[Downloaded free from http://www.ijaweb.org on Tuesday, May 03, 2016, IP: 117.248.141.

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Review Article

Ergonomical aspects of anaesthetic practice

Address for correspondence: RS Raghavendra Rao
Dr. RS Raghavendra Rao, Department of Anaesthesiology, BMCRI, Bengaluru, Karnataka, India
Department of
Anaesthesiology,
Victoria Hospital, Fort Road, ABSTRACT
Bengaluru, Karnataka, India.
E‑mail: dr.rraors@gmail.com
Anaesthesiologist’s 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
Access this article online the field of medicine which includes relevant developments in anaesthetic care, an adequate work
Website: www.ijaweb.org 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
DOI: 10.4103/0019-5049.181590
environment. Such ecological state demands an updated knowledge and ergonomics to aid him.
Quick response code
Unfortunately, ergonomics is an area of anaesthesia that has received little attention and should be
addressed through more education and training for workplace well‑ness. Hence, an attempt is made
to discuss few aspects on ergonomics for the interface between anaesthesiologist‑machine‑patient
systems regarded as human‑machine‑system.

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

INTRODUCTION tools, systems and jobs’. The objectives of ergonomists
are to improve safety, performance, and well‑being by
The anaesthesia workplace can be regarded as a optimising the relationship between people and their
human‑machine‑system complex, which not only work environment. It is the science of fitting the job
involves the anaesthesiologist, but also the anaesthesia to the worker and the practice of designing equipment
technicians and nurse anaesthetists involved in patient and work tasks to match the capability of the worker.
care. In this ‘cockpit’, the operator has to handle several The terms ergonomics, human factors, human
devices.[1] The intensive collection of information engineering and usability engineering are often used
and correlating and analysing them before putting interchangeably; however, the term ergonomics is
them into action is really challenging. Not only visual used exclusively.[2,3]
but also auditory cues have to be integrated in the
action‑control‑loop. It is obvious that in some stressful Ergonomics in a literal sense would mean, ‘scientific
and complex situations, a perceptual and cognitive study of a man at work’. The neglect of human errors
overloading could occur to the anaesthesiologist and, in such working environment is very common but
therefore, may inhibit an efficient and safe interaction. often ignored. This thought of ergonomics is mainly
The design of the interfaces and the form of information applied in health care industry and some branches and
presentation has a significant impact on these aspects. aspects of the medical field in the last few decades.
This is more pertinent in the present day since the The word ‘ergonomics’ is derived from two Greek
care of anaesthesiologist extends beyond the four words, i.e., ergo: Work and nomos: Base or foundation.
walls of the operation theatre, involving critical care It was coined by Murrel in 1949, who led a team of
and services extended at remote locations.
This is an open access article distributed under the terms of the Creative
TERMINOLOGY Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
Ergonomics is a discipline that investigates and For reprints contact: reprints@medknow.com
applies information about human requirements,
characteristics, abilities and limitations to the ‘design, How to cite this article: Raghavendra Rao RS. Ergonomical aspects
development, engineering and testing of equipment, of anaesthetic practice. Indian J Anaesth 2016;60:306-11.

306 © 2016 Indian Journal of Anaesthesia | Published by Wolters Kluwer ‑ Medknow
Page no. 16

