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PubMed2003

From the operating room of the present to the operating room of the future. Human-factors lessons learned from the minimally invasive surgery revolution.

The minimally invasive surgical revolution has changed the way surgery is practiced. It has also helped surgical innovators to break the tethers that anchored the practice of surgery in an early 20th century operating room environment. To some in surgery, the Operating Room of the Future will be seen as a revolution but to others, an inevitable evolution of the changes ushered in by the adoption of minimally invasive surgery. Although minimally invasive surgery has conferred considerable advantages on the patient, it has imposed significant difficulties on the surgeon, which in turn, have impacted outcomes. These difficulties were primarily human factor in nature and were poorly understood by critical groups such as device manufacturers, surgeons, and surgery educators and trainers. This article details what these human factors were, how they related to the practice of minimally invasive surgery, and how they will impact on the practice of surgery in the Operating Room of the Future. Much of the technology for the Operating Room of the Future currently exists (eg, surgical robotics, virtual reality, and telemedicine). However, for it to function optimally it must be integrated in a fashion that takes on board the human factor strengths and limitations of the surgeon. These advanced technologies should then be harnessed to optimize surgical practice. In some cases, this will involve rethinking existing technologies (ie, three-dimensional camera systems), applying technologies that currently exist in a manner that is more systematic and better managed (ie, surgical robots and virtual reality), and a reconsideration of who should be applying these technologies for the practice of surgery in the 21st century. In all cases, there will be education and training implications for the practitioner. Lastly, there must be unequivocal demonstration that these changes bring about positive benefits for patients in terms of better outcomes and for surgeons in terms of ability and ease of doing their job. After the experiences of the last decade with minimally invasive surgery, the Operating Room of the Future should be seen as a well-grounded evolution, not a revolution.

Human Characteristics↗
PubMed1978

[Wound contamination in conventionally air-conditioned operating rooms as compared to laminar-flow-operating-rooms (author's transl)].

Two operating rooms (OP K I, OP K II) with conventional air-conditioning and one operating room with horizontal laminar-flow-ventilation (TAVS) were compared by measurements of airborne microorganisms, settling microorganisms and wound contamination. In OP K I and OP K II the number of airborne colonie forming units (cfu) was about 8/m3 when the rooms were empty and between 70/m3 (OP K I) and 140/m3 (OP K II) during operations. The first air in the TAVS-OP contained less than 1 cfu/m3, downstream of the operating team up to 80 cfu/m3. The number of settling microorganisms at the wound site was about 13 cfu/100 cm2 h in OP K I and OP K II, and about 2 cfu/100 cm2 h in the TAVS OP. Wound swabs showed a contamination rate of 45% (OP K I) and 54% (OP K II) versus 31% under TAVS-conditions. The difference is statistically significant with p less than 0.05. Various other factors as e.g. the duration of exposition, traffic of persons into and out of the rooms and the fate of microorganisms after sedimentation into the wound are discussed. While the number of settling germs is growing in linear proportion to the duration of exposition, the number of wounds found contaminated does probably approach a steady state in dependence of sedimentation rate and die-off rate in the wound.

Air Conditioning↗
PubMed1980

Radiation hazard to operating room personnel during operative cholangiography.

During operative cholangiography, the surgeon and other operating room personnel are exposed to scattered radiation and its potential hazards. It was determined that a surgeon standing at the side of the patient during cholangiographic filming would receive 3.2 mR per film. Exposure would be only 0.5 mR per film if the surgeon stepped back 75 cm (2.5 ft) from the patient. This simple measure would reduce the monthly exposure of a surgeon who performs four cholangiograms per week from approximately 205 to 32 mR. The use of the new electronic video-disc recording systems and lead aprons can substantially reduce the amount of radiation exposure related to fluoroscopy. The prudent surgeon, recalling that no level of radiation may be totally safe, should use techniques that provide maximal protection for himself and all operating room personnel during performance of operative cholangiography.

Cholangiography↗
PubMed2005

Future of operating rooms.

Operating-room design has not changed significantly since the modern era of surgery began. Minimal invasive, endoscopic, procedures, and evolution of technology will affect operating-room design in the near future. Poor ergonomics has always been one of the major drawbacks of endoscopic surgery. Use of retractable arms and monitors will improve ergonomics of the operating team. Developments in telecommunication will allow surgeons to communicate with colleagues and experts during the procedure in virtually any location around the world, which increases teaching possibilities and procedural safety. Introduction and further development of intraoperative imaging, including real-time, three-dimensional (3-D) reconstructions of patient, and computer-aided surgery offer surgeons the opportunity to train the planned surgical procedure. Moreover, they will improve control and supervision of the procedure in learning situations. The last decade's robotics have made their introduction into the operating rooms. They improve control over the operating-room environment and will facilitate the performance of more complex procedures. However, high costs and lack of force feedback remain its major drawbacks. Improvements of robotic techniques and its implementation into the operating rooms will further guide their design into highly specialized operating units.

Ergonomics↗
PubMed2003

[Safety management in operating rooms].

