An evaluation of perioperative communication in the operating room

Communication failures can lead to sentinel events in the operating room. Knowledge of basic surgical steps is important for all team members to ensure work flow efficiency. Surgeons and non-surgeons were surveyed to determine perceived and actual quality of communication between team members, using knowledge of surgical steps as a marker of communication quality. Participants agreed that communication was important, but non-surgeons were unable to name the four key steps of a laparoscopic cholecystectomy (p = 5.0E-07), indicating poor communication between surgeons and non-surgeons.

[Intelligent operating room suite : From passive medical devices to the self-thinking cognitive surgical assistant]

Modern operating room (OR) suites are mostly digitally connected but until now the primary focus was on the presentation, transfer and distribution of images. Device information and processes within the operating theaters are barely considered. Cognitive assistance systems have triggered a fundamental rethinking in the automotive industry as well as in logistics. In principle, tasks in the OR, some of which are highly repetitive, also have great potential to be supported by automated cognitive assistance via a self-thinking system. This includes the coordination of the entire workflow in the perioperative process in both the operating theater and the whole hospital. With corresponding data from hospital information systems, medical devices and appropriate models of the surgical process, intelligent systems could optimize the workflow in the operating theater in the near future and support the surgeon. Preliminary results on the use of device information and automatically controlled OR suites are already available. Such systems include, for example the guidance of laparoscopic camera systems. Nevertheless, cognitive assistance systems that make use of knowledge about patients, processes and other pieces of information to improve surgical treatment are not yet available in the clinical routine but are urgently needed in order to automatically assist the surgeon in situation-related activities and thus substantially improve patient care.

Advanced Visualization Platform for Surgical Operating Room Coordination: Distributed Video Board System

One of the major challenges for day-of-surgery operating room coordination is accurate and timely situation awareness. Distributed and secure real-time status information is key to addressing these challenges. This article reports on the design and implementation of a passive status monitoring system in a 19-room surgical suite of a major academic medical center. Key design requirements considered included integrated real-time operating room status display, access control, security, and network impact. The system used live operating room video images and patient vital signs obtained through monitors to automatically update events and operating room status. Images were presented on a “need-to-know” basis, and access was controlled by identification badge authorization. The system delivered reliable real-time operating room images and status with acceptable network impact. Operating room status was visualized at 4 separate locations and was used continuously by clinicians and operating room service providers to coordinate operating room activities.

Auto Identification Technology and Its Impact on Patient Safety in the Operating Room of the Future

Automatic identification technologies, such as bar coding and radio frequency identification, are ubiquitous in everyday life but virtually nonexistent in the operating room. User expectations, based on everyday experience with automatic identification technologies, have generated much anticipation that these systems will improve readiness, workflow, and safety in the operating room, with minimal training requirements. We report, in narrative form, a multi-year experience with various automatic identification technologies in the Operating Room of the Future Project at Massachusetts General Hospital. In each case, the additional human labor required to make these `labor-saving' technologies function in the medical environment has proved to be their undoing. We conclude that while automatic identification technologies show promise, significant barriers to realizing their potential still exist. Nevertheless, overcoming these obstacles is necessary if the vision of an operating room of the future in which all processes are monitored, controlled, and optimized is to be achieved.

A Study on the Effect on Scheduling and Management of Surgeries with the Introduction of Excellent Medical Information

The services of OR play an important role in the medical business for department of surgery. The most important issue for OR is about the scheduling and management of surgeries. Good surgery schedule could elevate the utilization efficiency of OR. Therefore, the introduction of excellent medical information can both dramatically elevate the work efficiency of health care employees and reduce workload to reach win-win benefits in both management and performance.

Managing uncertainties in the surgical scheduling

Current surgical scheduling system has difficulties to handle unpredictable events or uncertainties. Source of uncertainties may come from the patient or the surgery itself, where several cases require immediate changes in data, such as when surgery delays or cancellation occurs on the same day. The study aimed to model the uncertainties for managing identified uncertainties during the continuous scheduling, framed by resilience concept to cope with the system fragility. In order to be able to control and adjust any changes which may affect the surgery schedule of the day, we provide alternatives of solution rather than strictly decide the best valued options. We identified dimensions of uncertainties and categorized them based on the resilience concept, computed the impact value of potentially conflicted resources as a result of schedule change. With the model applied, we would provide a list of most acceptable and less vulnerable alternatives for anesthesiologist as a scheduler to build resilience in the surgical scheduling.