[8] A chair with castors. its parts and design needs utmost which may be mechanically good but which ignore research and implementation. IP: 117. anaesthesiology. the degree of automation.. temperature and humidity.[Downloaded free from http://www. There are two interfaces. operating room pollution and minimised the risk (ii) to improve performance. productivity and safety. 60 | Issue 5 | May 2016 307 Page no.141. ergonomics which was much neglected in the past is now gaining huge WORK‑SPACE LAYOUT importance in providing a proper ‘machine/equipment’. Although the percentage of anaesthetic mishaps that Anaesthesiologist – (ergonomics) – equipment – are primarily due to equipment failure appear to be (bio‑engineering) – patient: Here there are three relatively small. It’s better if they are were mostly designed to war and weapons situations made agent specific.ijaweb. availability and reliability of be replaced with good quality ergonomically designed equipment. involvement of HFE in helping not only to characterise integrated style with inbuilt monitor. more so in those concerned with the There should not be sharp edges or high spots. ergonomics and significant. May 03. There intensive care.org on Tuesday. They are also expected to inform system design interventions. canisters on the side of a machine. The levers and handles the dimensions of the human who is to operate them.[10] bio‑engineering. height adjustable with proper backrest and easy accessibility with manoeuvrability There are four aspects to be concentrated under would be desirable.[3] The growth has been enormous in the knuckle and prevent excessive movement of the elbow. of exposure among permanent theatre personnel. end of the operating table for anaesthesiologist. monitors and their controls design (2) Work‑place layout (3) Environmental suggests the ideal build of an anaesthesiologist is conditions such as lighting and legibility (4) Skill something grotesque. 2016. ergonomics in relation to anaesthesia:[9] (1) Equipment anaesthesia machines. etc. drawers or other obstructions under what are meant as a work‑surface EQUIPMENT DESIGN and writing surface and the distance to operating table controls and lights are all instances of engineering The equipment. 17 . Awareness of the importance of insulation. it started progressing as human factor that movement should not cause interference with engineering. contribution due to poor equipment elements viz. height alterable seat with a provision for writing desk. noise. (iii) upkeep the well‑being. The first interface. not only and other patient safety domains have significantly resulted in better safety features with visible. It should be thick enough to be securely held These examples and many more suggest it is worth Indian Journal of Anaesthesia | Vol. should suit and be at the comfortable position to operate. Then. Today’s design of operating tables. One of the simplest and most basic Ergonomical factors contributing to the workload measures to take note of in the operation theatre is to for anaesthesiologists include issues associated with replace the traditional fixed rotating stool at the head hardware such as clarity and intelligibility of monitors. equipment and design in the incidence of error or mishap may be patient. the layout of theatres and anaesthetics. ventilator and system factors that contribute to patient safety but also data recording features as well.[4] Those and preferably possess feel grip. radiology. the can be applied as an effective and useful method for design is well‑planned such that there is option of the practice of anaesthesia in a model consisting of the desired parameters to be chosen and an option three elements and two interfaces. as seen in flow control knobs of and slowly started expanding into other fields of social anaesthesia machines.248. This to range and accuracy of alarms.6] Ergonomics to have stand‑by power backup option. Patient safety leaders call for increasing and programmable alarms but also a composite.[5. The evolution of anaesthesia machine to human factor in ergonomics (HFE) in medication safety the present day anaesthesia workstation.[7] These can be for upgrading easily without replacing the whole depicted with their relations as follows: equipment. Another measure is the introduction of anaesthetic scavenging system that has reduced the Objectives of ergonomics are: (i) To improve safety. field of medicine. anaesthesiologist. monitors should be proper blocking of static charges and proper and laboratory. The latter interface is concerned with the interaction The arrangement and selection of inventory and between patient and technology. audible increased. Hence. and environmental issues such as lighting. They must be positioned such upkeep.27] Rao: Anaesthesia and ergonomics scientists in England during World War II. The bulk of the soda‑lime acquisition. furniture should be given proper thought with improvisation.

