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All Hail the High-Def OR
Equipment experts and early adopters help guide you through your HD transition.
Irene Tsikitas
Publish Date: July 13, 2008   |  Tags:   Surgical Video and Imaging

High-definition technology is rapidly becoming the new standard in OR video, offering the best in image quality and clarity. "It's really not a frill anymore," says David Razavi, director of media services at California Pacific Medical Center in San Francisco. "You aren't overdoing it by building an HD suite."

According to an online poll of Outpatient Surgery Magazine readers, about 41 percent of you have installed HD video equipment in either some or all of your ORs, and another 19 percent are planning to do so. Those of you who've already made the leap (known in marketing terms as "early adopters") largely agree with Mr. Razavi, that the benefits of HD video are worth the investment in time and money. Sandy Berreth, RN, BS, MS, CASC, administrator of the Minnesota-based Brainerd Lakes Surgery Center, summed up the advantages with just one word: "Perfection!"

Respondents said the sharper, clearer images — the number one benefit cited by readers — promote better surgical outcomes, case efficiency and patient and surgeon satisfaction. "Everybody really seems to know what's going on in the room" when they're looking at HD images, says Lori Donovan, RN, MSN, CNOR, administrative director of surgical services at Arlington Memorial Hospital in Arlington, Texas. Mr. Razavi says having a clearer view of the surgical field has given some surgeons at his facility the confidence to do more minimally invasive procedures. And HD can be a great marketing tool: "As you have new surgeons coming out of school that you want to draw to your facility and establish their practice there, you've got to have the latest and the greatest, because they're used to that in school," says Joyce Danels, RN, CNOR, director of surgery at Twin Rivers Regional Medical Center in Kennett, Mo.

Purchasing and installing HD systems for the OR isn't as easy as going to Circuit City and buying a new TV for your living room. The technology is much more complex and the equipment is much more expensive. "When you upgrade your OR to high definition, you have to replace every component," says Mr. Razavi.

Nathan Pinkney, senior project engineer in the ECRI Institute's Health Devices Group in Plymouth Meeting, Pa., estimates that it takes at least three months, from the planning stage to the final installation, to outfit one OR with HD video technology. And he estimates that the cost of labor and equipment to outfit one existing OR could range from $25,000 to $50,000. Here's some advice to help you get started.

Anatomy of an HD Video System

Source: the cameras, mounted on surgical lights, scopes or booms, that capture video images from the surgical site.

Resolution: (specified as the number of horizontal and vertical pixels in the camera's charge coupled device) is typically 1920 x 1080, 1280 x 720 or 1280 x 1024. The higher the number of vertical pixels, the sharper the image, but the difference is not evident to the average user.

Distribution: the cabling and routers used to carry video signals from the source to the destination.

  • In an HD system, high-quality coaxial and/or fiber optic cables are used.
  • A video router (not the same as an IT network router), often called a local routing switcher, routes video signals within an OR from user-selected sources to user-selected destinations.

Destination: the monitors that display the video images. There are two main types:

1. Displays used in the surgical field

  • Can be mounted on booms, light hubs or carts.
  • The terms "medical grade" and "hospital grade" refer to safety requirements for use in the surgical field, not image quality.
  • Vertical resolutions of 1024, 1080 or 1200 are considered HD, with little noticeable difference among them.

2. Flat-panel HDTV displays used outside the surgical field

  • Typically mounted on the wall and come in two forms — LCD or plasma.
  • Resolution specified as 1280 x 768 pixels (known as 1080i or 720p) or 1920 x 1080 pixels (1080p or "True HD"). The latter is of a noticeably higher quality.

Nathan Pinkney, BS, RDMS

Mr. Pinkney ([email protected]) is senior project engineer for ECRI Institute's Health Devices Group in Plymouth Meeting, Pa.

Understanding the technology
Many readers cited technological issues as the biggest challenge they faced when making the transition to HD. "Some companies misrepresent themselves with what is true HD," warns Kim Price, RN, clinical administrator at Central Kentucky Surgery Center in Danville, Ky. Another respondent says there are "too many variables ??? you have to become an expert in HD."

