

[00:05:30] David Cummins: Yeah. And does your research go into further detail such as infection control the surfaces, the, the flooring, the walls, the fixtures even the ICT equipment?

[00:05:40] Does it go into that level of detail? 

[00:05:42] Kasey Irwin: It absolutely does, and certainly there's lots of research out there that addresses all of those certain components. Because we were asking about perspectives and how staff feel about foreseeing safety concerns working within the space, all of those items certainly did come up. And they are some of the things that they're talking about in terms of enhancing. 

[00:05:59] So particularly noise interruption in the operating theatre, there was lots of talk about selecting the correct flooring the locations of equipment beeping and those sorts of things. Certainly lighting. Doors was one that I was really surprised that was such a big feature in terms of the structure of the operating room. 

[00:06:16] Lots of participants talked about doors not working properly and that really impacting their work in there, in the space, and also transporting patients in and out so that was a big one. 

[00:06:26] David Cummins: I'll just stick on flooring for a minute. I must admit, in hindsight, some surgeons are there for 10, 12 hours sometimes.

[00:06:32] So what would be some of the best flooring? 

[00:06:35] The theatres that I've designed and built has pretty much been concrete slab on vinyl for infection control standards. But when you talk about it out loud, there's obviously more options for fatigue matting and things like that. 

[00:06:45] So what's your research showing in reference to flooring for surgeons and for nurses, I suppose?

[00:06:50] Kasey Irwin: Discussions about flooring have basically just been more about the materials in terms of noise.

[00:06:56] All of the theatres that I've been in have fatigue mats. So it certainly wasn't something that was raised in terms of the feel underfoot. One thing that was raised in terms of flooring is just the surface and the level of the flooring might make trolleys move around.

[00:07:08] So that was certainly something that the people I spoke to were concerned about more so than how that felt standing in there for 12 hours. 

[00:07:15] David Cummins: Yeah. And did you go into level of detail such as vinyl versus corian versus infection control and cleaning? 

[00:07:21] Kasey Irwin: Not in this research. 

[00:07:22] David Cummins: And so in reference to fixtures and fittings at the moment you've obviously got a lot of ICT, especially if you've got robotics versus manual... 

[00:07:30] What's your research showing in reference to surgeon fatigue, nursing fatigue, and also patient care in reference to the fixtures and fittings within the actual theatre itself?

[00:07:39] Kasey Irwin: Staff fatigue certainly came up when we were talking about traveling long distances as well. So that external sort of impact on the way that the work's undertaken in the operating room. The other thing that did fatigue staff was the noise, the beeping. 

[00:07:51] Certainly if people are having to bend down to get into cupboards, there might be a computer above, there might be a workstation on wheels that doesn't fit next to the anesthetic machine and dependent on where the power access is for that, where it will be plugged in and then that's creating cords on the floor and trip hazards. So it was certainly talked about in terms of movement within the space getting fatigued, having to travel long distances, but also just managing not tripping over items in the theatre. 

[00:08:21] David Cummins: Yeah. And sticking with theatre, I know there's a lot of research to show that the light in itself can actually cause extreme fatigue, where I've now started to see a lot more theatres with natural light versus pure artificial light.

[00:08:32] What does your research talk about with that? 

[00:08:34] Kasey Irwin: So we haven't specifically had any information about the lighting and the wellbeing of the staff inside. What was talked about particularly was windows and looking into the space, and that again, was more around being concerned with the safety of the staff and the patients.

[00:08:50] So examples of if there wasn't a window provided so a staff member could look inside the theatre and see what was happening, the doors needed to be opened far more often than they should be. 

[00:09:00] There was increased traffic in the theatre because people had to actually come in and check what was happening rather than being able to just have that visual access to the staff inside.

[00:09:09] David Cummins: And this is to the theatre itself, not the anesthetic bay? 

[00:09:11] Kasey Irwin: That's right. Yeah. 

[00:09:12] David Cummins: Yeah. Interesting. I must admit, I've only done that on very few hospitals, and that's showing that it provides a level of comfort to the staff and reduced their anxiety and increase their safety from their concern.

[00:09:23] Correct? 

[00:09:24] Kasey Irwin: Absolutely. And they certainly were very vocal about having access to either essential items that they needed to go and collect or access to staff who were able to get into theatre. And that was a part of it. 

[00:09:35] If there was a code happening if there was some kind of emergency, people were able to look inside through the window to see if there are enough people in there, or if it was just for meal breaks, they could just check rather than opening the door.

[00:09:46] David Cummins: And the preference would be a privacy shield as well so it's not always fully exposed depending on the field? 

[00:09:51] Kasey Irwin: Absolutely. 

[00:09:52] And patient confidentiality and privacy was also a big portion of that. 

[00:09:56] David Cummins: Yeah. Interesting. 

