SPECIAL REPORT
Improving Operating Room Efficiency and the Role of Digital Technology
Five Ways Digital Technology Can Improve Operating Room Productivity and Efficiency A Better View for the Surgeon Equipping the Operating Theatre Interdependence Helped by Integration Minimally Invasive: Maximum Organisation
Published by Global Business Media
Images for life We help surgeons and OR staff see lifelike images, improve operating room efficiency, and adapt to future technologies quickly. Setting up an operating room is no easy feat. We bring simplicity and efficiency into the OR. With our scalable and flexible solutions, you can adapt as you need to and expand as you grow. Whether in Full HD, 4K or 3D resolution, new imaging technologies will get the representation they deserve.
More info on www.barco.com/surgical
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
SPECIAL REPORT
Improving Operating Room Efficiency and the Role of Digital Technology
Five Ways Digital Technology Can Improve Operating Room Productivity and Efficiency
Contents
A Better View for the Surgeon Equipping the Operating Theatre Interdependence Helped by Integration Minimally Invasive: Maximum Organisation
Foreword
2
John Hancock, Editor
Five Ways Digital Technology Can Improve Operating Room Productivity and Efficiency
3
Barco
1. Reducing Setup and Preparation Time Published by Global Business Media
Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org
2. Enabling Efficient Decisions and Streamlining Treatment 3. Reducing Turnover Time 4. Reducing Technical Maintenance and Installation Time 5. Reducing Downtime Due to Equipment Problems OR-over-IP is the Future
A Better View for the Surgeon John Hancock, Editor
Publisher Kevin Bell
What Is Digital Technology?
Business Development Director Marie-Anne Brooks
Digital Technology in Surgery
Editor John Hancock Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.
8
The Advantages of Digital Technology
Equipping the Operating Theatre
10
Camilla Slade, Staff Writer
The Challenge of Maintenance and Troubleshooting What a Digitised Operating Environment Can Offer Image Guided Surgery
Interdependence Helped by Integration
12
Peter Dunwell, Medical Correspondent
Human Factors in Surgery Challenges Need Solutions
Minimally Invasive: Maximum Organisation
14
John Hancock, Editor
Advanced Digital Solutions as Aids to Efficiency and Productivity Advanced Digital Solutions as Aids to Accuracy and Quality Looking Ahead
References 16
Š 2020. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.
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IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
Foreword H
ealthcare providers face ever increasing
visualization solutions for the entertainment, enterprise
demands to deliver more and better-quality
and healthcare markets, identifying five ways in
care to growing numbers of people on more
which digital technology can support productivity
occasions at no greater or, if possible, less cost.
and efficiency in the operating theatre. We then
A whole range of developments have supported
continue with an article that looks at the technology
that challenging requirement, not least of which
itself as well as from a surgeon’s point of view and at
has been the introduction of minimally invasive
the advantages that digital technology can deliver to
surgery (MIS) and image guided surgery.
the surgeon. Following on from that, Camilla Slade
With less physical trauma to the patient’s body, MIS
considers the maintenance and troubleshooting
reduces the risk of infection during or after surgery and
demands of an operating theatre and how a digitised
reduces the time taken to heal from a less invasive
environment can better support that as well as giving
procedure. However, because the surgeon is not
an overview of image guided surgery, the essential
seeing directly inside the patient, he or she relies
component in MIS. Peter Dunwell’s article looks at the
heavily on pre-operative planning, X-Ray, CT and other
value of integrating the various inputs that a surgeon
images of the site and a camera that accompanies
needs and at some of the human factors that cannot
the tools used during the laparoscopic access to the
be neglected, even in a paper about technology.
operating site. The quality of the system that brings
Finally, we look at the ways in which new technology is
all of these inputs to the surgeon as well as the quality
being used and at the importance of a well-managed
of individual images is a key factor contributing to a
theatre: plus, a brief look into the future.
successful outcome and digital technology has enabled a significant leap forward in that. This paper opens with a contribution from Barco, a global technology leader that develops networked
John Hancock Editor
John Hancock, an Editor of Hospital Reports Europe, has worked in healthcare reporting and review for many years. A journalist for more than 30 years, he has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, wound management, complex health issues, Schizophrenia, health risks of travel, local health management and NHS management.
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IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
Five Ways Digital Technology Can Improve Operating Room Productivity and Efficiency Barco Businesses worldwide have embraced digital transformation. In the past decade, many organizations have ramped up their digital efforts in order to overhaul their business processes and improve the customer experience. The same can be said of the operating room (OR). As in other industries, the OR has not introduced digitization for digitization’s sake, but rather to reduce complexity, simplify workflows, and increase efficiency and productivity of the OR staff. Beneluxpark 21, 8500 Kortrijk Belgium +32 56 233211 info@barco.com www.barco.com
Technology has always been a driver of productivity and efficiency. But can digital technology also make this happen in the OR? First and foremost, let’s define what efficiency and productivity means for the OR. •E fficiency is about improving patient satisfaction and reducing errors or postoperative complications. •P roductivity relates to treating the maximum number of patients in order to increase hospital revenues. In many hospitals, surgical and interventional services already contribute to more than half of the hospital’s revenue, and this rate is going upi. Barco, a worldwide leader in visualization technology, has been supporting surgeons and OR staff to improve operating efficiency and to simplify workflows for several decades. In this article we’ll talk about five ways in which digital solutions can improve surgical teams’ productivity and efficiency, from OR preparation to patient turnover.
