O.R. Proactive prevention of ADRs.
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Clinical Pharmacy Information Systems↗
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Transposition of volumetric information derived from computed tomography scanning into stereotactic space.
A method for translation of a tumor volume defined by computed tomography (CT) into stereotactic space using a CT-comparible stereotactic headholder, localizing system, arc--quadrant stereotactic instrument, and operating room computer system is described. Clinical applications, including computer-assisted stereotactic laser resection of deep-seated neoplasms of the central nervous system and simulation of stereotactically implanted radionuclide sources, are discussed.
Brain Neoplasms↗
Access denied; care impaired: the benefits of having online medical information available at the point-of-care.
The availability of Internet-enabled computers in the operating room (OR) facilitates unparalleled physician access to current peer reviewed research, either in abstract or full text format, a development that provides physicians with an exciting opportunity to incorporate such findings into clinical practice at the point-of-care. In this report I describe how the availability of online peer reviewed medical literature altered, in one case a planned surgical procedure and, in the other, the interpretation by the anesthesiologist of the clinical significance of an intraoperative echocardiographic finding. In case one, a free, rather than an intact, internal mammary (IM) artery graft was placed to the left anterior descending coronary artery of a patient with renal failure and an ipsilateral upper extremity arteriovenous fistula. The change occurred after the full text results of a study indicating that steal could well occur during the initiation of dialysis if an intact IM was used were made available to the surgeon. In case two, the occurrence of mild central mitral regurgitation in a Carpentier-Edwards Perimount prosthetic mitral valve was confirmed to be a benign finding after a study detailing the long term performance characteristics of this valve was accessed online in the OR. The benefits and potential pitfalls of searching and interpreting online medical information are discussed.
Adult↗
Weekend operating room on call staffing requirements.
This article describes a statistical method used to determine the minimum number of OR teams that should be on call for urgent procedures, in-house versus on standby from home, to minimize labor costs. The OR manager obtains the number of ORs staffed at each hour of the 24-hour period of interest (e.g., 7 AM Saturday to 7 AM Sunday) from the surgical suite's information system. The minimum number of total staffed hours needed to care for patients is calculated for a prespecified level of the acceptable risk of inadequate staffing. A method used to determine whether each staff member should work in-house or on standby from home then is introduced. This method enumerates all possible combinations of shifts to find the one with the lowest cost, and it ensures a prespecified service level. An example based on 248 weeks of data collected from a large surgical suite is presented, and staffing for emergency procedures is reviewed.
Costs and Cost Analysis↗
A frameless stereotaxic operating microscope for neurosurgery.
A new system, which we call the frameless stereotaxic operating microscope, is discussed. Its purpose is to display CT or other image data in the operating microscope in the correct scale, orientation, and position without the use of a stereotaxic frame. A nonimaging ultrasonic rangefinder allows the position of the operating microscope and the position of the patient to be determined. Discrete fiducial points on the patient's external anatomy are located in both image space and operating room space, linking the image data and the operating room. Physician-selected image information, e.g., tumor contours or guidance to predetermined targets, is projected through the optics of the operating microscope using a miniature cathode ray tube and a beam splitter. Projected images superpose the surgical field, reconstructed from image data to match the focal plane of the operating microscope. The algorithms on which the system is based are described, and the sources and effects of errors are discussed. The system's performance is simulated, providing an estimate of accuracy. Two phantoms are used to measure accuracy experimentally. Clinical results and observations are given.
Algorithms↗
Identification of teaching excellence in operating room and clinic settings.
BACKGROUND: A system for obtaining learner feedback on surgical faculty teaching is a program-specific resource for recognizing faculty accomplishments as well as being a requirement of the Accreditation Council for Graduate Medical Education (ACGME). This investigation uses 5 years of feedback from residents to identify surgical teaching behaviors that define teaching excellence. METHODS: Between 1995 and 1999 full-time surgeons in a division of general surgery were evaluated biannually by every resident on their services, using two 10-item Likert scales to assess frequency of performing selected teaching behaviors. Response categories ranged from 0 (does not demonstrate) to 4 (demonstrates the behavior to a very high degree). Mean scores > or =3.7 (1 SD above the mean) were categorized as evidence of superior teaching, whereas mean scores < or =2.4 (1 SD below the mean) were categorized as mediocre. Residents wrote statements identifying teaching strengths. RESULTS: There were 753 individual resident assessments of 16 faculty. The overall mean rating for operating room and clinic teaching was 3.1, with 24% of the ratings > or =3.7 and 14% of the ratings < or =2.4. For operating room, discriminant behaviors were: demonstrates sensitivity to resident learning needs (3.85 versus 1.62, P <0.01) and provides direct feedback (3.60 versus 1.27, P <0.01). Residents' statements yielded themes tied to superior teaching: demonstrates technical expertise, allows resident participation, and maintains a learning climate of respect. CONCLUSIONS: A resident-based teaching assessment system can offer a reasonable and valid form of feedback to academic surgeons. The use of mixed methods to identify teaching behaviors that characterize excellence informs faculty of how they are perceived as educators and provides examples of specific behaviors that merit commendation.