In operating rooms, patients with a wide range of conditions are transferred from the wards to undergo surgery. Furthermore, because surgeons with different specialties perform various operations using instruments unique to their specialty, it is possible that operating room nurses, surgeons, and ward nurses do not always communicate clearly. Patients are anesthetized and unconscious, and as a general rule, family members are not allowed entry. As a result, operating rooms are unique environments where neither the patients receiving medical services nor their families can express opinions and concerns. Therefore an especially strict crisis management approach is needed in operating rooms. At present, individual hospital implement their own crisis management systems to prevent medical accidents. However, national debate is needed to establish medical accident prevention guidelines before each hospital compiles a manual that suits its needs.

Operating Rooms↗
PubMed2006

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

BACKGROUND: The Joint Commission on Accreditation of Healthcare Organizations is proposing that hospitals measure culture beginning in 2007. However, a reliable and widely used measurement tool for the operating room (OR) setting does not currently exist. METHODS: OR personnel in 60 US hospitals were surveyed using the Safety Attitudes Questionnaire. The teamwork climate domain of the survey uses six items about difficulty speaking up, conflict resolution, physician-nurse collaboration, feeling supported by others, asking questions, and heeding nurse input. To justify grouping individual-level responses to a single score at each hospital OR level, the authors used a multilevel confirmatory factor analysis, intraclass correlations, within-group interrater reliability, and Cronbach's alpha. To detect differences at the hospital OR level and by caregiver type, the authors used multivariate analysis of variance (items) and analysis of variance (scale). RESULTS: The response rate was 77.1%. There was robust evidence for grouping individual-level respondents to the hospital OR level using the diverse set of statistical tests, e.g., Comparative Fit Index = 0.99, root mean squared error of approximation = 0.05, and acceptable intraclasss correlations, within-group interrater reliability values, and Cronbach's alpha = 0.79. Teamwork climate differed significantly by hospital (F59, 1,911 = 4.06, P < 0.001) and OR caregiver type (F4, 1,911 = 9.96, P < 0.001). CONCLUSIONS: Rigorous assessment of teamwork climate is possible using this psychometrically sound teamwork climate scale. This tool and initial benchmarks allow others to compare their teamwork climate to national means, in an effort to focus more on what excellent surgical teams do well.

Anesthesiology↗
PubMed2002

How to schedule elective surgical cases into specific operating rooms to maximize the efficiency of use of operating room time.

UNLABELLED: We considered elective case scheduling at hospitals and surgical centers at which surgeons and patients choose the day of surgery, cases are not turned away, and anesthesia and nursing staffing are adjusted to maximize the efficiency of use of operating room (OR) time. We investigated scheduling a new case into an OR by using two patient-scheduling rules: Earliest Start Time or Latest Start Time. By using several scenarios, we showed that the use of Earliest Start Time is rational economically at such facilities. Specifically, it maximizes OR efficiency when a service has nearly filled its regularly scheduled hours of OR time. However, Latest Start Time will perform better at balancing workload among services' OR time. We then used historical case duration data from two facilities in computer simulations to investigate the effect of errors in predicting case durations on the performance of these two heuristics. The achievable incremental reduction in overtime by having perfect information on case duration versus using historical case durations was only a few minutes per OR. The differences between Earliest Start Time and Latest Start Time were also only a few minutes per OR. We conclude that for facilities at which the goals are, in order of importance, safety, patient and surgeon access to OR time, and then efficiency, few restrictions need to be placed on patient scheduling to achieve an efficient use of OR time. IMPLICATIONS: We showed how elective cases should be scheduled to maximize the efficiency of use of operating room time. The analysis applies to surgical suites at which surgeons and patients have access to operating room time every workday.

Ambulatory Surgical Procedures↗
PubMed1999

An operating room scheduling strategy to maximize the use of operating room block time: computer simulation of patient scheduling and survey of patients' preferences for surgical waiting time.

UNLABELLED: Determining the appropriate amount of block time to allocate to surgeons and selecting the days on which to schedule elective cases can maximize operating room (OR) use. We used computer simulation to model OR scheduling. Inputs in the computer model included different methods to determine when a patient will have surgery (on-line bin-packing algorithms), case durations, lengths of time patients wait for surgery (2 wk is the median longest length of time that the outpatients [n = 367] surveyed considered acceptable), hours of block time each day, and number of blocks each week. For block time to be allocated to maximize OR utilization, two parameters must be specified: the method used to decide on what day a patient will have surgery and the average length of time patients wait to have surgery. OR utilization depends greatly on, and increases as, the average length of time patients wait for surgery increases. IMPLICATIONS: Operating room utilization can be maximized by allocating block time for the elective cases based on expected total hours of elective cases, scheduling patients into the first available date provided open block time is available within 4 wk, and otherwise scheduling patients in "overflow" time outside of the block time.

Anesthesia↗
PubMed2003

Labor costs incurred by anesthesiology groups because of operating rooms not being allocated and cases not being scheduled to maximize operating room efficiency.