org on Tuesday.[11] The ratio of the height to distance should be 1:200.[13] Ofek et al. theory and practice in ways that not only provide for the sharing of information Display of typed material on equipment: Numbers and across interested parties but also serve to move the letters should both be legible at a distance of 30 cm. such as the maker’s name conditions. flashing 3–5 times per second as visible alarms’ along with audible warnings to be ENVIRONMENTAL CONDITIONS: LIGHTING AND used. factors in the 308 Indian Journal of Anaesthesia | Vol. cover current research. These lights have almost nullified the problem making has grown rapidly in recent decades. of data. provide conduits for compressed gas. Temperature and operating field including colour changes in the patient humidity obviously need control. and standard presentation through the floor into the base of the operating table. generators. Information presented to the anaesthetist may All devices will be connected to electrical sockets be of measured quantities or status. In the past only surgical lighting was given importance.000 to 1. Controls and displays for patient safety. and control of supply systems and environmental Non‑urgent information. The size of the operating theatre general room lighting to that at the surgical site should must allow sufficient room for the nurses and technical not exceed 1:5. The main power supply units. amber or red. view the monitor display clearly without any glare. maintenance should be shielded while controls which vacuum and drain systems.ijaweb. together with an efficient hospital engineering service The problems faced with routine top lights to present to maintain them in good working conditions. pumps and central plumbing tubes are to be stored The design of displays is a large subject on its own. legible. as well as the patient. linked to the central electrical system status are best shown by indicator lights coded power supply. and there should (cyanosis/pallor). Preferably.141. supply. non‑heat producing from impairing efficiency of work. The design utilises the space below the and model and serial numbers of equipment. there must be a separate induction room and one for recovery There is provision to adjust these lights directly by with provision to attend to any complications if they the operating team or independently manually or by ensue. Distracting chatter. Lighting should be ample enough to be simple gauges for these in operating theatres. tubes and lines in an operating font which makes them easiest to read and also for theatre leads to frequent episodes of tipping the wording placed on the equipment.27] Rao: Anaesthesia and ergonomics reviewing all aspects of anaesthetic practice to find lights (preferably of 70. Displays should be grouped have been tried and suggested. different sets of tubes and wires. and have an obvious which manages the entire process of patient flow relation in space to the controls which alter them. intrusive. IP: 117. 2016. preferably 1:3.20. water for heating and are critical to life should be handiest and protected cooling. there are other the team and theatre as a whole. The field of cognitive engineering and decision remote. There must be a protocol for the style of print and Congestion of wires. Even low‑level noise disturbs good working LEGIBILITY rhythm and may mask necessary conversation or audible signals. scales whose a simple colour coded elastomeric bands holding direction of increase contradict the user’s expectation. pointers hiding numerals.[14] green. noisy equipment Proper lighting. It will of glare. in a lower intermittent service floor. more emphasis is on Apart from lighting and vision. Mistakes occur over (Spaghetti syndrome).248. non‑glare able. The light should environmental factors which can affect theatre staff be good enough to appreciate colour changes in the adversely. Apart day shadow free. they may better be avoided or modified technology to connect patient sensors with monitors to suitable alternatives.[15] and helping staff to circulate.[12] and use of a single polycarbonate plastic covers which reflect light and console for multiple set of wires. Different grades of located inside the table. and pass directly and entails simple. communication lines and backup power against accidental activation or de‑activation. should operating table to store equipments required for not be on the front face. field forward. Over the decades. proposed according to function. Solutions varying from from parallax.000 luminous more effective ways to arrange equipment and other intensity) are appreciable.[Downloaded free from http://www. 60 | Issue 5 | May 2016 Page no. May 03. The ratio of intensity of facilities optimally. to use of wireless scratch easily. visibility and legibility (readability) and inappropriate impromptu lectures may all be are the most desirable features in indoor engineering. follow a logical sequence from an integrated self containing “built in” operating table top to bottom and left to right. 18 .