1. Reducing Setup and Preparation Time Among other things, the productivity of surgical teams and the efficient use of the OR depends on easy and flexible scheduling of cases and on the time required for their preparation
and technology setup. However, by bringing more technology into the OR, the setup and configuration before surgeries have become increasingly complex and time-consuming. As a result, it has become increasingly difficult to prevent case start delays, cancellations and long patient waiting lists. Setting up the OR environment for a new patient should be simple and straightforward. A technology like IP-based video integration for the operating room, also called “OR-over-IP”, can reduce complexity in the operating room and reduce the preparation time. By offering a standard architecture, the OR-over-IP approach simplifies installation and reduces set-up time in the OR. Barco’s Nexxis OR-over-IP platform makes it possible to share uncompressed, high-resolution video (and audio) in and between operating rooms. This technology has been specifically designed for integration into the digital OR. With Nexxis, adding new devices or switching sources works on a plug and play basis, and images can be displayed on any OR display connected through the network. To reduce clutter and complexity even more, all imaging sources can be brought together in the interventional control room on a single display, managed by a single keyboard and mouse.
Among other things, the productivity of surgical teams and the efficient use of the OR depends on easy and flexible scheduling of cases and on the time required for their preparation and technology setup
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4K UHD resolution display for referral imaging
Working in an operating room can be stressful, hectic and physically demanding
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2. Enabling Efficient Decisions and Streamlining Treatment Working in an operating room can be stressful, hectic and physically demanding. One of the roles of digital technology in the OR is to enhance the surgical team’s working conditions, so they can operate in all comfort, make quick and accurate decisions, and reduce errors. However, an OR that is crammed with equipment – navigation devices, machinecontrolled applications, PACS equipment, etc. – only adds to the stress levels of the OR staff. Again, a video-over-IP system like Nexxis allows the them to reduce the number of cables and devices and to create a much cleaner and comfortable working environment. A video-over-IP system also makes it possible to centralize all available information and present it to the OR staff exactly where needed. With Nexxis, content can be positioned flexibly from display to display, from procedure to procedure, and according to the surgeon’s personal preference. According to Dr. Peter Müller, Senior Physician, Trauma Surgery at Augsburg Hospital (Germany), it is this kind of equipment that makes life easier for the surgeons. The hospital uses Nexxis and Barco surgical displays. As such, it is able to manage the distribution to the OR displays individually, by a simple drag and drop action on a screen. “In the case of an arthroscopy, for example, I have a clear view of the site of the procedure, irrespective of where the arthroscopy cart is. In addition to the live image, I can look at the MRI image on the second monitor.”ii Similar feedback comes from AZ Maastricht hospital (The Netherlands): “The success of our procedures in the hybrid operating room greatly depends on the flexibility of the system.
Near-patient surgical display
Nexxis is a very versatile, flexible system that allows us to see, use and switch images on any monitor in the OR, without disruption,” says Prof. M. de Haan, interventional radiologist. “The platform is clear and simple, so that we can easily connect and disconnect sources. Only the used sources are visible, which is a clear benefit,” adds Klaas Braat from the IT department. “Moreover, the image remains exactly the same, with no latency or compression – what you see is what you get.”iii Ergonomic comfort also pertains to the quality of the images on which surgeons base their decisions. Medical images should be highly accurate, lossless (i.e. uncompressed so none of their original quality is lost in the translation to the screen), and they should come with minimum latency, so surgeons can maintain perfect handeye coordination.
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
3D visualization with passive glasses
Nexxis makes sure that high-resolution, uncompressed medical images are presented with pixel-perfect precision and with near-zero latency. In addition, Barco’s Full HD and 4K surgical displays make sure that images from endoscopic cameras, room and boom cameras, ultrasound, PACS and patient information, are rendered with razor-sharp precision, allowing surgeons to see details they wouldn’t have seen before. 3D endoscopic surgery is already a reality, especially with more complex cases that require an in-depth view. With Nexxis, the step towards 3D is a small one to take: with a simple software upgrade, already installed encoders can now take in the 3D source and send out a 2D and a 3D video stream on the network. This way, the 3D source can be shown on any surgical display in the OR, regardless whether it’s 2D or 3D.
3. Reducing Turnover Time Patient turnover – the time between two consecutive patients – consists of cleaning the OR setup of the preceding patient and setting it up for the following case. With a technology setup that is too complex and time-consuming, patients as well as surgeons risk having to wait for the treatment to begin – a major source of dissatisfaction in the ORiv. In addition, all time that is lost on technology configuration leads to the OR being underutilized. Another issue is that smaller operating rooms are often not designed to cope with the increasing amount of high-tech medical equipment today. This is also a cause for time-consuming rearranging and moving around of equipment, leading to an increased turnover time. Decreasing turnover time between patients can pave the way for additional cases to be
scheduled, leading to increased revenue for the hospital. Reducing the complexity of the technology setup is a first big step in that direction. With a flexible, IP-based video integration system, you can easily switch between configurations and procedures, add or remove devices, and reduce turnover time. With an IP-based system, there are less components to set up and worry about: less cables, but also less external converters, extenders or splitters.