[00:09:57] Did you go into the level of detail such as the infection control surfaces for walls and so forth?

[00:10:02] Because the Australian Health Facility Guidelines Report, you have to have as smoother surface as possible, but not all fixes and fittings are smooth.

[00:10:11] So you have to be very careful from that and an infection control point of view. What did your research talk about with that? 

[00:10:16] Kasey Irwin: Yeah, it was quite interesting in the variants in the groups that I spoke to and what their priorities were for safety.

[00:10:21] Certainly the design teams that I spoke to, but very focused on the surfaces ensuring that infection control principles were followed, providing hand washing stations, warning lights outside of the theatre. So we knew that there was laser happening inside, or X-ray. 

[00:10:36] The staff working in the operating room weren't as concerned about that and whether that was because they felt that what was in their theatres was suitable I'm not too sure, but it certainly didn't come up as a core concern for those people working in the space. 

[00:10:49] David Cummins: A lot of private hospitals now are moving towards corian for that smoother finish. 

[00:10:53] Vinyl, I think is as good as corian in many respects, and obviously a lot cheaper, but certainly a lot of the newer and private hospitals are going towards corian for that smooth finish and they do look amazing, I must admit. 

[00:11:04] Kasey Irwin: Absolutely. I think there was a lot of discussion around also, most of the people I spoke to that worked in the operating room had some private hospital experience as well as public hospital experience. 

[00:11:14] And they certainly talked about the differences in public and private and the way that redevelopments or new builds happen. 

[00:11:20] There was also lots of discussion around redeveloping aged infrastructure and being able to ensure all of those elements were in the operating room as well. That is quite challenging when you're working within a defined structure and you can't modify that very much. 

[00:11:35] David Cummins: Yeah, I've done a few redevelopments where people have this great idea for a new theatre, but the ceiling space just isn't there and they can't get the services in and you can't get the flow right. 

[00:11:46] And so what might be a good idea to someone is obviously a nightmare to your engineers. Did you talk about the difference with pendants versus wall service power? So pendants is quite new, probably maybe last five, 10 years, it's really come out to have pendants and in some areas I've seen two to three pendants where it does have all the services there, the IT, the information and also the power.

[00:12:07] Is that really that beneficial or is it something that's a fad? 

[00:12:11] Kasey Irwin: Yeah, so there's quite a bit of discussion around that as well. There was certainly operating room staff that felt that, that restricted their flexibility in terms of having some fixed pendants versus some mobile equipment. 

[00:12:24] The positioning within the room and just being limited to actually adjust that to what works best for them and their workflow.

[00:12:30] And again, the anesthetic staff that I spoke to had a different priority to the nursing staff and the surgeons just based on simply where they work within the room. So there was a preference in some regards to that fixed option with all of those services within, and then there were other roles that felt flexibility was a bit better.

[00:12:49] David Cummins: Yeah. Cause I imagine when something does go wrong in theatre, you do want access to that patient as quickly as possible, but those pendants, and I do know that they're hydraulically easy to move, but they are very close to the patient. 

[00:13:00] Kasey Irwin: And I think the additional challenge is that I don't know that there's a perfect place to put those because you might also have suction that's sitting on the floor as well.

[00:13:09] There might be a bin, there might be an anesthetic machine. It's close to the bed that there's a lot of items that are just within that really small space and then you've got that above as well. So it is really challenging. 

[00:13:21] David Cummins: A lot of staff have to, especially anesthetics, a lot of staff have to write notes in the theatres.

[00:13:26] Obviously as we are more digital, people are moving away from that. But I still know there are certain hospitals out there that do prefer the hard copy notes. 

[00:13:34] Was there a preference from staff, especially anesthetists and some of the surgeons and doctors who had to write, would their preference be computers or hard copy within the theatre itself?

[00:13:45] Kasey Irwin: Certainly the people that I spoke to had a preference for electronic medical records and documentation, and that was certainly present in all of the operating rooms of the people that we did talk to. There was a big focus on integration though, and making sure that everybody had access to what they needed to have access to in terms of that documentation.

[00:14:04] Some operating rooms might have different computers in different locations within the room for different roles to undertake that work. 

[00:14:10] As I said before, some of them might be on wheels so they can position them, for example next to the anesthetic machine to do their documentation. But again, then that creates another item that's in the space that needs to be plugged into power that can create a trip hazard.

[00:14:23] So the focus was really on considering that as part of the design process and the amount of items within the space that need to be shared among all the rules. 

[00:14:34] David Cummins: Yeah, so I think it was Einstein that said 90% planning, 10% execution. Don't quote me on that, but I'm pretty sure it's something like that.

[00:14:41] So you've got health planners who do their health planning and everyone wants the project done now, but I think sometimes people just rush a little bit with that planning phase, because the more planning that goes into it, the more thinking, the more research that goes into it, the better it is to understand the theatre space.

