Post on 15-Dec-2015
Operating Efficiency and Safety in Operating Efficiency and Safety in Minimal Access SurgeryMinimal Access Surgery
Alfred CuschieriInstitute for Medical Science and Technology, DundeeScuola Superiore Sant’Anna di Studi Universitari, Pisa
Operating Room Efficiency and SafetyOperating Room Efficiency and Safety
GovernanceTeamworkCommunicationStandard operating procedures (SOPs)Operational systemOR DesignTime and motion analysisStressEnd of procedure scoring
System does not reduce authority/ accountability of Chief – remains in chargeChief encourages all team members to contribute their knowledge and skills towards safe and effective execution of interventionComponents of good team dynamics:briefingsstandard operating procedures (SOP)check listsenvironment that encourages constant team interaction
Surgical Team Skills Based on CRM ModelSurgical Team Skills Based on CRM ModelSurgical Team Skills Based on CRM ModelSurgical Team Skills Based on CRM Model
Empower junior staff to voice their concerns
Train senior staff to listen to perspectives of the rest of the team: honest concern or need for clarification NOT insubordination/ doubts about leaders’ ability
Standard Standard OperatingOperating Procedures and Check Procedures and Check Lists in SurgeryLists in Surgery
Standard Standard OperatingOperating Procedures and Check Procedures and Check Lists in SurgeryLists in Surgery
SOPs in surgery are the best practice guide lines based on evidence-based researchStill permit individual technique but ensure that critical steps are executed in a way that is documented to yield the best outcomeCheck lists ensure that everything that needs to be done, actually gets done. Not ‘cookbook surgery’
Operational System vs. OR architectureOperational System vs. OR architectureOperational System vs. OR architectureOperational System vs. OR architecture
Operational System
Real time workflow process
Patient and staff tracking system (RF
identification tags)
Clinical decision support system
Asset management
Measuring outcomes
OR architecture
Design considerations to maximize work
flow
Different interventional approaches require
specific configuration/ layouts/ technologies
Operating room cluster to replace ‘all
purpose OR’
Communication and Technology within the ORCommunication and Technology within the ORCommunication and Technology within the ORCommunication and Technology within the OR
Common ground theory of team communication (Clark and Schaefer 1989, Clark 1996)Common ground: efficiency depends on the individual’s working knowledge and/or assumptions about what other individuals within a communication setting (team) knowCommunication success is reflected by the lowest level of shared knowledge (common denominator)Established common ground (team knows all there is to know) results in more efficient communication (less time/ fewer words) and more successful outcome ( better task performance by team)
Caroline G.L. Cao , and Holly Taylor. Effects of New Technology on the Operating Room Team in Work with Computing Systems 2004. H.M. Khalid, M.G. Helander, A.W. Yeo (Eds)
Information need by the surgeon in order to complete Information need by the surgeon in order to complete operation without robotoperation without robot
Time motion and communication study: remote master-slave surgical robot (LaproTek) vs direct lap surgery
Caroline G.L. Cao , and Holly Taylor. Effects of New Technology on the Operating Room Team in Work with Computing Systems 2004. H.M. Khalid, M.G. Helander, A.W. Yeo (Eds)
Time motion and communication study: remote master-slave surgical robot (LaproTek) vs direct lap surgery
Information need by the surgeon in order to complete Information need by the surgeon in order to complete operation with robotoperation with robot
Nature of Motion AnalysisNature of Motion AnalysisNature of Motion AnalysisNature of Motion Analysis
MA involves the study of patterns of movementIt draws conclusions on their efficiency based on comparisons made between certain recorded angles and paths of movementInvestigative technologies include:cinematography and video recordingoptoelectronic systemsgoniometerssystems combining photocells, light beams and timersNewer video software tracking system (Dundee)Industrial MA is driven by need for information on:enhanced productivity (profit)improved quality
Motion Analysis & Motion Analysis & Telemetric EMG for Telemetric EMG for research in grip research in grip forces, muscle forces, muscle recruitment and recruitment and fatiguefatigue
Motion Analysis & Motion Analysis & Telemetric EMG for Telemetric EMG for research in grip research in grip forces, muscle forces, muscle recruitment and recruitment and fatiguefatigue
Motion Analysis in Minimal Access Motion Analysis in Minimal Access SurgerySurgery
Motion Analysis in Minimal Access Motion Analysis in Minimal Access SurgerySurgery