With a technology setup that is too complex and time-consuming, patients as well as surgeons risk having to wait for the treatment to begin
4. Reducing Technical Maintenance and Installation Time With an increasing number of devices and cables, the OR risks becoming a complex hodgepodge of technology that is hard to maintain. Technicians not only have the task to increase the OR’s uptime as much as possible, but the maintenance work in and of itself needs to be done efficiently as well. Time spent on technical maintenance cannot be used for surgery. For many years, operating rooms have relied on conventional audiovisual (AV) systems. However, ever-changing video formats, limited integration possibilities, and complex and nonfuture-proof cabling made OR maintenance a cumbersome affair. Complicated configurations of AV equipment were often not fit to meet the changing imaging requirements of the modern OR. An IP-based video integration platform can make the job of maintenance personnel a lot easier. By using unified fiber cabling that connects directly to the devices, cable clutter can be reduced and errors during maintenance can be avoided. WWW.HOSPITALREPORTS.EU | 5
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
VoIP platform for digital operating room
A good demonstration of the power of the NexxisCare platform is the New Children’s Hospital in Helsinki (Finland)
Maintenance professionals also like to schedule ahead. That’s why they value a digital OR that can smoothly evolve over time, along with the needs of the OR staff. With a networked solution based on a standard architecture, cabling can be laid in advance and new sources or devices can be added at any time, so OR upgrades can run quickly with limited disruption. Barco Nexxis is ready for any new technology (e.g. 4K) as soon as the OR team is. Nexxis can integrate practically any signal type through ‘plug and play’. In addition, the system is scalable and flexible, and allows you to adapt as you need to and expand as you grow. But the plug and play nature of the Nexxis platform also has the welcome side-effect that it can contribute to the economic viability of the OR. This is explained by Augsburg Hospital trauma surgeon Dr. Müller: “We cannot purchase an imaging modality for each OR – this would be too expensive as well as ineffective. Therefore, we share those devices between different ORs. Nexxis greatly facilitates this: all you have to do is connect the encoder, integrate it, plug it in with a single cable and it simply starts working.”v
5. Reducing Downtime Due to Equipment Problems Usually, problem solving of OR equipment requires a lot of expertise. Finding the root cause of a technical problem, such as a faulty cable, may require a lot of time, knowledge and sometimes expensive measurement equipment. This is one of the reasons why equipment problems in the OR often lead to delays. 6 | WWW.HOSPITALREPORTS.EU
Finding errors in faulty equipment faster can be a way to reduce the time the OR is not used due to technology problems. To accomplish that, OR maintenance staff can make use of Barco’s NexxisCare cloud platform, which makes it possible to remotely monitor visualization infrastructure in the OR 24/7 to ensure everything is in top condition. With NexxisCare, operation room maintenance professionals can detect possible issues in a proactive way and schedule the necessary maintenance actions in time. NexxisCare constantly monitors a wide variety of system parameters and reports any anomalies before they become problematic. A good demonstration of the power of the NexxisCare platform is the New Children’s Hospital in Helsinki (Finland). The hospital’s maintenance team had been suffering a long time with a quality problem in the hospital due to a bad fiber cable. But immediately after the installation of NexxisCare at the New Children’s Hospital, the platform detected several critical technical issues. Without NexxisCare, the hospital would have had to order an on-site investigation by a skilled technician. With the cloud platform, however, the maintenance team could see in a few mouse clicks where maintenance was needed. But even with the cloud platform, the support of a human medical imaging expert in times of crisis, can be invaluable. With Barco’s Care maintenance and support services, customers always get priority support. OR professionals that step into this support program can be confident that their medical display systems are always up and running, ant that their medical images are always compliant with medical standards.
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
VoIP platform for digital operating room
OR-Over-IP is the Future In an environment where the patient’s stakes are so high and where every minute literally means money, digital technology can help improve the productivity and efficiency of today’s already highly skilled top OR professionals. The OR of today and of the future is one where conditions are created that allow surgeons to do their best work, by delivering highly accurate images, and by providing the most ergonomic working conditions.
But technology continuously evolves and thus, the OR also needs to be easily adaptable and interchangeable to meet future requirements. Its environment must be flexible enough to accommodate the most recent technologies, such as 4K imaging, without having to shut down the current infrastructure. IP-based video integration, or the so-called OR-over-IP, is a solution that will support this expansion of technologies well into the future.