It is found to increase the success rate and conductivity is 1 mΩ and maximum 10 mΩs. Some of can be carried further. Central air conditioning should ensure temperature range of 18-24° C with 50‑60% humidity levels. Some attention also has to be simulators are used for teaching. The surface/flooring must be slip resistant. The introduction of 1. AND SAFETY The later stages are arranging coded elements of movement into a sequence. human well‑being and operational effectiveness. so that they are carried out by specially trained technicians and Table 1: Basic requirements for an ergonomically nurses under the supervision of the anaesthesiologists efficient operating room instead of directly by them. PRODUCTIVITY. A minimum of 20 Components of ergonomics air exchanges/h should be ensured. electric learning is quicker with better feedback and if shock and radiation. Physical problems that may be The psychological analysis of how skills are acquired encountered include back and neck ailments. remain steady together by abolishing normal hand tremor until the completion of the task. during performance of an ultrasound‑guided block by 7. issues relevant to equipment or systems design and Indian Journal of Anaesthesia | Vol. Few anaesthetic procedures The ergonomics of controls and displays has special have been analysed regarding their elements. nerve.[Downloaded free from http://www. Use 3.248. and more reliable adding to better patient safety. 19 . defining stages of learning. This is a skillful task where two hands should programme. mosaic with copper and has largely influenced the practice of regional plates for antistatic effect ) or jointless conductive tiles/ terrazzo. Sufficient electric points should be available on the wall to regarding the competencies involved with use of such prevent entangling of wires and also preferably at a height of practices. but this anaesthesiologist may learn the resistance of vein very danger has meant earlier recognition and control wall through a run of haematomas. for these benefits is the ability to accurately inject 5. It is even more important to accuracy of movement that is important.[17] 8. May 03..141. 60 | Issue 5 | May 2016 309 Page no.org on Tuesday. A budding acquire skills in certain aspects of work. A study assessing the common inadequacies less than 1. inputs which help in training of novice.5 m x 6. regularly practiced. x‑ray unit).27] Rao: Anaesthesia and ergonomics environment can be downright dangerous. 2016. Such skills are A basic implication of ergonomics for anaesthesia learnt very fast when regularly practiced. The presumptive mechanism reduces reflection of light and tiring of eyes of OT personnel. There should be emergency communication system that can ergonomics embrace a range of human centered be activated without the use of hands. seamless. Sound level in OT should be limited to 25-35 db. reduce the onset and procedure times for peripheral 4. save space and prevent air turbulences. Taps in the scrub room should be knee/elbow operated or preferably electronically controlled taps activated by infrared novice in the field has provided important ergonomical sensor. to be considered in planning the working environment of operating rooms. Someone is to have a fresh look at the requirement of the who has found it difficult to thread a needle will infrastructure and the work of the anaesthetist to find this task laborious in his entire lifetime.[16] However. it is the accuracy of feel rather than the complex and advanced. which eventually becomes ‘Threading a needle’ is a good example of an illustration an unconscious act like the sub‑routine of a computer of skill. In relevance as anaesthetic technology became more many skills. The size of the operating room can be as per the the areas of monitoring has made features non‑invasive requirement but recommended size is 6. linoleum etc. It is preferred to have 100% fresh air. To optimise system performance while maximising 9.g. strong & of ultrasound has grown beyond monitoring purposes impervious with minimum joints (e. use of ultrasound and echocardiogram in 2. unless define his activities in a logical and detailed way. A semi matt surface paint localization techniques. The recommended minimum anaesthesia. The the basic requirements for designing an ergonomically first of these is the coding of individual movements. and the details of the common pattern lack of sleep and efficiency and stress of all kinds has of hand posture used by experts are very essential. Analogies suggest of such threats as anaesthetic gas pollution. SKILL ACQUISITION. Induction room and post operative care unit may be integrated with operating room to minimize anaesthesiologist least exposure radiology equipment (C‑arm mobile movement and fatigue.5 m for easy movement of the staff. The sliding doors are preferred to the double action leaf type local anaesthetic circumferentially around the target since they are more user friendly.5m x 3. IP: 117.ijaweb. Walls and ceiling should be aesthetically pleasing nerve blockade compared with traditional nerve nonporous. non‑reflective and easy to clean. fire resistant. An example of this is been given earlier in Environmental conditions. 10.[15] especially hand and body posture. there exists little information 6. efficient operating room are listed in Table 1. water and stain proof.5 metres from the floor for easy approach. Understanding the paid towards the workload of hospital staff regarding forces involved.

