Wired ORs Are Works of Wonder

Marc Dean, MD, a board-certified otolaryngologist who practices at Ear and Sinus Institute in Fort Worth, Texas, integrated his facility’s procedure and clinical space with a system that utilizes a video over IP solution to give him comprehensive access to clinical information from the surgical table, exam rooms and his office. His move to integrate all aspects of his practice coincided with the shift of more complex ENT cases to office-based and outpatient settings and the onset of the pandemic when additional precautions added a level of difficulty to providing safe elective surgical care. Dr. Dean doubled down on his plans to integrate his clinical space, which now serves as an office-based procedure area. “I get more use out of my integrated suite than most facilities because I’m using it on a daily basis to assess and treat patients,” says Dr. Dean.

His original platform included about half of the capabilities with which he’s currently working. The system he uses is modular and modality neutral, a key design feature, so he’s been able to scale it up without needing to change the core set-up. “Flexibility is the essential benefit of working with an integrated OR,” he says. “Connections are built into the infrastructure that aren’t dependent on physical space to display or access information.”

Using a touchscreen interface, Dr. Dean can toggle between views of the surgical endoscope and a surgical navigation system as well as the patient’s pre-op CT scans, vital signs, nerve monitoring and other diagnostic tests on a wall-mounted 55-inch surgical monitor. Many procedures are performed under local anesthesia with the patient awake, so the room is also equipped with a smaller monitor he can position so patients can watch the progress of their own surgery.

The ENT navigation system he uses features a small monitor positioned at a fixed height atop a mobile cart. Dr. Dean is six feet, three inches tall, so he’d be forced to look down at the monitor while operating if he weren’t able to route the image to the large flat screen monitor on the OR wall. “The number one benefit is that I don’t have to move while operating,” he says. “Having all the information in front of me on a single screen is an ergonomic way to work. I’m able to operate more effectively and efficiently and my muscles don’t fatigue as quickly, which is important during long procedures.”

His ability to work off a single monitor also leads to safer surgery. Preventing even the slightest shift of the head to look at an image guidance platform or the patient’s clinical data during sinus surgery, when Dr. Dean is operating within millimeters of the orbital and cranial cavities, is critical.

Dr. Ross points out that mounting video monitors and surgical equipment on booms around the sterile field frees up valuable floor space and gives members of the surgical team plenty of room to move freely about the patient, making for a safer environment.

Integration adds a great deal of predictability to surgery, which many surgeons prefer.
— Dr. Marc Dean

Robotic surgery has moved surgeons away from the bedside, forcing them to rely on members of the surgical team at the sterile field to relay critical clinical information. “Having that information displayed on screens that can be positioned in the direct line of sight of surgeons enhances their understanding of the case and improves their level of communication with the other members of the team,” says Dr. Ross. “Seeing the patient’s blood pressure in real time or pre-op CT scans and preoperative test results while you’re operating leads to safer and more effective surgery.”

Surgeons can speak with members of the team through a wireless intercom system, points out Dr. Ross, allowing them to troubleshoot issues or ask important questions without lifting their head from the robot console.

OR integration allows physicians to add technology or features without changing how they operate. “I can adapt to a new way of doing things, but I need time to get used to something that alters my workflow,” says Dr. Dean. “If I can work with a single monitor positioned the same way every time, that’s one less thing I need to worry about. Integration adds a great deal of predictability to surgery, which many surgeons prefer.”

When the surgeon operates with a surgical microscope, the rest of the team is unable to monitor the action, prepare for the next step of the case or record the procedure for future reference. “When the images captured by the microscope are projected onto a large monitor, team members can follow along and ask questions about the procedure,” says Dr. Dean. “As surgeons, we’re often primarily focused on the surgical field. Having a talented and dedicated team in place that can monitor the progress of surgery facilitates a more efficient and productive environment.”

Dr. Dean works with the same scrub tech, circulator and anesthesia provider during every case. “They can see what’s going on and prepare instruments or medications before I ask for them,” he says.