Time-motion analysis of clinical nursing documentation during implementation of an electronic operating room management system for ophthalmic surgery

Efficiency and quality of documentation are critical in surgical settings because operating rooms are a major source of revenue, and because adverse events may have enormous consequences. Electronic health records (EHRs) have potential to impact surgical volume, quality, and documentation time. Ophthalmology is an ideal domain to examine these issues because procedures are high-throughput and demand efficient documentation. This time-motion study examines nursing documentation during implementation of an EHR operating room management system in an ophthalmology department. Key findings are: (1) EHR nursing documentation time was significantly worse during early implementation, but improved to a level near but slightly worse than paper baseline, (2) Mean documentation time varied significantly among nurses during early implementation, and (3) There was no decrease in operating room turnover time or surgical volume after implementation. These findings have important implications for ambulatory surgery departments planning EHR implementation, and for research in system design.

Automated notification of suspected obstructive sleep apnea patients to the perioperative respiratory therapist: a pilot study

BACKGROUND

Obstructive sleep apnea (OSA) increases the risk of central and obstructive apneas after anesthesia, but the vast majority of patients with OSA are undiagnosed preoperatively. Current guidelines promote the use of postoperative continuous positive airway pressure (CPAP) in patients with OSA. Owing to the complex postoperative requirements of these patients, respiratory therapists (RTs) could substantially improve these patients' clinical management in the immediate postoperative period. We describe a system that identifies patients with suspected or documented OSA and automatically alerts the perioperative RT.

METHODS

Patients who presented for surgery were preoperatively assessed, and if the patient had a diagnosis of OSA or OSA risk factors, the perioperative RT automatically received a paging alert, after the surgery. The RT reviewed the patient postoperatively and instituted CPAP or bi-level positive airway pressure (BiPAP), as indicated. We collected data on triggers for the automated alerts and utilization of CPAP and BiPAP. We reviewed risk-management data to analyze the effect of this intervention on postsurgical sudden-onset acute respiratory compromise.

RESULTS

Of 7,422 patients who presented for surgery over a 5-month period, 766 had an OSA diagnosis or OSA risk factors. There were an average of 7-8 alerts per work day (range 2-18 alerts per day). On average, 2 patients per day were treated with CPAP/BiPAP in the post-anesthesia care unit or the postoperative general ward as a result of the alerts. The median paging alert time was 10:30 am. There were no episodes of sudden-onset postoperative acute respiratory compromise after institution of the OSA alert system.

CONCLUSIONS

As part of a hospital-wide postoperative policy, our automated OSA alert and perioperative RT system helped prevent sudden-onset acute respiratory compromise in postoperative patients with OSA or at risk of OSA.

How to implement information technology in the operating room and the intensive care unit

The number of operating rooms and intensive care units looking for a data management system to perform their increasingly complex tasks is rising. Although at this time only a minority is computerized, within the next few years many centres will start implementing information technology. The transition towards a computerized system is a major venture, which will have a major impact on workflow. This chapter reviews the present literature. Published papers on this subject are predominantly single- or multi-centre implementation reports. The general principles that should guide such a process are described. For healthcare institutions or individual practitioners that plan to undertake this venture, the implementation process is described in a practical, nine-step overview.

Visualizing patient trajectories on wall-mounted boards - information security challenges

Since operating room departments are among the costliest resources at a hospital, much attention is devoted to maximize their utilization. Operating room activities are however notoriously hard to plan in advance. This has to do with the unpredictable, problem-solving nature of the work and that the work is carried out by a multidisciplinary team of health personnel, members of which also have commitments outside the operating room department. We assume that operating room teams have the capacity to coordinate themselves and that coordination might be facilitated by visualizing relevant information on wall-mounted boards. To characterize clinical situations that require coordination and re-planning of the teams' work, we have developed a realistic scenario. We analyse and discuss the information security challenges that follow from displaying information on the whereabouts of other teams, actors and patients on wall-mounted boards in the operating rooms. Information security threats could be mitigated by de-identification techniques. Information demands could thereby be met without sacrificing the privacy of those whose information is displayed.