With NexxisCare, operation room maintenance professionals can detect possible issues in a proactive way and schedule the necessary maintenance actions in time
References: i
https://www.brainlab.com/journal/5-big-trends-in-o-r-digitalization/ and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4944359/
ii
https://www.barco.com/en/customer-stories/2014/q4/2014-11-12%20-%20klinikum%20augsburg
iii
https://www.barco.com/en/customer-stories/2013/q2/2013-06-10%20-%20az%20maastricht
iv
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878989/
v
https://www.barco.com/en/customer-stories/2014/q4/2014-11-12%20-%20klinikum%20augsburg
In an environment where the patient’s stakes are so high and where every minute literally means money, digital technology can help improve the productivity and efficiency of today’s already highly skilled top OR professionals
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IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
A Better View for the Surgeon John Hancock, Editor The digital world reaches into the operating theatre and offers a range of possibilities for improvement
Transformation comes from new ways of working, not the technology itself – what is needed is a transformation programme supported by new [i.e. digital] technology, not the other way round
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Go to any exhibition or trades related conference these days and it won’t be long before an exhibitor or a speaker utters the word ‘digital’. Digital capabilities are at the heart of Industry 4.0 whose reach considerably exceeds the manufacturing range of previous industrial revolutions. This digital revolution is being applied in every area of human activity and that includes healthcare plus, in particular for the subject of this paper, the operating theatre or room.
What Is Digital Technology? So, what is the big deal with digital technology: how does it differ from its predecessor, analogue? Funnily, analogue technology is the harder one to explain but, understanding it helps clarify why digital is so much better. As this isn’t a technology paper, we’ll just state as Explain That Stuff1 does, that analogue is a direct representation or analogy of a dimension (say, length), an image (film-based photography) or a process (say time marked by the progress of hands on a clock). “Digital is entirely different. Instead of storing words, pictures, and sounds as representations on things like plastic film or magnetic tape, we first convert the information into numbers (digits) and display or store the numbers instead.” That means that, whenever the information, in whatever format, is stored and called up, it is recreated from the stored numbers and, therefore, the quality is retained. But the capabilities are a lot more than just accurate reproduction. The Nuffield Trust2 has considered why it has been difficult to deploy digital technology in healthcare. Read the reference for a full explanation but the key statement seems to be that, “Transformation comes from new ways of working, not the technology itself – what is needed is a transformation programme supported by new [i.e. digital] technology, not the other way round.” In other words, a digital solution will not remedy a
bad process but will ensure that a good process works to the full extent of its potential. The onus is to create good processes that can fully benefit from digital technology.
The Advantages of Digital Technology There are many advantages, other than retained quality, that digital brings to the job. Again, rather than spell them all out, not our purpose in this paper, I’ll direct readers to Ten Benefits whose ’10 benefits of Digital technology’3 include compactness, connectivity, speed of process, versatility… up to ten advantages, all of which will be applicable in healthcare and most of which will benefit work processes in the operating theatre. Digital Health Buzz’s ‘Benefits of Digitization in the Healthcare Industry’4 gets more specific, focusing on the automation of administrative tasks and, “Communication between Multiple Physicians”, an application of digital capability that is relevant to surgical procedures. Focusing clearly on the operating theatre, Annals of Translational Medicine5 reports, “The continuing enhancement of the surgical environment in the digital age has led to a number of innovations being highlighted as potential disruptive technologies in the surgical workplace. Augmented reality (AR) and virtual reality (VR) are rapidly becoming increasingly available, accessible and, importantly, affordable... applications are already being investigated for their role in the surgeon’s armamentarium.” However, notwithstanding the advantages of digital technology, as the Nuffield Trust report above explains, “… there is agreement that health care is at least a decade behind other industries in the use of information technology. It may be even further behind in realising the productivity and value improvements that have been seen elsewhere as the result of information
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
Today, 3D is being used in laparoscopic technology.” Further on, the report considers opportunities to drive improvements from the leveraging of technology, including, “Improved access to specialist expertise – I, and those that support me, can access the specialist advice I need, wherever and whenever I need it.”
Digital Technology in Surgery The Cleveland Clinic highlights the possibilities from introducing digital imaging technology into surgical practice. “For years, surgeons have… [depended] on their own eyes and interpretations to execute the most precise of tasks. In these cases, his or her head is down, thereby limiting peripheral vision and communication with staff, while straining his or her back and neck muscles for hours at a time… This past year, two of the most intricate surgical practices, ophthalmology and neurology, have been experimenting with new technology that not only keeps surgeons’ heads up, but also immerses the surgeon into a high resolution, 3D visual representation of their subject.” It does seem that the health sector is waking up, and at an accelerating rate, to the possibilities of using digital technology. MD+DI Online7 predicts, “Hospitals are replacing antiquated surgical spaces with new operating suites to better support outpatient surgery, minimally invasive techniques, and digital and technological innovations. Robotic surgical systems and 6
imaging technologies like surgical navigation systems are projected to become ubiquitous.” Among the many advantages to be gained from employing digital imaging in the operating theatre is that of maximum access and visibility of the operation site with minimum need to open-up the patient. Keyhole surgery is an established part of surgical practice but often surgeons are working with lower visibility of an, often constricted, area. Imaging of any sort will help and the instruments used in keyhole procedures have long had some sort of camera attached in order to assist the surgeon. With digital imaging, it is possible to go one stage further and to generate a 3D image on a larger than life screen. This will greatly assist with not only accuracy of the procedure but also with the quality of the job. In 2014, John Nosta, writing in Forbes8 explained, “Today, 3D is being used in laparoscopic surgery, a technique in which an operation in the abdomen or pelvis is performed through small incisions with the aid of a camera, as close in clarity and depth perception as surgical teams can get without opening the patient. Compared to open surgery, laparoscopic approaches offer reduced pain and haemorrhaging, as well as shorter recovery times and better cosmetic results.” Digital technology is definitely here to stay and its companion, digital imaging, is similarly fast becoming an indispensable support in the operating theatre.
