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

Telemetric electromyographyTelemetric electromyography

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

STG Smart Arm Rest for MASSTG Smart Arm Rest for MAS

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

STG Sterile Screen Projection SystemSTG Sterile Screen Projection System

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