4.1Introduction

Office-based surgery is a continually growing segment of medical practice and is the standard for Mohs micrographic surgery. The American Academy of Dermatology Committee on Guidelines of Care has developed guidelines for practicing dermatologists who work in office-based surgical facilities [1, 2]. The guidelines define three classes of facilities: Class I facilities use only local, regional, or topical anesthesia; Class II facilities utilize intravenous sedative or analgesic drugs; Class III facilities use general anesthetics. This chapter will focus on operative room set-up for Mohs surgery performed in Class I office-based surgical facilities. Histopathology laboratory setup and certification will be covered in other chapters of this book.

The design and layout of an office-based Mohs surgical suite are extremely important. The minimum space requirements include: a comfortable waiting room, wellequipped operative rooms, a laboratory for frozen tissue processing/histopathology slide reading, and space for cleaning and sterilizing equipment. The space must provide an environment for comfortable and efficient care of the patient, while meeting regulatory safety standards and the ergonomic needs of the staff.

A contractor, architect, and interior designer, knowledgeable about surgical facilities, are critical in the planning process. These individuals will ensure that the facility meets local building and fire codes. Basic start-up costs will vary, but a good consultant can help save unnecessary costs through an organized and critical approach. Visiting established Mohs surgery practices can also provide useful tips regarding successful office space layout. In addition, consultation with an occupational health specialist is highly recommended for a thorough ergonomic assessment of the office space to reduce the risk of musculoskeletal disorders that can result from the repetitive nature of Mohs surgery. A potential layout of an office-based Mohs surgery suite is detailed in Fig. 4.1.

Summary: Mohs Surgery Waiting Room

•Mohs surgery patients spend several hours between Mohs stages in the waiting area. A dedicated, fully equipped waiting room can be designed to cater to their needs.

4.2Mohs Surgery Waiting Room

Mohs surgery patients will spend several hours between Mohs stages in the waiting area. Ideally, a dedicated waiting room for Mohs surgery patients is important as patients are wearing gowns and have surgical dressings. The waiting area should accommodate a family member or friend who may accompany the patient to the procedure. This waiting room is best located near the nursing station, so that staff can remain alert to potential emergencies. Easy access to a wheelchair-accessi- ble bathroom is also desirable. In addition, Health Insurance Portability and Accountability Act (HIPAA) regulations must be followed when discussing patient issues near this waiting room. Playing soft music, offering television viewing, or a laptop workstation in the waiting room can reduce procedure-related anxiety. Using the checklist below, the basic needs of the patients can be accommodated in the waiting room:

Mohs surgery waiting room checklist: [] Food (bagels, crackers, or pretzels)

[] Drinks (water, juice, coffee, or tea) [] Magazines

[] Patient education materials [] Blankets

[] Closet/Locker (patient clothing and valuables) [] Reclining chairs

Summary: Mohs Surgery Operative Room

Planning

•Important considerations when planning a Mohs surgery operative room include: room size, storage space, and the use of durable materials on walls and floors. Digital photography needs and laser safety regulations should be addressed during the planning process

4.3Mohs Surgery Operative Room Planning

There are multiple considerations when planning a Mohs surgery operative room. The rooms should be clustered together to increase efficiency. A flag system outside of each room can help physicians and staff prioritize patient needs. An intercom and/or phone system in the room is useful for improving communication

between staff. Important nonsurgical equipment in each room includes a desk area with chair and a computer for accessing electronic medical records and digital photographs. A sample layout of a Mohs surgery operative room is detailed in Fig. 4.2.

The recommended size of an operative room is 12 × 12 ft, although it can range from 10 × 14 to 14 × 20 ft [3–5]. An adequately sized room allows for free movement around the operating table, houses surgical equipment, and in the event of an emergency, can accommodate emergency equipment and personnel. The doorway should be at least 36 [3] to 44 in. [6] wide to allow stretcher or wheelchair access comfortably. It is important to consider future growth when planning an operative room. Extra space in the room can later accommodate additional equipment and supplies.

Mohs surgery operative rooms require a large amount of storage space for all the necessary equipment and supplies. Ideally, stocking all surgical supplies in the operative room avoids lost time when staff exit the room to search for items. Organizing all room layouts and cabinet arrangements in an identical manner allows the staff to efficiently locate supplies and instruments. The cabinets can be labeled with their contents and supplies should be restocked daily.

When designing an operative room, consider using durable materials for the walls and floor. Light colored latex paint or washable vinyl walls and ceilings are preferable. Linoleum or vinyl flooring is resistant to stains and easy to clean. Though carpeting creates a cozy atmosphere and reduces noise, it is not recommended in operative rooms. There is evidence that

Fig. 4.2 Mohs surgery operative room layout: Overhead cabinets, counter and sink with foot pedals (a), Trash can (b), Curtain (c), Closet (d), Computer desk and chair (e), Electrosurgery

carpeting does not increase the risk of bacterial contamination and may decrease dust particles in the air [4]. However, carpeting can easily become stained and soiled and is difficult to clean. This can lead to a “dirty” appearance of the room. In addition, it may be difficult to roll equipment (Mayo stand, portable devices) over carpeting. Similar to walls and floor, the ceiling covering should be light colored and washable.

4.3.1Photography

Digital photography is essential to clinical dermatology for tracking changes in the skin, medical record keeping, and teaching purposes. Currently, digital photography is cheaper and more precise than purchasing and developing film. Costs can vary depending on the type of camera selected and accompanying equipment.

unit, smoke evacuator and suction (f), Exam light (g), Mayo stands (h), Kick bucket (i), Sharps container (j)

Table 4.1 Comparison of digital cameras

The Mohs surgery suite’s needs, budget, layout, and staff experience with photography will determine what is suitable for the office. Comparison of digital camera options is outlined in Table 4.1.

Digital photography relies on databases that allow archiving, retrieving, and organization of digital images.