surgery, a technique in which an operation in the abdomen or pelvis is performed through small incisions with the aid of a camera, as close in clarity and depth perception as surgical teams can get without opening the patient
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Equipping the Operating Theatre Camilla Slade, Staff Writer The risk that the quantity of equipment to help the patient will degrade the working environment
It seems logical to group the equipment into categories and try to address the issues separately from each component. However, all these groups of equipment are interconnected and they work in unison and harmony to produce a clear picture
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In the previous article, John Hancock looked at digital technology with a brief view of some applications and at the application of, particularly, digital imaging in the operating theatre. But while the features of the technology are well known, why would any healthcare provider wish to introduce them to their processes?
The Challenge of Maintenance and Troubleshooting It isn’t that operating theatres don’t have everything needed to deliver image guided surgery, as we have already alluded to, but rather it is that the equipment needed, while it might well improve patient outcomes, does not always improve working conditions for the surgical team. With an increasing number of devices and cables, the operating theatre risks becoming a complex array of technology that is hard to maintain. Technicians not only have the task to increase the theatre’s uptime as much as possible, but the maintenance needs to be done efficiently as well. Time spent on technical maintenance cannot be used for surgery. And that complexity can be inflexible as well as the risk that the equipment available might not be exactly what the surgeon needs for the surgery at hand. We have already mentioned the need for surgeons to take their eyes away from the operating site in order to assimilate data from several different sources presented on several different displays. Similarly, with maintenance and troubleshooting, there are challenges that can arise even during a procedure. Some challenges faced in the operating theatre are revealed in Innovative Surgical Sciences9 paper, ‘Technical problems during laparoscopy: a systematic method of troubleshooting for surgeons’ which identifies, “The commonest source of problems when having trouble with laparoscopy equipment seem to be the scope, camera head, light cable, light source, insufflation tube and gas insufflator… It seems logical to group the equipment into categories and try to address the issues
separately from each component. However, all these groups of equipment are interconnected and they work in unison and harmony to produce a clear picture… We suggest a method of troubleshooting laparoscopic tower problems by categorising them into either image quality problems or insufflation problems.” One solution would be to use an IP (Internet Protocol) based video integration platform which will allow an array of inputs to have access to where the surgeon is working without filling the room with equipment and cables. That seems to be the way that the technology is now progressing.
What a Digitised Operating Environment Can Offer Pharma Times ‘Digitising the Operating Room with IP’10 offers a clue. “the NHS’ 2018 Operating Theatres Project Report… found that 13% of patients were having to wait over 18 weeks for surgery - the highest level since January 2009.” Healthcare is a sector under all sorts of pressures including the conventionally contradictory needs for speed (faster turnover of patients through the operating theatre) and quality (always important and the more so in these litigious times). As Pharma Times adds, “With pressure mounting on the health service, the need for greater operational efficiency is paramount and modern technologies promise a powerful solution. From the operating room (OR) and beyond, integrated solutions and IP (internet protocol, referring to methods used to share data between two or more devices) technology promise to streamline operations, transform conventional clinical spaces and subsequently strengthen standards of clinical care.” Forbes magazine 11 explained in 2019, “Surgeons and their teams have to continuously winnow through a clutter of images, vital signs data, and other patient indicators on a number of displays and 2D flat screens scattered across the operating room (OR). This often forces them
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
to look away from the patient and even from their own hands while operating. If we add to this the pin-point accuracy required for aspects like depth of incision, the placement of a screw or implant as well as perfectly locating a deep-seated organ within the patient’s body, the focus suddenly shifts from surgical efficiency to error prevention.” Given that challenge, what solution might be able to address all those factors? The answer is higher quality images placed in the surgeon’s field of work on devices that offer augmented reality and that are connected with other resources on a network. With such a solution the surgeon can work more comfortably and can better navigate around the work area.
Image Guided Surgery The principles of ‘keyhole’ surgery (minimally invasive or endoscopic surgery) were explained in the previous article including how it relies heavily on image guidance. Find A PhD12 describes guided surgical navigation as, “… the same thing as the SatNav in your car, but rather than tracking the position of a car, it tracks the position of surgical tools inserted in the human body.” Further on, the article also explains the advantages of an integrated system, “A surgical navigation system shows pre-operatively scanned medical images of the patient during surgery and
super-imposes a cross-hair on these scans to pin-point the current position of the endoscope.” It is this ability to simultaneously deliver information to the surgeon from more than one source that has marked the big leap forward in surgery. “Image-guided surgery (IGS) is the use of a real-time correlation of the operative field to a preoperative imaging data set that reflects the precise location of a selected surgical instrument to the surrounding anatomic structures.” is how Medscape13 describes the solution. ResearchGate ‘Impact of image-guided surgery on surgeons’ performance: A literature review’14 revealed, “apparent benefits of IGS in terms of patient safety and surgical outcome. Moreover, IGS systems which provide information support seem to shorten surgery duration. The reason for this effect is less clear. It could be, as several studies included in this review show, that IGS improves surgeons’ situation awareness and reduces their workload and stress.” Perhaps we can leave the last word on image guided surgery to Prasanna Vadhana Kannan writing in Imaging Technology News15, “Imageguided surgical systems have revolutionized conventional surgical techniques by providing a precise treatment guidance system that can help ensure the safety of vital structures, while maintaining the best outcome for patients.”