[00:14:56] So how would you like to see your research implemented to not only theatres in Australia but around the world? 

[00:15:01] Yeah, so there is quite a bit of work in this sort of space in the USA and they do have some nurse-led initiatives where they have some involvement in planning in terms of providing support to clinical teams.

[00:15:14] Certainly what I'd like to see to come out of my research is a resource that would be available for staff that are engaged in, in user groups that might be able to just consider the things that have come out of this research as that initial part of planning and then all the way through or to provide clinical staff with resources to engage with their own staff. 

[00:15:36] So certainly what we heard from the designers is you can get too many people in a room providing opinion and it can slow down the process, things can get missed. And then on the other hand, there are challenges from the designer's perspective in making sure the right people are in the room at the right time.

[00:15:52] So what I hope to do is be able to provide a resource to the clinical team so they can do some of that preparation work within their own clinical teams, and then take with them to the designers what's really important for them in their own space. 

[00:16:04] Do you think there's any benefit of having prototypes where they literally deal with the space, get the nurses in actually pretend to do a mock theatre case to actually just see the operations because there is so much variance within theatres, whether it's a child or an adult, or cardio..

[00:16:18] There is so much variance, especially with equipment and nursing and support. Do you think there's any benefit in having prototypes or do you think that's a step too far? 

[00:16:27] Kasey Irwin: I certainly think there is. The people that I did speak to said it was really difficult to understand a space on a floor plan.

[00:16:33] They couldn't understand dimensions. They talked about the size of the room in terms of dimension rather than being able to move around it as well. And they certainly had a desire to have some additional options to help them with planning and whether that was a simulated environment, whether it was VR, but they certainly suggested that it would be easier for them to understand the space in those sorts of ways. 

[00:16:56] David Cummins: Yeah, so generally as with all things more, and it's certainly happening a bit more these days, more space doesn't necessarily mean a better design. It can actually raise a lot more complications. 

[00:17:06] So do you think the solution is actually understanding the users, making sure those users are there and being part of that design process or providing everyone with bigger space and power cords that go connect to the ceiling?

[00:17:18] Is it a spatial problem or is it an operational problem? 

[00:17:20] Kasey Irwin: I think it's an operational problem. I think certainly the priority would be having the people who work within the space are provided with an opportunity to foresee safety concerns. And then as a part of that design process, those safety concerns are responded to in some way.

[00:17:41] David Cummins: Yeah, I 100% . Agree. But the challenge for that as well is that every hospital is so unique. Every theatre is so unique, or the staff are so unique. So how would one, especially listen to this podcast, apply those principles to their theatres overseas or in Australia? 

[00:17:56] Kasey Irwin: Yeah, I think certainly just getting an understanding of what the core concerns are for the group within that space.

[00:18:02] Absolutely. Every single operating room is different, every situation is going to be different, and that is the challenge I think, in evidence-based Health design, particularly for these really critical spaces because by the time you do the research on that one space it's not going to apply to the next space perhaps.

[00:18:19] So I certainly think understanding what the core concerns are for the group that are working in the space and then having that guide some of the discussions with the design teams. I think just a greater awareness that the staff within the operating room are the experts in their work, while the designers are the experts in that design planning process.

[00:18:39] So just that respect between both of those processes, I hope would enhance operating room design moving forward. 

[00:18:46] David Cummins: As with any research, there's generally something that you are discovering that you may not have known before.

[00:18:52] What do you think's been the main discovery that you hadn't anticipated or one of the biggest highlights that you hadn't actually thought about in your research? 

[00:18:59] Kasey Irwin: Certainly the biggest thing in terms of the structure and what impacts workflow was some of those things that really impact staff in their work, like being able to enter or exit the operating room.

[00:19:10] Being able to see those staff inside was really a focus of all of the staff in terms of safety. I think what has been really good so far Is that the priority for both, the design planning group and the clinicians, is the same. It's a patient focus and it's really about understanding how these spaces can be as safe as possible.

[00:19:31] But I think that in engaging the right people at the right time, having time to plan for these spaces and really understanding what the staff within the operating room as well as the patient's need has been a highlight. 

[00:19:44] David Cummins: I think one of the other benefits of having such specialist nurses and doctors and anesthetists in that design process is because a lot of them have so much experience and generally from multiple hospitals so they do know what works and what doesn't work. 

[00:19:56] But one thing that I would imagine would be very beneficial is to have them look at the actual finishes themselves. Look at the pendants before they go in. 

[00:20:03] Maybe they've got a preferred supply for their vinyl, just like they would for their surgical kits with their suppliers for their CSSD equipment.

[00:20:09] Maybe that would be another level of complexity that they could resolve. 