At first, Dr. Dean used his integration platform only to route endoscope images to the large monitor hung on the OR wall. He then realized he could easily send video and clinical information throughout his practice, using the touchscreen interface to broadcast to any screen in the facility. “Each monitor in the facility becomes a window into whatever digital output I have,” says Dr. Dean.

One of the first lessons he learned in medical school was that he has 10 minutes to walk into an exam room and make the patient feel comfortable enough to gain their trust and have confidence in his abilities to treat their ailment. His integrated practice helps here, too. Instead of presenting clinical information on several platforms, Dr. Dean can send what he wants to share with patients to a single screen. He can pull in visual aids, videos of past procedures, images of the patient’s anatomy and clinical studies to support the points he’s making and emphasize the importance of complying with the care plan.

Dr. Dean placed pan-tilt-zoom cameras in the OR and every exam room to record what happens during clinic appointments with patients without having another staff member present to witness the interactions, a necessity from a medico-legal perspective. It also helps him conduct more productive assessments of patients. “Patients are more willing to openly share the information I need when it’s just us talking,” he points out. He can also monitor the OR being set up for the next case from his office and arrive just in time to operate. Those extra few minutes allow him to be more productive between procedures.

During the pandemic, family members couldn’t come into the facility with their loved ones to offer important support before and after surgery. Dr. Dean has been able to FaceTime with family members and project their phone image onto the large screen in the OR so they can talk with the patient. “We’ve all learned to live remotely over the past couple years,” says Dr. Dean. “The integration technology allows me to provide the same quality of care by creating a welcoming environment even without a physical presence.”

Dr. Dean also came up with a reverse telemedicine concept to continue caring for patients during the pandemic. Patients would come into the clinic and a single staff member who was masked and vaccinated checked them in and hooked them up to diagnostic testing equipment. He and other members of the care team would use the integrated camera and monitor set-up to interact with the patient remotely from another exam room. “Fewer people touched the patient,” says Dr. Dean. “The pandemic reminded us that sick patients get sicker. We did our best to protect patients and have continued that practice for immunocompromised individuals.”

Many patients appreciate receiving a video recording of their procedure, especially as health care is becoming more transparent. “The recording provides documentation of what happened in the OR,” says Dr. Dean. “It makes them feel like they’re more involved in their own care and that they have access to the record of their case. And as a surgeon, I appreciate the opportunity to show that I was able to deliver on what was promised.”

Integrated ORs have the potential to take surgical education to the next level, according to Dr. Ross. She’s working on a video-based assessment and education project for SAGES, exploring how to process the information and videos captured during operations, break them down into individual critical steps and use artificial intelligence to improve outcomes of specific procedures. The goal is to assess outcomes based on factors such as the length of the procedure, surgical technique used by the surgeon, the patient’s overall health and complications. “Researchers can look back at each step of the operation to determine what, if anything, the surgeon could have done to achieve a better result,” says Dr. Ross.

The lessons could be used to coach the physician who performs an individual procedure, but also other surgeons when the results are analyzed in aggregate. “The data capture marries elements of surgery with outcomes with the aim of developing a standardized approach to surgery that achieves best outcomes,” says Dr. Ross.

Facilities with integrated ORs will be able to compare the outcomes of individual surgeons and review the supplies, instruments and techniques they used to determine the best approaches for specific surgeries, according to Dr. Ross. “Leadership could then approach other surgeons to see if they can incorporate some of the practices into their surgical routines,” she says. “Embracing quality and innovation is when technology becomes invaluable.”

The integrated system Dr. Dean uses features a 24-terabyte server, allowing him to catalogue a library of case videos, which he can access remotely through a secure web-based portal from his home or office instead of needing to keep track of numerous encrypted USB drives. Rewatching his past cases makes him a better surgeon and teacher of innovative surgical techniques. “The remote access is more than simple convenience,” he says. “I wouldn’t watch as many videos as I do now if I couldn’t get to them online.”

Seamless connectivity among the various components of a high-tech OR allows for the downloading, storing and reporting of outcomes data. “Integration improves surgical care,” says Dr. Dean. “If you extend the technology beyond the clinical space, it becomes that much more powerful.” OSM