Image-guided surgery (IGS) is the use of a real-time correlation of the operative field to a preoperative imaging data set that reflects the precise location of a selected surgical instrument to the surrounding anatomic structures
It is this ability to simultaneously deliver information to the surgeon from more than one source that has marked the big leap forward in surgery
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Interdependence Helped by Integration Peter Dunwell, Medical Correspondent For successful surgery outcomes, people and technology have to work together and the technology needs to make the work more effective
Imaging is an important part of the assessment which the surgeon will use during the procedure
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In the two preceding articles, we have looked at some of the technology aspects of surgery and work in the operating theatre. But machines, even robots and guidance systems, are no more than tools. At the heart of any surgical procedure are people: the patient on whom the operation is being performed and the team who are carrying out the surgery. The comfort of the team, especially of the surgeon, will impact the way they work.
Human Factors in Surgery As in any aspect of healthcare, in the operating theatre, patient safety is the foremost consideration and it is also a key driver of processes. As BMC explains in ‘Patient safety in surgery’ 16, “The surgical environment must be considered as HRO [High Reliability Organisation], therefore, it demands a high level of standardization and safety processes in place with redundant system to decrease errors and human mistakes.” For surgery, part of that safety consideration is addressed in the pre-operative assessment during which is, as ‘Teach Me Surgery’17 explains, “… an opportunity to identify co-morbidities that may lead to patient complications during the anaesthetic, surgical, or post-operative period.” continuing to add that imaging is an important part of the assessment which the surgeon will use during the procedure. Given the complexity of almost any surgery, it will come as no surprise that stress is a factor affecting performance and outcomes. The American Journal of Surgery18 confirms, “Surgical adverse events persist despite several decades of system-based quality improvement efforts, suggesting the need for alternative strategies. Qualitative studies suggest stress-induced negative intraoperative interpersonal dynamics might contribute to performance errors and undesirable patient outcomes. Understanding the impact of intraoperative stressors may be critical to reducing adverse events and improving outcomes.” The causes of such stress will vary
and are often the same as in any workplace as Europe PMC suggests in ‘Conflicts in operating room: Focus on causes and resolution’19, “The operation theater (OT) environment is the most complex and volatile workplace where two coequal physicians share responsibility of one patient. Difference in information, opinion, values, experience and interests between a surgeon and anesthesiologist may arise while working in high-pressure environments like OT, which may trigger conflict.” Stress in the operating theatre can also derive from factors specific to the equipment. We have mentioned in previous articles the problem of surgeons having to look up from their hands and the operation site in order to view instruments or images, and that can be both physically and mentally stressful. Other human factors would include eye strain and eye fatigue which can often be caused by light quality; as obp20 points out, “One of the most notable effects of poor illumination on surgeons is eye strain and fatigue. Too much lighting is likely to fatigue the surgeon’s eyes and cause glare. Such adverse effects on the visual performance of the surgeon could lead to incorrect assessments and errors. Proper surgical lighting should provide the right amount of illumination and the correct patch size for surgery.” But it isn’t only lighting that can lead to eye strain for surgeons. NVision21 highlights a problem that is very much of our age, “Computer vision syndrome (CVS) is a condition caused by using digital displays – including computer monitors, laptops, tablets, e-readers, and smartphones – for too long without a break, without blinking enough, at an improper distance, or before sleep. Symptoms include dry eyes and headaches, along with other kinds of strain that lead to overall fatigue.” That is something with which every reader will be familiar but add to that the pressure of performing a complex and intricate procedure on the success of which a patient’s welfare depends and you can see how anything that can reduce the strain will be a very positive contribution to good outcomes.
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
Finally, the use of 2D imaging, while helpful, brings its own problems. Sage Journals 22 explains, “Minimally invasive surgery (MIS) poses visual challenges to the surgeons. In MIS, binocular disparity is not freely available for surgeons, who are required to mentally rebuild the 3-dimensional (3D) patient anatomy from a limited number of monoscopic visual cues. The insufficient depth cues from the MIS environment could cause surgeons to misjudge spatial depth, which could lead to performance errors thus jeopardizing patient safety.” In other words, a 3D image will offer a lot more useful image with which a surgeon can work.