[00:20:13] Kasey Irwin: And I think you're right, giving that choice and people having the ability to sort of understand. Some of the nurses, certainly the nursing group described they were not involved in design planning processes at all, although they could see what those safety concerns were... they perhaps weren't engaged to provide that information. 

[00:20:30] And they suggested that, as being part of that design process, without directly being involved, is just having that reported back through their managers. 

[00:20:38] Okay, this is the flooring that we've gone with. These are the surfaces and perhaps the reasons around those.

[00:20:45] Surgeons on the other hand, because they work across different sites and they see different operating rooms. They had a fairly good understanding of what they thought would work based on what they'd seen before. 

[00:20:55] So yeah, it's just about that experience and being able to see what's available. And of course, budget was a big part of that as well, so lots of discrepancy between clinicians' understanding of budget and then what was actually able to be selected. 

[00:21:10] David Cummins: Yeah. And there's always that balance between surgeon A and surgeon B, who both want to block out that theatre, but one surgeon prefers this type of pendant, one surgeon prefers this type of bed. 

[00:21:20] So you do have to have that balance between flexibility and knowing that surgeons will sometimes leave. How to actually get that balance. 

[00:21:27] That's why I think it's even more important to be speaking to the nurses who would generally have a less variance than the surgeon's preferences as well. 

[00:21:33] Kasey Irwin: Yeah. And there was certainly discussion among the design teams that I spoke to about biasing the design to particular roles.

[00:21:41] And that would vary obviously across different organisations and sectors as well.

[00:21:46] David Cummins: I'm interested in your research. Did you actually go to the level of detail where putting maybe a monitor on each. Person to literally see how far they go, what their level of activity is, and their radius of circle.

[00:22:00] Did you go to that level of detail or is more, is more verbal and subjective? 

[00:22:03] Kasey Irwin: Yeah, it's certainly more subjective for the first phase that I've done, but there's actually quite a bit of research out there that has already done that. So there is a study that has looked at the circulating nurse patterns.

[00:22:13] They've also looked at the surgeon patterns, the anesthetists as well. And there's a really great study that actually demonstrates exactly how often they move throughout that space and the space within the operating room that's used. 

[00:22:25] So I hope that in the future I can do a bit more research and that might be something that I consider, but not as part of this study. 

[00:22:32] David Cummins: I've got a few more questions but we're running outta time. I have done design a few theatres and . One of the best ones I've ever done was in Geelong. And the surgeons' number one preference universally, one thing they agreed upon was to make sure that they had speakers for their music.

[00:22:46] Did that come into your research as well? Cause I was astounded by that, that the surgeon wanted to listen to music while performing theatre, but apparently that's quite common. 

[00:22:54] Kasey Irwin: Very common. 

[00:22:54] And every theatre operating room that I've been in, they've had music. And I think the sites that I did my research at... that's certainly the case.

[00:23:01] There's music available. You're not ever in an operating room when there's not music available. So I just don't think it was a concern for them at the time. 

[00:23:08] David Cummins: Yeah, right. I mean, that was something that shocked me. 

[00:23:11] I think bringing more people in as part of that journey is always good as well. 

[00:23:14] Kasey Irwin: Yep. We certainly had some examples of similar sorts of things and perhaps people had even been through a mocker and missed things. So I think engagement in design is really challenging and then getting a really good outcome is also challenging.

[00:23:27] David Cummins: So what do you think would be one of the take home messages for especially designers listening today when it does come to theatre design and that interrelationship between stakeholders within the theatre? 

[00:23:36] Kasey Irwin: Probably just the understanding that the work within the space, the movement of all of the staff within the space, and there is a large group of staff that are actually working in that really small space. 

[00:23:46] The way that one role move, actually has an impact on another role's movements and then the actual ability to provide that patient care. So I think when concerns are raised about power points or pendants or door positioning or materials, I think it's just really an understanding that those working within this space face a lot of challenges in moving within the operating room.

[00:24:09] And if those sorts of things are raised, it's certainly because the staff can foresee impacts to safety. 

[00:24:15] David Cummins: Yeah, I agree. I think you are a absolute superstar. I think your research is very, very smart and it's, it, it will actually have universal appeal, not only in Adelaide in Australia, but also the globe.

[00:24:26] We've spoken to quite a few people, especially about theatres. But to get this level of detail, I think there's a lot of thirsty people out for this research, and especially in the design world even to that level of detail of visibility over staff within the theatres is something I didn't know, but I think little details like that will help improve patient care, staff care and operations care.

[00:24:46] So I think it's very impressive. So we look forward to seeing your research ones as published. 

[00:24:49] Kasey Irwin: Excellent. Thanks so much. 

[00:24:51] David Cummins: Thank you Kasey for your time. 

[00:24:53] You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. If you would like to learn more about the AHDC, please connect with us on our website or LinkedIn. 

[00:25:03] Thank you for listening.