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Bonneau G.ahrq. • The bodies should formally acknowledge the relevance of ergonomics to anaesthetic Conflicts of interest equipment and work‑place design and also There are no conflicts of interest.141. FL: CRC Press Taylor & Francis Group. Roth  E.[Downloaded free from http://www. Haynes  J.htm. National should take active part in the design and Academy Press. the field such as the use of ultrasound‑guided regional mental fatigue and performance.317:1321. 60 | Issue 5 | May 2016 Page no. Michael Imhoff. probably reduce the workload associated with Melbourne.ijaweb. anaesthesia. Murrell KF. 2. 7‑8. Available from: https://mpatkin. J Cogn Eng Decis Making 2007. convinced about the validity and significance of the foregoing analysis and certain practical steps taken. including[18] (i) Body size (anthropometry). 1999. age. 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Jha Memorial & Dr. 2016 Ish Narani Best poster Award Chairperson. Wiley CW. M.isaweb. Anaesthetical Ergonomics. [Last accessed on 2016 Feb 22]. Bhoj Raj Award Hon. Secretary.51:193‑9 18. 2016 ISACON 2018 Bidding Hon. popliteal sciatic nerve block? A proof‑of‑concept study. Koshkin A. Secretary. 17. 61:548–52. copy to Chairperson Chansoriya Travel Grant Scientific Committee of ISACON 2016 20 Oct. Public Awareness . 60 | Issue 5 | May 2016 311 Page no.in Cut Off Date Name of Award / Competition Application to be sent to 30 June 2016 Bhopal Award for Academic Excellence Hon. 2016 Prof. Bertrand ML. P. Venkatagiri K. Public Awareness – City / Metro 6. Hard copy with all supportive documents to be sent by Regd. learning ultrasound‑guided peripheral regional anesthesia.com. Singhal Life Time Achievement Award Hon. Dr. ISA 30 June 2016 Late Prof. From a radial operating theatre to Blike GT.) of the same by E Mail to secretaryisanhq@gmail. May 03. Y. Secretary. Kasaragod 671 121. (Hon Secretary. Venkat Rao Oration 2017 Hon.98:566–7. Chetty J. ashx. Scientific Committee ISACON 2016 with Copy to Hon. Ind J Anaesth 2007. 2016 Awards (01 Oct 2015 to 30 Sept 2016) Hon. 21 . 16.ukzn. Sites BD. Anaesthesia 2006. Maharaj A.27] Rao: Anaesthesia and ergonomics Analg 2004.org on Tuesday. Pizov R.State 7. Secretary. Secretary. 14. Ayyappa Temple. Secretary. Parrington SJ. Announcement CALENDAR OF EVENTS OF ISA 2016 The cut off dates to receive applications / nominations for various Awards / competitions 2016 is as below. Secretary. Gallagher JD. Characterizing novice behavior associated with a self‑contained operating table. Post with soft copy (Masking names etc. Membership drive 9. IP: 117. ISA 30 Sept. Scientific Committee ISACON 2016 30 Sept.36:266‑70. Chan VW. ISA 30 June 2016 Dr. Secretary & also accessed from www. Designing an ideal operating room Reg Anesth Pain Med 2007.anaesthetics. Naidoo L. Ofek E. 2016 Kop’s Award Chairperson. Nullippady. complex. K. ISA National) “Ashwathi”’ Opp. Macfarlane AJ. Public Awareness – Individual 5. Brull R.32:107‑17.za/Libraries/Documents2011/L_Naidoo_Ergonomics. Spence BC. A. Dr. The masked soft copy will be circulated among judges. Best City Branch 2. Best State Chapter 4. ISA 30 Sept. 2016 ISA Goldcon Quiz Chairperson. Scientific Committee ISACON 2016 10 Nov. ISA Send hard copy (whereever applicable) to Dr. Bitterman N. Is circumferential injection advantageous for ultrasound‑guided 2011. Hon. p. P. Best Metro Branch 3.ijaweb. 15.248. 2016. Email: secretaryisanhq@gmail. Reg ac. Available from: http://www. ISA 1. ISA 30 June 2016 Rukmini Pandit Award Hon. Secretary. Anesth Pain Med 2011.com / Mobile: 093880 30395 Indian Journal of Anaesthesia | Vol.[Downloaded free from http://www. T.sflb. Only ISA members are eligible to apply for any Awards / competitions. Kerala. Harsoor SS. 2016 Late Dr. ISA. Bala Bhaskar S. N. Ether Day (WAD) 2016 City & State 8. Proficiency Awards 20 Oct.141. G. 14. The details of Awards can be had from Hon. ISA 30 Sept. Secretary.

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