Mr. Pinkney agrees that you've got to educate yourself before taking the plunge, but he stops short of saying you have to be an expert. Facilities should be familiar with the most basic components of HD video systems (the sources, distribution channels and displays) and the two main specifications (resolution and aspect ratio), he says. (See "Anatomy of an HD Video System" on the left.)

The greatest point of confusion, according to Mr. Pinkney, is the language manufacturers use to describe resolution. In the surgical setting, it's important to recognize the distinction between HD (a general term used to describe any digital signal with resolution higher than standard definition) and HDTV (a specific term referring to commercial broadcast standards). There is no HD standard for medical video, says Mr. Pinkney, but "all manufacturers claiming to have HD offer cameras with resolution greater than standard definition." The HDTV standard, meanwhile, "may only find a few applications in the OR environment." Two terms to keep in mind:

  • Native resolution. To ensure the quality and integrity of your HD images, manufacturers say your distribution channels and displays should be capable of transmitting and reproducing signals in their "native resolution" — the same dimensions captured by the charge coupled device (CCD) in your HD camera. "Your system's only as good as its weakest link," says John Mayor, marketing manager for Stryker Endoscopy. "You don't want to scale or modify the image in any way" as it travels from its source to its destination, adds Bob Ferguson, vice president of operations at CompView Medical.
  • Aspect ratio. Another key specification is aspect ratio — the ratio of the image's width to its height, calculated by dividing the number of horizontal pixels by the number of vertical pixels. The most common aspect ratios used in the OR are 4:3 (more circular/ square) and 16:9 (widescreen/rectangular). Manufacturers say the widescreen format is ideal for HD video systems, but Mr. Pinkney notes you may need to acquire a mix of equipment with different aspect ratios to accommodate the preferences of multiple surgeons and specialties. If that's the case, he recommends you identify which aspect ratio will be used most frequently (this will largely depend on the cameras used in your facility), and outfit most of your ORs with displays that match.

Finally, experts advise that you plan ahead for future technology advances. "It's very likely that improved distribution components are going to be available" in the near future, says Mr. Pinkney. He suggests you run additional cable plus a more advanced router that's capable of multiple formats "to handle present as well as future needs."

"Don't look at your immediate needs," agrees Mr. Razavi, who recommends installing extra auxiliary inputs. "Look at your wildest dream and multiply that times three."

If all the technical terminology makes your head spin, you're not alone. Several readers suggest seeking outside help. "Use a qualified consultant to work with you in determining your needs now and in the future," says Jeff McKune, BBA, MHA, director of the ambulatory surgery unit at Phelps County Regional Medical Center in Rolla, Mo.

Benefits of HD

What's the single greatest benefit of having HD cameras and displays in your ORs? Here are our survey respondents' most common answers:

  • image quality
  • surgeon satisfaction
  • patient safety
  • faster cases
  • smaller video screens
  • staff can better follow procedures

Justifying the cost
Although prices are going down, nearly half of survey respondents (49 percent) said cost was the biggest challenge they faced when switching to HD. Other frequently cited challenges included getting surgeons to agree on a vendor (18 percent) and specific equipment concerns such as getting a "true HD" signal and installing the right kinds of cables and routers (6 percent). Here's advice for overcoming the cost factor.

  • Buy one piece at a time. Mr. Pinkney and several readers suggest you start by purchasing HD cameras when your old ones need replacing (they now cost about the same as SD cameras) and upgrade the rest of the equipment as your budget allows. If you take that route, be sure the cameras you purchase have both SD and HD capabilities.

One drawback to buying in pieces: You run the risk of having your physicians grumble over who gets to work in the rooms with the best equipment. "To not have HD availability on all your video equipment leads to unfavorable comparisons and surgeon dissatisfaction," warns Elaine C. Jones, RN, CNOR, BS, director of surgery and perioperative services at St. Elizabeth's Hospital in Youngstown, Ohio.

  • Assess your needs. Not every facility needs (or has the budget for) a large-scale HD transformation. OR Director Colleen Canfield, RN, BSN, CNOR, decided to stick with a standard-definition slave monitor for her HD-equipped OR at Washington-based Quincy Valley Medical Center, a move that saved her $5,000. "The person who really needs to see the detail is the surgeon who's doing the surgery," explains Ms. Canfield. She also purchased a smaller HD monitor than the manufacturer originally suggested.