Investigation of ergonomic flow in the OREvaluation of proficiency in execution of operations in the ORStudy of joint movements and muscle recruitment and work – coupled with telemetric EMGResearch and development of instrumenation/ devices for laparoscopic surgeryInvestigation of muscle fatigue and the overuse syndrome in MASTraining of residents in skills laboratoriesMotion analysis of the abdominal wall during insufflation
Benefits of Benefits of TTime-motion ime-motion AAnalysis in nalysis in MASMAS Benefits of Benefits of TTime-motion ime-motion AAnalysis in nalysis in MASMAS
Identifying unproductive and unnecessary activity during the surgical procedure itself
Improving OR layout and equipment design
Achieving better pre- and peroperative planning
Dundee StudyDundee StudyTime-Motion Studies During Laparoscopic SurgeryTime-Motion Studies During Laparoscopic Surgery
Dundee StudyDundee StudyTime-Motion Studies During Laparoscopic SurgeryTime-Motion Studies During Laparoscopic Surgery
Theatre Timei. Anaesthesia inductionii. Surgical preparationiii. Set-upiv. Operativev. Recoveryvi. Instruments cleaning
Components of theatre time
Operative68%
Surgical preparation
6%
Anaesthesia induction
12%Recovery
11%
Set-up3%
ResultsResultsResultsResults
Activity of the surgeon
Instrument exchange
13%
Cholangiogram8%
Introducing access ports
23%
Camera cleaning
1%Intra-corporeal
activity55%
ResultsResultsResultsResults
Adjusting equipment set-up by circulating nurseMachine Frequency Time (min)
Monitor 3 (4.75) 1.025 (0.96)
Gas insufflator 4 (1.75) 0.64 (0.43)
Diathermy device 3 (1.00) 0.6 (0.42)
Suction-irrigation 3 (2.75) 1.23 (1.49)
Camera control 2 (2.00) 0.74 (0.41)
Light source 4 (1.50) 0.56 (0.43)
ResultsResultsResultsResults
Activity of the scrub nurseTime spent:Preparing instruments 23%Handing instruments 04%Following the procedure on the monitor 21%______________________________________
Total 48% Frequency of preparing and handing instruments 8 (21)
33 (14)
Disruption in the OR: Motion Analysis StudyDisruption in the OR: Motion Analysis Study
Surgical workflow: Uninterrupted continuation of a surgical process within a specific observation periodIncidence of disruptive events: 114 episodes /hintra-operative conversations: 71/h - 1% delayinstrument change: 41/h – 33% delaySurgeon position change: 2/h – 44% delayNurse duty shift: 1/h - 12% delay Phone/ Page: 3/h – 3% delayExtraneous: 2/h Disruptive events caused 4.1min delay/case/h and corresponded to 6.5% of procedure time
Zeng et al Surg Endosc 2008, 22: 2171-7
Surgical Service Strategic DevelopmentSurgical Service Strategic Development
•Assess demand and resource requirements
•Plan for OR expansion
•Continued professional development of Staff
•Assess demand and resource requirements
•Plan for OR expansion
•Continued professional development of Staff
OR Governance , Policy & ManagementOR Governance , Policy & Management
Anaesthesia and Staffing NeedsAnaesthesia and Staffing Needs
OR Operational Performance ImprovementOR Operational Performance Improvement
OR Supply Chain and ManagementOR Supply Chain and Management
•Restructure governance mechanisms
•Identify operational management requirements
•Develop measurement and monitoring systems •Communication
•Restructure governance mechanisms
•Identify operational management requirements
•Develop measurement and monitoring systems •Communication
•Identify anaesthesia resource options
•Restructure anaesthesia relationships
•Team work based on CRM
•Identify anaesthesia resource options
•Restructure anaesthesia relationships
•Team work based on CRM
•Reduce OR turnover time•Increase OR utilization
•Increase available block time
•Maximize staffing resources
•Reduce OR turnover time•Increase OR utilization
•Increase available block time
•Maximize staffing resources
•Product standardization
•Inventory reduction
•Value analysis programs •Aged receivables management
•Product standardization
•Inventory reduction
•Value analysis programs •Aged receivables management
OR operational strategyOR operational strategyOR operational strategyOR operational strategy
Apgar Neonatal ScoreApgar Neonatal Score
The Apgar score was devised in 1952 by Dr Viginia Apgar (anaesthetist) as a reproducible method of assessment of the health of newborn babiesThe Apgar score is determined by evaluation based on five criteria (on a scale from zero to 2): Appearance, Pulse, Grimace, Activity, Respiration) then summing up the five values thus obtainedMax Apgar score (best condition) = 10Revolutionized neonatal care
Apgar, Virginia (1953). A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anesth. Analg. 32 (4): 260–267
Surgical (Apgar) Outcomes ScoreSurgical (Apgar) Outcomes Score
A 10-Point Surgical Outcomes Score*0 points 1 point 2 points 3 points 4 points
Estimated blood loss (ml) > 1,000 601-1000 101- 600 ≤ 100 — Lowest mean arterial bp < 40 40 - 54 55 - 69 ≤ 70 —Lowest heart rate /min > 85 76 - 85 66 - 75 56 - 65 ≤ 55†
Surgical score sum of the points for each category in the course of a procedure.