[Development of operation patient security detection system]

This paper describes a patient security detection system developed with two dimensional bar codes, wireless communication and removal storage technique. Based on the system, nurses and correlative personnel check code wait operation patient to prevent the defaults. The tests show the system is effective. Its objectivity and currency are more scientific and sophisticated than current traditional method in domestic hospital.

Operating Room Managerial Decision-Making on the Day of Surgery With and Without Computer Recommendations and Status Displays

BACKGROUND

There are three basic types of decision aids to facilitate operating room (OR) management decision-making on the day of surgery. Decision makers can rely on passive status displays (e.g., big screens or whiteboards), active status displays (e.g., text pager notification), and/or command displays (e.g., text recommendations about what to do).

METHODS

Anesthesiologists, OR nurses, and housekeepers were given nine simulated scenarios (vignettes) involving multiple ORs to study their decision-making. Participants were randomized to one of four groups, all with an updated paper OR schedule: with/without command display and with/without passive status display.

RESULTS

Participants making decisions without command displays performed no better than random chance in terms of increasing the predictability of work hours, reducing over-utilized OR time, and increasing OR efficiency. Status displays had no effect on these end-points, whereas command displays improved the quality of decisions. In the scenarios for which the command displays provided recommendations that adversely affected safety, participants appropriately ignored advice.

CONCLUSIONS

Anesthesia providers and nursing staff made decisions that increased clinical work per unit time in each OR, even when doing so resulted in an increase in over-utilized OR time, higher staffing costs, unpredictable work hours, and/or mandatory overtime. Organizational culture and socialization during clinical training may be a cause. Command displays showed promise in mitigating this tendency. Additional investigations are in our companion paper.

Clinical Dashboards

There is a vast array of technical data that is continuously generated within the intensive care unit environment. In addition to physiological monitors, there is information being captured by the ventilator, intravenous infusion pumps, medication dispensing units, and even the patient's bed. The ability to retrieve and synchronize data is essential for both clinical documentation and real-time problem solving for individual patients and the intensive care unit population as a whole. Technical advances that permit the integration of all relevant data into a singular display or "dashboard" may improve staff efficiency, accelerate decisions, streamline workflow processes, and reduce oversights and errors in clinical practice. Critical care nurses must coordinate all aspects of care for one or more patients. Clinical data are constantly being retrieved, documented, analyzed, and communicated to others, all within the daily routine of nursing care. In addition, many bedside monitors and devices have alarms systems that must be evaluated throughout the workday, and actions taken on the basis of the patient's condition and other data. It is obvious that the complexity within such care processes presents many potential opportunities for overlooking important details. The capability to systematically and logically link physiological monitors and other selected data sets into a cohesive dashboard system holds tremendous promise for improving care quality, patient safety, and clinical outcomes in the intensive care unit.

Usability factors in the organization and display of disparate information sources in the operative environment

The integration and presentation of information from a number of disparate sources in the operative environment raises a number of usability and human factors challenges. Through a collaborative effort, a display combining persistent and dynamically switching panes provides a rich source of information to help orient team members, provide indications of case progress, and organize information into stage-based tabbed panes. This provides maximal flexibility within visibility and usability constraints.

Integration of hospital information systems, operative and peri-operative information systems, and operative equipment into a single information display

The integration of disparate information systems in the operative environment allows access to information that is typically unseen or unused. Through a collaborative effort, a variety of information systems and surgical equipment are being integrated. This provides improved context-sensitive information display and decision support and improved access to information to improve workflow, safety and visualization of information that was previously unattainable.

Improving operating room coordination: communication pattern assessment

OBJECTIVE

To capture communication patterns in operating room (OR) management to characterize the information needs of OR coordination.

BACKGROUND

Technological applications can be used to change system processes to improve communication and information access, thereby decreasing errors and adverse events. The successful design of such applications relies on an understanding of communication patterns among healthcare professionals.

METHODS

Charge nurse communication was observed and documented at four OR suites at three tertiary hospitals. The data collection tool allowed rapid coding of communication patterns in terms of duration, mode, target person, and the purpose of each communication episode.

RESULTS

Most (69.24%) of the 2074 communication episodes observed occurred face to face. Coordinating equipment was the most frequently occurring purpose of communication (38.7%) in all suites. The frequency of other purposes in decreasing order were coordinating patient preparedness (25.7%), staffing (18.8%), room assignment (10.7%), and scheduling and rescheduling surgery (6.2%).

