Wired for Success


High-tech ORs produce efficient procedures that yield better outcomes for patients and safer environments for surgical teams.

In her 24 years as a nurse at Penn Medicine, Connie Croce has seen the evolution from open to laparoscopic to robotic surgery. About 10 years ago, the Philadelphia-based health system’s Penn Presbyterian ASC got a high-tech connection system whose touchscreen allows a circulating nurse to control an operating room’s boom and camera box, as well as place multiple images on wall-mounted 72-inch screens for the entire perioperative team to see.

In its simplest form, the concept of an integrated operating room means all devices and other technical components of the OR environment can be connected into one operating system and controlled from a single console. These wired ORs are works of wonder that transform how surgery is performed. “It’s amazing,” says Ms. Croce, RN, BSN, CNOR. “Procedures are more precise and efficient and the surgical environment is safer for the staff.”

Operating smarter

An integrated system has multiple benefits. Some surgeons watch the screens as they operate after the instruments are inserted into tiny laparoscopic incision holes. Surgeons also often want to see the CT scan and leave it up on the field while they operate.

“That’s all through the integration system,” says Ally Silver, FACHE, MPH, assistant vice president of surgical service operations at Stony Brook Medicine in Long Island, N.Y. “They’re looking at multiple screens in real time to help them navigate.”

The hardware and software in the integration systems allow all components of a surgery to be shown on two large wall screens. There is usually a third monitor at the field as well. One member of the OR team, generally the circulating nurse, decides which image will be shown on which screen for specific members of the OR team to see and use.

“Basically you’re using all the inputs such as old X-rays or imaging scans, current video or new images from a surgical scope or a robot in real time, so it can all be put together to get a sense of what’s going on in the room, even if you’re not at the field,” says Ms. Silver.

High-tech efficiencies and time savings

Nonintegrated ORs are less efficient, more clumsy systems that exclude other members of the perioperative team by not allowing them to watch the procedure as it’s happening. If a low-tech OR has a lone small screen facing the surgeon, an anesthesiologist won’t be able to begin removing a tube from a patient because they can’t see when the surgeon is nearly done with their work.

The same applies to the circulating nurse, says Ms. Silver, whose job is to essentially stay one step ahead of the surgeon. That’s harder to do when the field isn’t in front of circulators, and there are no huge wall screens that allow them to know exactly what stage of the surgery is taking place.

“There are multiple eyes looking at the procedure on the screen, so there are more opportunities for a team member to see something that may be unusual and let the surgeon know about it,” adds Ms. Croce. This heightened situational awareness for everyone in the room leads to better communication among staff and, by extension, better outcomes for patients.

Booms and lights

Most integration systems come with a fair amount of equipment booms that keep the laparoscopic towers, electrocautery devices, insufflators, RFID scanners and other devices off the floor and off additional towers. This setup makes it easier to clean rooms and set them up again, because fewer things need to be pushed to the side or removed from the room before inside-out cleaning can begin, says Ms. Silver. Equipment and anesthesia booms also centralize where all the cords are located, keeping them closer to the field and off the floor because they don’t need to be plugged into wall outlets.

Ms. Croce suggests facilities that are expanding or starting a new construction project consult with circulators, scrub techs and other surgical team members before deciding on the spot where the booms should come out of the ceiling.

“You can swing them, but they only go so far, which could be sufficient for some procedures and suboptimal for others,” she says. “Don’t build a new room based on the idea that it will always be used for arthroscopic shoulders, for example. For your facility to be as efficient as possible, you need to be able to use every room for every type of case that you perform.”

Safety and education

ONE-TOUCH CONTROL Touchscreen interfaces allow circulators to control multiple stored and live images so the entire surgical team can see them on large wall-mounted screens in real time.

The lack of cords on the floor makes for safer working conditions for staff, while the precise cuts surgeons can make from viewing multiple data points on the large screens results in safer procedures. “It’s definitely a safer environment for the OR team to be moving around, especially because some procedures are done in the dark or with dimmed or ambient lighting, depending on the surgeon’s preference,” says Ms. Croce. “The circulator and others are moving about, so there’s always a high chance of a trip-and-fall injury with multiple cords on the floor.”

Some portable ENT navigation systems have a small monitor at a fixed height that allows surgeons to perform their procedures more ergonomically and reduce their fatigue levels. Ms. Silver notes that viewing high-quality images on the large wall screens is also helpful, and that many setups are customizable and adjustable to how high and where in the room each surgeon wants them.

“Many integration systems include built-in surgeon profiles, so with the touch of a button, a circulator can control the lights, how the images will be set up, and where certain items go based on each of their preferences,” says Ms. Silver.

The large monitors allow medical students to stand on the outskirts of the room — safely outside of the sterile space — and watch the surgery on giant wall-mounted screens.

The integrated systems can also record video and images, which is a plus on multiple fronts. It allows surgeons to refer to saved media if they are working on the same patient in the future, or need to make a referral to another physician.

“The teaching aspect has increased tremendously,” says Ms. Croce. “You can teach in the room and you can conference out to a full room of physicians, or you can record the procedure and use that in a lecture later.” Stony Brook, which has a 22-OR hospital and a 10-OR ASC, uses some of the recordings to show loved ones of patients what’s happening with their relative’s procedure on a tablet as they wait, notes Ms. Silver.

Some systems can be used as “Zoom in a room” to communicate with the pathology department during the surgery in real time if a surgeon has questions about an image of a tumor.

Integration systems can also incorporate tools for monitoring residents and testing their competencies by using artificial intelligence to capture whether they performed the correct steps in the correct sequence while using proper techniques.

Hierarchy of needs

Imaging is the most basic component of surgical cases that should be inputted to an integration system, as pulling images up in the middle of the cases is common because surgeons can’t see radiology images on a side computer in ORs that are outside of the sterile field.

Other valuable system components include the ability to add surgeon profiles and or put information into patients’ electronic health records. Ms. Croce notes that facilities adopting new integration systems should research which EHRs are used the most in their region and make sure their OR teams will be able to communicate with those systems.

These systems can even bolster safety procedures. For instance, Stony Brook posts its surgical time out checklist on one of the large screens before each procedure.

Finally, advanced applications of integrated systems include surgical planning and mapping software. Some facilities collect data for macro purposes, with hopes of collecting information about enough procedures to determine what techniques and devices could drive innovation and improve future surgeries.

Integration systems should be modular- and modality-neutral, so anything that’s purchased in the future can simply be inputted and plugged into your existing infrastructure. Ms. Silver recommends planning for growth when building cable and data capacity into ceilings. “That will give you flexibility in the future so, as technology evolves, you’ll be able to plug in a new microscope, for example,” she says.

Both Ms. Silver and Ms. Croce recommend standardizing the setups of all ORs rather than making specialized rooms. Vendors of integration systems offer 3D tours of their products that allow you to see what the rooms will look and feel like when you’re in them. “Not committing to a room setup will ensure that you’re not stuck when larger equipment such as robots shift to ASCs,” says Ms. Silver. OSM

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