†Occurrence of pathologic bradyarrhythmia, including sinus arrest, atrioventricular block or dissociation, junctional or ventricular escape rhythms, and asystolealso receive 0 pts for lowest heart rate.
Thirty-day Outcomes for 767 Patients Undergoing Thirty-day Outcomes for 767 Patients Undergoing General or Vascular Surgery, in Relation to Surgical General or Vascular Surgery, in Relation to Surgical
ScoresScores
Surgical score Major complication/death Relative risk n % (95% CI) p Value*
0 - 2 4 3 75 20.6 (8.550.0)
0.0001
3 - 4 25 14 56 15.4 (7.233.1) 0.0001
5 - 6 123 20 6 4.5 (2.09.8) 0.0001
7 – 8 395 25 6 1.7 (0.83.8) 0.16
9 – 10 220 8 4 1 —
c-statistic 0.72.
*Chi-square test. Patients with scores of 9 or 10 served as the reference group
30-day mortality and major complications for 767 patients undergoing 30-day mortality and major complications for 767 patients undergoing general or vascular surgery, in relation to surgical scores. *p 0.0001 for general or vascular surgery, in relation to surgical scores. *p 0.0001 for an association between surgical score and major complications/ deathan association between surgical score and major complications/ death
Stress in Laparoscopic SurgeryStress in Laparoscopic Surgery
Physical – morbidity
Mental – fatigue syndrome
Psychological – cardiac bio-signals of stressBeat-to-beat variability (MSSD) reflects changes in vagal activityPre-ejection period (PEP) beta adrenergic activity
Average heart rate (HRA)
Visual
Morbidity InvolvedMorbidity Involved
Nerve Injuries17 case reports of digital nerve injury (neuropraxia, axonotmesisBack/ neck/ shoulder pain and arthralgiaMental StressSurgical fatigue syndromeVisual disturbances
Survey Lawther et al Survey Lawther et al (2002 Surg Endosc)(2002 Surg Endosc)
Respondents50 surgeonsMorbidity reported:finger numbness (40%) unilateral (45%), bilateral (25%). Median duration 9 hoursFactors involvedmagnified operative viewdifficult dissection (tight grasp syndrome)lengthy proceduresCorrelations reportedcase load – symptomatic group performed significanly more operations annuallyno correlation with years of practice
Body and Grip Stance of the SurgeonBody and Grip Stance of the Surgeon
Predominant stance of surgeon during laparoscopic surgery:static upright position with abducted armsSame muscle groups are activated for long intervals of timePosition of surgeon does not alter Magnified view exaggerates transmitted movements/ tremors – surgeons tend to grip instruments tighter than is needed to achieve fine instrument control
Operating From Images (Late Perception)Operating From Images (Late Perception)
Interpretation:Image is first identified (snap shot) by saccadesImage is then scanned by slow-pursuit eye movements with fixation/ refixation by ocular muscles
Manipulation:Scans the picture and eye tracks the tips of the instruments
Display:NaturePosition and distance from surgeonImage quality
Effect of position of ‘image display’ Effect of position of ‘image display’ on execution time on execution time Hanna et alHanna et al
40
60
80
Rt/HL Rt/EL F/HL F/EL Rt/HL Lt/EL
Location of image display system
Exe
cuti
on
tim
e (s
)
p<0.0001p<0.0001
Rt = right, HL = level of hands, F = in front, EL = eye level, Lt = leftRt = right, HL = level of hands, F = in front, EL = eye level, Lt = left
Effect of position of ‘image display’ onEffect of position of ‘image display’ ontask quality) task quality) Hanna et alHanna et al
20
25
30
35
Rt/HL Rt/EL F/HL F/EL Lt/HL Lt/EL
Location of image display system
Kn
ot
qu
alit
y sc
ore
(%
) p=0.08p=0.08
Recognised Immediate Needs for a Modern Recognised Immediate Needs for a Modern OROR
Recognised Immediate Needs for a Modern Recognised Immediate Needs for a Modern OROR
Integration of various technologies into physical layout of OROR design optimises work flowOptimal OR size -70m2 (650feet2), flexible to support new technologies as they emergeClutter-free work space around patient and operating teamCeiling mounted utilitiesIntegrated data and communication systems
Key IssuesKey IssuesKey IssuesKey Issues
Modern or future OR?Generic or dedicated OR?Single room OR or Interventional OR Cluster?Increased safety in OR - technology vs. human factors?Useful vs. status OR technologies ?How do we assess OR functionality? Consider patient and surgeon welfareTime and motion and ergonomic studies needed to improve efficiency without compromise of safetySafe operational systems – the players not just the theatre