Challenges Need Solutions So, we’ve managed to identify a number of challenges to the performance of surgeons and some of those challenges relate to the increasing amounts of equipment used in the operating theatre and the associated infrastructure (cables, connections, etc.) that it needs in order to operate and to deliver a
range of information to the working surgeon. But what might be the solutions that can address those challenges? One new idea that promises much is to apply IP (Internet Protocol) solutions built on the IP network to improve the quality as well as the flexibility of the network. Whereas traditional AV solutions are fairly static and resistant to new video standards, IP solutions are extremely flexible. They require just one universal cable to distribute any audio, video and data signal. As well as simplifying the physical complexity of the operating theatre, IP solutions can facilitate integration of services. Steris Healthcare 23 explains, “An OR Integration System is designed to simplify and streamline the OR by consolidating data, access to video, and controls for all of these devices at a central command station, allowing the surgical staff to perform many of their tasks efficiently without needing to move around the OR. OR Integration also commonly involves suspending monitors and imaging modalities within the OR, removing trip-hazards caused by cabling and allowing for easy access and visibility to surgical video.” Keckler Medical24 sums up, “By putting comprehensive patient data into one efficient platform that works in existing environments and across multiple disciplines, Operating Rooms Audio/Video integration systems can help hospitals around the world lighten the load on surgical teams, improve Hybrid Operating Room workflow and decrease OR downtime.”
Over 70% of nurses surveyed said they preferred syringes where hands and fingers stay behind the needle area when activating the safety mechanism, and where the syringe is permanently disabled after the safety mechanism is activated
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Minimally Invasive: Maximum Organisation John Hancock, Editor To ensure a smooth and efficient surgery process requires a manageable and well-managed operating theatre
3D simulation also makes planning for surgery easier and more accurate. Being able to measure a patient’s soft tissue can help surgeons better understand both the problems they face and how to fix them
Minimally invasive surgery (MIS) is gaining traction in the healthcare sector. British Journal of Family Medicine’s25 reported on Southend University Hospital’s ‘Colin George Laparoscopic Theatre’ where Mr Mike Dworkin, Consultant Surgeon said: “Many of these patients would have previously had to have ‘open’ surgery’ which would have meant longer hospital stays and recovery times, and greater post-operative pain and scarring. The great news for patients is we have now got faster set up times for surgery and quicker change over between cases and have the equipment to carry out on table colonoscopy, which will make cancer surgery more accurate.” But, whereas with open surgery, the surgeon can see the work site in real life, with MIS they have to rely on pre-operative planning and images of the operation area. In the preceding articles we’ve looked at the operating theatre from a human and a technology point of view but all factors need to be managed and improved in order to ensure effectiveness in operating theatres and the work undertaken in them.
Advanced Digital Solutions as Aids to Efficiency and Productivity Efficiency is a very important topic at the top of every healthcare provider’s agenda these days but a more efficient process cannot be traded for quality. BMJ, ‘Improving theatre turnaround time’26 reported, “The NHS Institute for Innovation and Improvement has determined that a £7 million saving can be achieved per trust by improving theatre efficiency. The aim of this quality improvement project was to improve orthopaedic theatre turnaround without compromising the patient safety.” As well as theatre efficiency, it is also possible to improve surgeon efficiency by adding to their armoury in the matter of pre-operative planning; a great asset in that has been the introduction of 3D imaging. As MirrorMe27 explains, “3D simulation also makes planning for surgery easier and more accurate. Being able to measure a patient’s soft 14 | WWW.HOSPITALREPORTS.EU
tissue can help surgeons better understand both the problems they face and how to fix them… Surgeons are now able to better plan surgical procedures, more accurately achieve desired outcomes, and increase trust with their patients.” That works well for planning but the actual procedure will be a more dynamic affair in which the surgeon might well need access to real time images, known as intraoperative images. Science Direct28 explains, “Although diagnostic imaging systems designed for use in diagnosis and treatment planning are often used intraoperatively, the requirements for intraoperative imaging are rather different. Whereas the main requirement for most diagnostic systems is image quality, the overriding requirement for intraoperative imaging is timeliness. Although quality is still important, a perfect image obtained some hours (or even several minutes) after it is taken is not so useful in an operating room setting. Generally, one needs the images to provide sufficient information for positioning an instrument relative to target anatomy or monitoring an interventional process within acceptable latencies that may range from fractions of seconds to a few minutes, depending on the particular task.”
Advanced Digital Solutions as Aids to Accuracy and Quality What will most interest patients is how well the operation deals with their needs. The greater precision with which a surgeon can work, the more effective will be the outcome. MedStar Franklin Square Medical Center29 confirms the efficacy of minimally invasive surgery (MIS), “Minimally invasive surgery also offers a higher accuracy rate compared to traditional open surgery. Accuracy is improved because procedures use a camera, allowing the surgeon to have a better visualization of your internal organs.” Among the issues related to minimally invasive surgery cited by The Hamlyn Centre for Robotic Surgery, Imperial College London30 include, “… the limited field of view; reduced manoeuvrability of the tools; lack of haptic feedback; loss of depth
IMPROVING OPERATING ROOM EFFICIENCY AND THE ROLE OF DIGITAL TECHNOLOGY
perception…” but the paper continues to address how those issues are being overcome with the latest technologies. Technology is definitely the key to optimal precision in MIS whether robot assisted or non-robotic.