Adult↗
Development of a computerized database for the study of anaesthesia care.
To record, tabulate and report problems associated with anaesthesia, we have developed an information collection system and computer software to follow all patients attended by an anaesthetist at a teaching hospital in Canada. For the last 15 mo, data for 17,000 patients have been collected and the system is ongoing. Data collection is from three sources: carbonless copies of the handwritten Operating Room (OR) and Post Anaesthetic Care Unit (PACU) records, other hospital databases, and postoperative visits. Adverse events (observations which differ from specific physiological variables, or require an intervention and do not normally occur during the routine conduct of anaesthesia), are defined directly on each OR and PACU record. These events are recorded when they occur by the attending anaesthetist or the PACU nurse. All data are verified by a research nurse and an anaesthetist. Computer software, developed from DBase IV, is used to track 95 individual items on preoperative status and anaesthetic technique and another possible 1,450 selections for drugs, physicians, airways, surgical procedures and events for each patient. Data are analyzed with SAS software and reports generated to link the casemix and process with outcome. Comparison of data entered into the computer programme to a retrospective chart review revealed discrepancies of less than 0.5%. Collection, verification and computer entry takes five minutes per patient and the on-going cost is estimated at $4 per patient record. Analysis of the information collected in this database has been useful for research of adverse outcome following anaesthesia, resident expertise profiles, and the administrative management of an anaesthesia department.
Anesthesia Department, Hospital↗
Improved cost allocation in case-mix accounting.
Traditionally, many hospital costs have been allocated to patients using indirect measures that do not always reflect the value of the resources used to provide care. When, for example, costs are allocated by multiplying the patient's charges by the hospital's ratio of costs to charges, the allocated cost does not reflect actual cost because the hospital does not uniformly charge for services in proportion to their cost. The choice of method for cost allocation will be as important for the newly developed case-mix cost-accounting systems as it has been for traditional cost-accounting systems. To illustrate how the use of an indirect cost-allocation method might affect the output of a case-mix cost-accounting system, operating room, radiology and clinical laboratory costs were assigned to 106 hospitalized inguinal hernia patients in two diagnosis-related groups (DRGs) using both the hospital's existing cost-allocation method and a method that measures costs directly. Total costs and the costs in each department were significantly lower in each DRG using the direct method. It was concluded that patients in these two DRGs were being assigned more than the actual cost of their care with the existing cost-allocation method and, therefore, that the existing method prevented the case-mix accounting system from providing accurate management information.
Accounting↗
Cerebral monitoring in the operating room and the intensive care unit: an introductory for the clinician and a guide for the novice wanting to open a window to the brain. Part I: The electroencephalogram.
While there is an increasing body of knowledge in regard to central nervous system function and/or the mode of action of centrally active agents on neuronal function, little is done to develop new techniques on how to measure such changes. Also, monitoring of the cardiovascular system in the past has made extensive progress especially when it comes to evaluate the failing heart. In contrast monitoring of the central nervous system is only done in rare cases where operative procedures likely impede nervous function integrity. Since in the past decade the aging population undergoing operation has rise considerably, the risk of cerebral malperfusion or minute signs of degradation of the aging central nervous system (CNS) to anesthetics and agents being used in the operation room (OR) or the intensive care unit (ICU), needs continuous monitoring of an organ which presents the highest vulnerability and is likely to deteriorate faster than the cardiovascular system. In spite the rapid improvement in technology regarding the electroencephalogram (EEG) and evoked potential monitoring, physicians still are reluctant to use a technology on a routine base, which will give them insight information into brain function and activity. Such "windows to the brain" now not just are reserved to specialists working in the area of neurology and/or psychiatry. More so, cerebral monitoring is getting an integrated part in the overall therapy in patients undergoing operation or who need ventilatory support in the ICU as it effects the well-being and the outcome. The present book therefore, is intended for the practitioners who work with the patient, guide the clinician in his decision making and outlining those situations where cerebral monitoring presents an integrated part in the diagnosis and therapy of patient care. Without going too much into the technical details, representative cases underline the potential use of cerebral monitoring in the underlying clinical situation where either the patient presents borderline perfusion of the CNS, undergoes vascular surgery, or where monitoring of cerebral function in the intensive care in a head trauma patients is an integrated part in therapy. The book therefore is meant for all those clinicians who have to deal with the CNS in a day-to-day situation. This may be the anesthesiologist, the surgeon, the intensive care therapist, the nurse anesthetist as well as all other medical personal involved in intensive care therapy. The aim of the book therefore is to outline the possibilities, the limitations, and the options for therapy when the windows to the brain are opened, how to interpret the data in the light of other physiological parameters and aid the user in the technical details of how to avoid artifacts in recording which may have an impact on final decision making. Therefore, emphasis is placed on the electrode placement, artifact and electrical noise reduction, as well as data interpretation so that cerebral function diagnosis can be made on reliable grounds. The following serves as an introduction to and as a reference guide for Cerebral Monitoring in the OR and the ICU: Gives complete coverage of EEG power spectra analysis. Describes in detail the EEG machines available to be used in the OR and ICU setting. Describes in detail the major features of EEG power spectra and evoked potential measurements, including amplifiers, filter setting and microprocessor algorithm for data reduction. Gives suggestions for assessing and improving signal quality, including noise and artifact rejection, which usually are encountered in the operation room and the intensive care unit, both of which can be considered as electrically contaminated. Gives examples of EEG power spectra and evoked potential monitoring related to different types of anesthesia, in coma, after head trauma, and for the detection of ischemic events. In addition, gives complete coverage of those machines being available for the OR and the ICU, including a list of parameters regarding latency and amplitude in evoked potential As an introductory, recommendations are given for the novice to start cerebral monitoring and guide the beginner in setting up cerebral monitoring in the clinical environment.