Boston Out-Patient Surgical Suites Administrator Gregory P. DeConciliis, PA-C, CASC, recommends getting your surgeons involved in the decision-making process. "In some specialties, the analog quality may be just as good as the HD," he says, "and therefore they may be able to wait to purchase the units until the technology further improves."

  • Consider financing alternatives. You can save money by leasing instead of purchasing HD equipment, says Jon Lewis, RN, director of ASC administrative operations at St. Mary's Dean Ventures in Madison, Wis. His facility's leasing arrangement lets it trade its current analog equipment for credit toward HD devices; eliminates the upfront capital costs associated with HD purchases; and allows it to purchase the equipment or upgrade it when the lease is up, says Mr. Lewis.
  • Demonstrate the value. It makes good business sense to upgrade to HD when you're purchasing new equipment, says Ms. Danels; otherwise "you're going back in time, not forward." But the decision-makers might not see it that way at first.

Mr. Lewis convinced his facility's board of directors by bringing them in for a demonstration of the difference between digital and analog signals used during a procedure. "It is without a doubt an eye-opening experience," remarks Carolyn McKee, RN, CNOR, bariatric program coordinator at Clark Memorial Hospital in Jeffersonville, Ind., who enlisted her surgeons' help to show the benefits of HD to the hospital executives.

Reader Survey

Do you have high-definition video systems installed in ___________ :

Response

Percent

some of your ORs

21.1%

all of your ORs

20.2%

none of your ORs, but you're in the process of purchasing and installing HD video systems

19.3%

none of your ORs, and you're not planning to install HD

39.4%

SOURCE: Outpatient Surgery Magazine Reader Survey, June 2008, n=109

Finding the right vendor
Cost shouldn't be the only factor driving your purchasing decisions. A number of readers stressed the importance of good, reliable service contracts to go with your HD equipment. "The system is as good as the representative that supports it," says Ms. McKee. "Be sure to negotiate for extended on-site vendor assistance in your purchase contract," adds Teresa Lute, RN, CNOR, perioperative clinical educator at Southern Ohio Medical Center in Portsmouth, Ohio. But read the fine print, warns David Kurowski, video product manager at Richard Wolf Medical; some warranties and service contracts cover only "manufacturer defects," while others cover any problems you may encounter, no questions asked.

Mr. Pinkney notes that you don't have to purchase all your video equipment from a single source. Do side-by-side comparisons of HD systems offered by the various manufacturers, says Evan Krachman, Sony Medical's marketing manager for surgery products. Darlene Cook, RN, CNOR, CRNFA, manager of surgical services at Wuestoff Medical Center in Melbourne, Fla., recommends a background check: "Evaluate several different vendors. Ask for a list of places that use their system and call them for their opinions of the service and quality of the video system."

Clearing HD Hurdles

What challenges are you likely to face when purchasing and installing an HD video system? Here's a sampling of responses from our survey:

  • Cost. Not surprisingly, this was far and away the top concern. It's estimated to cost $25,000 to $50,000 to outfit one OR. "We need to prove that it will pay for itself with the number of (additional) procedures we can do with it," says an OR manager.
  • Trialing. Arranging for all your surgeons to trial HD systems is no easy feat. "The biggest challenge was getting the vendors to cooperate in the timing of the trials and the length of the trials," says a survey respondent, "and getting the physicians to not make up their minds until all the trials are completed." "If the reps want your business, they will allow a trial period. See if you can get it for a month or two," offers another respondent. One offered this tip: Have all interested vendors come in for a video fair for the surgeons. Then have surgeons vote and the two systems with the most votes bring their equipment in for trial at different times.
  • Equipping all rooms. Watch out for HD envy, which is what happens when some ORs have HD and some do not. How do you decide which surgeons get the updated equipment? Staff may like standardization for efficiency, some say. However, in some specialties the analog quality may be just as good as HD, others say.
  • Information overload. One flustered respondent said, "You have to become an expert in HD." Perhaps she'd have been better off following this reader's lead: "We really did not encounter any challenges because we also contracted to have a full-time tech to take care of the equipment."

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