The Challenges of Set-Up and Workflow in an Operating Theatre Operating theatres need to be wholly sterile places, whether the preparation and preoperative areas, sterile storage, the anaesthesia and equipment storerooms or the entrances and the exits and especially the operation area and the sterile preparation area. All of this gives rise to a number of challenges for those whose responsibility is the maintenance and setting-up of theatres. This side of running and preparing a theatre is a manual task so anything that simplifies the infrastructure of the facility will not only help to improve the job of those who do the setting up but will also reduce the time needed for setting up, which can have significant financial value – see the BMJ reference at the start of this article. Also, workflows are very important factors in the efficient and timely running of an operating theatre. BMC31 explains, “The design and internal layout of modern operating rooms (OR) are influencing the surgical team’s collaboration and communication,
ergonomics, as well as intraoperative hygiene substantially.” In these days of ever tighter budgets and greater demands, the exploration of ways to improve “how theatre resources and clinical expertise can be best used” is always under way, according to NHS Improvement32. In a similar vein, Annual Symposium Proceedings Archive on NCBI33 clarifies, “Surgeons and other proceduralists are very highly trained professionals; the technology and resources they employ are typically advanced, expensive, and scarce. Optimization of these limited resources is paramount to the safe, effective, and efficient delivery of healthcare.” A great asset in the drive to improve workflow is the arrival of the control room as part of the integrated solution.
Looking Ahead
The design and internal layout of modern operating rooms (OR) are influencing the surgical team’s collaboration and communication, ergonomics, as well as intraoperative hygiene substantially
The technology behind minimally invasive surgery has advance in leaps and bounds in recent years with no sign of let-up. HP in ‘The future of surgery: how technology is transforming the operating room’ suggests that, “In the not-toodistant future, surgeons could use augmented reality to bring multiple streams of information together for surgeons via hologram.” Well that’s in the future but already, today, surgeons have available to them an array of high-quality tools to ensure that their interventions are well-informed and well-managed.
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References: E1 Explain that Stuff www.explainthatstuff.com/analog-and-digital.html
1
2
Nuffield Trust www.nuffieldtrust.org.uk/files/2017-01/delivering-the-benefits-of-digital-technology-web-final.pdf
3
Ten Benefits tenbenefits.com/10-benefits-of-digital-technology/
4
Digital Health Buzz digitalhealthbuzz.com/5-benefits-of-digitization-in-the-healthcare-industry/
5
Annals of Translational Medicine www.ncbi.nlm.nih.gov/pmc/articles/PMC5220044/
6
Cleveland Clinic innovations.clevelandclinic.org/Programs/Top-10-Medical-Innovations/Top-10-for-2017/8-3-D-Visualization-and-Augmented-Reality-for-Sur
7
MD+DI Online www.mddionline.com/digital-health/future-digital-surgery
8
Forbes www.forbes.com/sites/johnnosta/2014/01/15/3d-surgery-now-playing-at-an-operating-room-near-you/#8e6990f7be96
9
Innovative Surgical Sciences www.ncbi.nlm.nih.gov/pmc/articles/PMC6754030/
10
Pharma Times www.pharmatimes.com/web_exclusives/digitising_the_operating_room_with_ip_1316005
11
Forbes www.forbes.com/sites/reenitadas/2019/02/04/the-top-five-digital-health-technologies-in-2019/#43eaae6b6c0f
12
Find A PhD www.findaphd.com/phds/project/augmented-reality-for-image-guided-surgery/?p37300
13
Medscape emedicine.medscape.com/article/875524-overview
14
ResearchGate www.researchgate.net/publication/313403250_Impact_of_image-guided_surgery_on_surgeons’_performance_A_literature_review
15
Imaging Technology News www.itnonline.com/article/image-guided-surgery-tools-facilitate-navigation
16
BMC – Part of Springer Nature pssjournal.biomedcentral.com/articles/10.1186/s13037-015-0067-4
17
Teach Me Surgery teachmesurgery.com/perioperative/preoperative/assessment/
18
The American Journal of Surgery on Elsevier https://bit.ly/3mpGStK
19
Europe PMC europepmc.org/article/PMC/4610095
20
obp Medical obpmedical.com/poor-illumination-impacting-surgeries/
21
NVision www.nvisioncenters.com/conditions/computer-vision-syndrome/
22
Sage Journals journals.sagepub.com/doi/10.1177/1553350616639141
23
Steris www.steris.com/healthcare/knowledge-center/surgical-equipment/integrated-operating-rooms
24
Keckler Medical hybridoperatingroom.com/hybrid-operating-room-audio-video-integrations
25
British Journal of Family Medicine www.bjfm.co.uk/state-of-the-art-operating-theatre-with-near-infrared-technology-launched
26
NCBI/BMJ Quality improvement www.ncbi.nlm.nih.gov/pmc/articles/PMC5306684/
27
Mirror Me https://bit.ly/3e1x3PY
28
Science Direct www.sciencedirect.com/topics/computer-science/intraoperative-imaging
29
Medstar https://bit.ly/3oy0i1y
30
Imperial College London
spiral.imperial.ac.uk/bitstream/10044/1/43798/2/The%20role%20of%20technology%20in%20minimally%20invasive%20surgery_accepted.pdf 31
BMC bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-020-1086-3
32
NHS Improvement improvement.nhs.uk/resources/operating-theatres-opportunities-reduce-waiting-lists/
33
NCBI www.ncbi.nlm.nih.gov/pmc/articles/PMC3540545/
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Notes:
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