UNLABELLED: Determination of operating room (OR) block allocation and case scheduling is often not based on maximizing OR efficiency, but rather on tradition and surgeon convenience. As a result, anesthesiology groups often incur additional labor costs. When negotiating financial support, heads of anesthesiology departments are often challenged to justify the subsidy necessary to offset these additional labor costs. In this study, we describe a method for calculating a statistically sound estimate of the excess labor costs incurred by an anesthesiology group because of inefficient OR allocation and case scheduling. OR information system and anesthesia staffing data for 1 yr were obtained from two university hospitals. Optimal OR allocation for each surgical service was determined by maximizing the efficiency of use of the OR staff. Hourly costs were converted to dollar amounts by using the nationwide median compensation for academic and private-practice anesthesia providers. Differences between actual costs and the optimal OR allocation were determined. For Hospital A, estimated annual excess labor costs were $1.6 million (95% confidence interval, $1.5-$1.7 million) and $2.0 million ($1.89-$2.05 million) when academic and private-practice compensation, respectively, was calculated. For Hospital B, excess labor costs were $1.0 million ($1.08-$1.17 million) and $1.4 million ($1.32-1.43 million) for academic and private-practice compensation, respectively. This study demonstrates a methodology for an anesthesiology group to estimate its excess labor costs. The group can then use these estimates when negotiating for subsidies with its hospital, medical school, or multispecialty medical group. IMPLICATIONS: We describe a new application for a previously reported statistical method to calculate operating room (OR) allocations to maximize OR efficiency. When optimal OR allocations and case scheduling are not implemented, the resulting increase in labor costs can be used in negotiations as a statistically sound estimate for the increased labor cost to the anesthesiology department.

Anesthesiology↗
PubMed2006

How to teach and evaluate learners in the operating room.

The operating room is the universally established forum for learning surgical skills. It is the least structured and studied format, however, for teaching surgery. Establishing mutual, clear goals and expectations with residents or fellows before each case and reviewing their performance immediately after the case maximizes learning in the operating room.

Clinical Competence↗
PubMed1999

Statistical method to evaluate management strategies to decrease variability in operating room utilization: application of linear statistical modeling and Monte Carlo simulation to operating room management.

BACKGROUND: Operating room (OR) managers seeking to maximize labor productivity in their OR suite may attempt to reduce day-today variability in hours of OR time for which there are staff but for which there are no cases ("underutilized time"). The authors developed a method to analyze data from surgical services information systems to evaluate which management interventions can most effectively decrease variability in underutilized time. METHODS: The method uses seven summary statistics of daily workload in a surgical suite: daily allocated hours of OR time, estimated hours of elective cases, actual hours of elective cases, estimated hours of add-on cases, actual hours of add-on cases, hours of turnover time, and hours of underutilized time. Simultaneous linear statistical equations (a structural equation model) specify the relationship among these variables. Estimated coefficients are used in Monte Carlo simulations. RESULTS: The authors applied the analysis they developed to two OR suites: a tertiary care hospital's suite and an ambulatory surgery center. At both suites, the most effective strategy to decrease variability in underutilized OR time was to choose optimally the day on which to do each elective case so as to best fill the allocated hours. Eliminating all (1) errors in predicting how long elective or add-on cases would last, (2) variability in turnover or delays between cases, or (3) day-to-day variation in hours of add-on cases would have a small effect. CONCLUSIONS: This method can be used for decision support to determine how to decrease variability in underutilized OR time.

Humans↗
PubMed2002

Uncertainty in knowing the operating rooms in which cases were performed has little effect on operating room allocations or efficiency.

UNLABELLED: At many US surgical facilities, applying the previously published method that maximizes the efficiency of use of operating room (OR) time is an effective way to optimize the allocation of OR time. Results are resistant to small errors in recorded OR times. However, at some facilities, the OR information systems data have as much as a 10% error in the correct OR where each case took place. This decreases the total OR time attributed to each service, which is the basis for the allocation method. Such errors could result in incorrect OR allocations and increased OR staffing costs. Expensive and time-consuming data-cleaning steps may be required to resolve the actual OR allocation for each case. We used 1 yr of data from a large, tertiary academic hospital to investigate, through simulation, how increasing levels of error in the correct OR affect OR efficiency and allocations. To apply noise to the data, the actual ORs were changed randomly to unique, "unknown" rooms. At a 30% error level, OR allocations decreased by 4.8%, and costs increased by 1.4% relative to knowing the actual location of every case. Only 1 of 11 surgical services had an allocation decrease at room error rates of less than 25%. We conclude that, in most circumstances, data-cleaning steps to resolve uncertainty in OR locations are not necessary to make accurate OR allocations. IMPLICATIONS: Up to a 30% uncertainty in knowing the actual operating room (OR) in which cases were performed had a minor effect on OR allocations to maximize OR efficiency and on the resulting staffing costs. Thus, facilities with this common error in their OR information systems data will generally be able to use their existing data for accurate OR allocations.

Efficiency↗