CONCLUSION

The results of this study suggest that automating aspects of preparing patients for surgery and surgical equipment management has the potential to reduce information exchange, decreasing interruptions to clinicians and diminishing the possibility of adverse events in the clinical setting.

Scheduling of elective surgical cases within allocated block-times: can the future be drawn from the experience of the past?

We determined a strategy to regulate the elective occupation of operating rooms; it was based on the determination of a median operating room occupation time, per procedure and per operator.

METHODS

Median occupation times were determined from a retrospective analysis of 12 consecutive months of operating activity (966 patients). These data were prospectively used in surgical planning, with a daily occupation limit set at 10 hours. After four months collecting data, daily recorded (ROT) and predicted (POT) occupation times were compared. The surgical activity during that test period (group A) was compared to the activity of the same period in the previous year (group B) and the evolution of the waiting lists for surgery were analysed for each of the operators.

RESULTS

At the end of the four-month observation period, 317 surgical cases spread over 105 operating days were recorded. The correlation between ROT and POT was strong (r = 0.911, p < 0.001). The relative error in this prediction was 13 +/- 11 min. In comparison with group B, group A was characterized by a significant reduction in occurrence (p = 0.015) and duration (p = 0.007) of time limit overruns and in variability of daily occupation time (p < 0.001). The waiting list was reduced for all operators at the end of the test period.

CONCLUSION

Determination of individualized median occupation times, associated with definition of a daily limit, resulted in reduction of time overruns and delays before surgery.

Process-optimized operating room: implementation of an integrated OR system into clinical routine

The surgeon's working environment has changed continuously in recent years regarding the technical complexity of the components in use in the operating room (OR). Parallel to this development, demands for process-optimized procedures have also grown constantly. The impetus for these changes was the beginning of use of minimally invasive techniques in surgery. In contrast, overall development of the OR itself has been slight or nonexistent. What we are typically confronted with currently is an OR outfitted with high-tech medical equipment, whereas only to a limited extent can the design of the OR itself be regarded as ergonomic or holistic. This situation has spread to related specialties as well, and represents a general tendency. Whereas dentists, for example, already enjoy the benefits of a centralized management and operation workplace, this development has not yet reached a satisfactory level for surgeons.

[Implementation of a new electronic patient record in surgery]

INTRODUCTION

The increasing amount of clinical data, intensified interest of patients in medical information, medical quality management and the recent cost explosion in health care systems have forced medical institutions to improve their strategy in handling medical data. In the orthopedic department (3,600 surgeries, 75 beds, 14,000 consultations) software application for comprehensive patient data management has been developed.

METHOD

When implementing the electronic patient history following criteria were evaluated: 1. software evaluation, 2. implementation, 3. work flow, 4. data security/system stability.

RESULTS

In the first phase the functional character was defined. Implementation required 3 months after parametrization. The expense amounted to 130,000 DM (30 clients). The training requirements were one afternoon for the secretaries and a 2-h session for the residents. The access speed on medically relevant data averaged under 3 s. The average saving in working hours was approximately 5 h/week for the secretaries and 4 h/week for the residents. The saving in paper amounted to 36,000 sheets/year. In 3 operational years there were 3 server breakdowns.

CONCLUSIONS

Evaluation of the saving on working hours showed that such a system can amortize within a year. The latest improvements in hardware and software technology made the electronic medical record with integrated quality-control practicable without massive expenditure. The system supplies an extensive platform of information for patient treatment and an instrument to evaluate the efficiency of therapy strategies independent of the clinical field.

Statistical method using operating room information system data to determine anesthetist weekend call requirements

We present a statistical method that uses data from surgical services information systems to determine the minimum number of anesthetists to be scheduled for weekend call in an operating room suite. The staffing coverage is predicted that provides for sufficient anesthetists to cover each hour of a 24-hour weekend period, while satisfying a specified risk for being understaffed. The statistical method incorporates shifts of varying start times and durations, as well as historical weekend operating room caseload data. By using this method to schedule weekend staff, an anesthesia group can assure as few anesthetists are on call as possible, and for as few hours as possible, while maintaining the level of risk of understaffing that the anesthesia group is willing to accept. An anesthesia group also can use the method to calculate its risk of being understaffed in the surgical suite based on its existing weekend staffing plan.

Determining staffing requirements for a second shift of anesthetists by graphical analysis of data from operating room information systems

Some operating room (OR) managers face the dilemma whereby all cases in a surgical suite are not completed during a regularly scheduled (e.g., 8-hour) day. If the anesthesia group at the surgical suite plans for its employed anesthetists to work a fixed number of hours each day, then more than 1 shift of anesthetists may be needed to care for the patients in the ORs. We developed a graphical statistical method that anesthetists and anesthesiologists can use to determine how many anesthesia providers are required on the second shift to minimize labor costs. The method uses data from surgical services information systems or hospital information systems to compensate for seasonality or seasonal variation in the number of ORs running at different times of the day. We also consider application of our method to scheduling surgical nurses with multiple overlapping shifts throughout the day.

Computerization in the OR

This article highlights the process of establishing a computerized scheduling and materials management system in a surgical department. The following facets of the computerization process are discussed: options staff members should consider when choosing a computer system, the importance of scheduling and inventory control, cost savings, how computer systems work when using electronic data interchange and bar coding, and case studies.

Technology: evolution or revolution--changing times

Technology is changing the way work in a department is processed, often leading to greater efficiency and cost savings over time. How nurses engage in the process of business reengineering may help to determine the agency's competitive edge. This article discusses the process and the use of computer technology in the perioperative area.

Perioperative system design and evaluation

Moving toward an electronic record is both challenging and rewarding. The implementation of a computerized scheduling and management system for the operating room is evaluated. Components of the system include Scheduling, Personnel, Supply, Intraoperative, and InSight modules.

Computers in the operating room: the staff nurse perspective

Computers and information management are long-standing tools for the Perioperative Manager. As paperless nursing documentation makes its way into the operating room, the staff nurse must become adept at the use of the computer. How to get the staff nurse comfortable with this new role, and concerns the staff nurse may voice are the subject of this article.

Implementing an informatics system in a perioperative environment

This article identifies and describes strategies for successful implementation of an informatics system in a perioperative environment. With the trend toward managed care, perioperative nurses must address the challenge of instituting advanced technology in organizations with limited staffing and other resources. Planning methods of the past no longer are relevant in today's health care systems; therefore, innovative planning approaches are important. Five key elements in implementation of an informatics system are: a collaborative planning process, education and involvement of staff members regarding the systems design, development of a timetable, selection of a focus group, and assessment of staff members' training requirements. Methods are described for using a focus group process, including recommendations for structuring the focus group and establishing responsibilities of core group members.

Development of a Comprehensive Surgical Information System at Madigan Army Medical Center

The Operative Registry (DA Form 4108) has been the information source for surgical data supporting quality assurance and utilization review efforts at Madigan Army Medical Center. Recently, Madigan's requirements for data and reporting changed. Like other government medical facilities, Madigan began pervasive quality-improvement efforts. This resulted in new ideas to measure hospital performance. Consequently, requirements for surgical data required to support quality and resource management reporting, utilization review, residency review reporting, research and credentialing changed. This article details Madigan's approach to addressing these requirements via development of a comprehensive computing solution. It discusses Madigan's fragmented data environment before system development, and gives the reader perspective on the decision-making process that led to system development rather than purchasing a commercial product. Finally, the article describes how a strong partnership between staff and developers was key to providing a solution that exceeded established goals.

Cost-effective use of operating room supplies based on the REMEDY database of recovered unused materials

It is estimated that $200 million worth of prepared materials are discarded unused in operating rooms in the United States each year. Although some of these materials have been successfully recovered for overseas donation, they nevertheless constitute an undesirable burden on health care efficiency. This situation has prompted a reevaluation of the procedures that result in the overpreparation of surgical supplies, in the hope of reducing hospital, patient, and third-party payer expenditures. A database, which was initially developed to track the overseas donation of recovered supplies from Yale-New Haven Hospital, is now being applied to measure approaches to waste reduction. This report summarizes the application of this database to an integrated program designed to modify nursing procedures and physician prespecified supply lists.

Comparison of subjective versus data base approaches for improving efficiency of operating room scheduling

This paper compares subjective and four data-based models to estimate length of surgery for operating room scheduling systems. The four data-based models for predicting case block length are based on 1) procedure, 2) procedure and surgeon, 3) procedure and case complexity, and 4) procedure, case complexity, and surgeon. Data-based approaches performed better than subjective estimates. In establishing data-based standards it is more important to account for complexity of cases than for differences among surgeons.