Artifacts↗
Augmentation of reality using an operating microscope for otolaryngology and neurosurgical guidance.
The operating microscope is an integral part of many neurosurgery and otolaryngology procedures; the surgeon often uses the microscopic view for a large portion of the operation. Information from preoperative radiological images is often viewed only on X-ray films. The surgeon then has the difficult task of relating this information to the appearance of the surgical view. Image guidance techniques attempt to relate these two sets of information by registering the patient in the operating room to preoperative images using locating devices. Conventionally, image data are presented on a computer monitor, which requires the surgeon to look away from the operative scene. We describe a guidance system, for procedures in which the operating microscope is used, which super-imposes image-derived data upon the operative scene. We create a model of relevant structures (e.g., tumor volume, blood vessels, and nerves) from multimodality preoperative images. By calibrating microscope optics, registering the patient to image coordinates, and tracking the microscope and patient intraoperatively, we can generate stereo projections of the three-dimensional model and project them into the microscope eyepieces, allowing critical structures to be overlaid on the operative scene in the correct position. Measurements with a head phantom gave a root mean square (RMS) error of 1.08 mm, and the estimated error for a human volunteer is between 2 and 3 mm. Initial evaluation in the operating room was very promising.
Computer Simulation↗
Intraoperative 3D shape recovery of abdominal organs for laparoscopic data fusion.
Precise measurements of geometry should accompany robotic equipments in operating rooms if their advantages are further pursued. For deforming organs including the liver, intraoperative geometric measurements play an essential role in computer surgery in addition to pre-operative geometric information from CT/MRI. The laser-scan endoscope system acquires and visualizes the shape of the area of interest in a flash of time. Results of in-vivo experiments on the liver of a pig verify the effectiveness of the proposed system. In the next stage, we aim to make a data-fusion in laparoscopy.
Animals↗
Leigh syndrome: anesthetic management in complicated endoscopic procedures.
BACKGROUND: Leigh's syndrome, a disorder of infancy and childhood, is characterized by gray matter degeneration and focal brainstem necrosis. It presents with special clinical features such as developmental delay, nervous system dysfunction, respiratory abnormalities, and hypertrophic cardiomyopathy that can be a real challenge to the anesthesiologist. Anesthesia or sedation has rarely been reported in patients with Leigh disease. We report our experience in sedating five children with Leigh syndrome in seven procedures undertaken in the endoscopy suite (outside the operating room). METHODS: Five children with Leigh disease, three girls and two boys, have been referred to us for percutaneous endoscopic gastrostomy (PEG) insertion and or replacement (a total of seven procedures). The average age was 2.6 years with a range of 4 months to 6 years. Informed consent was obtained from the patient's parents or guardian. An anesthesia machine, scavenging system, O(2) source and routine monitoring were available. Sedation was accomplished with propofol intravenous (i.v.) (0.5-1 mg x kg(-1)) maintained with a propofol infusion (50-100 microg x kg(-1) x min(-1)). The spontaneously breathing patients received oxygen through an oxygen facemask during the procedure and afterwards recovery was managed in the gastroenterology unit. RESULTS: All the children underwent the procedure without complications. One patient developed transient desaturation (SpO(2) 80%) for a few seconds. Body temperature, heart rate, arterial blood pressure, O(2) saturation and endtidal CO(2) were stable during the endoscopies. No special post-procedure management was required; the patients woke up at the end of the endoscopy and were able to drink and eat as usual. CONCLUSIONS: This rare mitochondrial disease presents unique management problems to the anesthesiologist when using general anesthesia. Our patients were managed appropriately before endoscopy and underwent the procedure under deep sedation. No complications occurred. We concluded that deep sedation in the endoscopy suite was safe in this small series of patients with this rare disease.
Anesthetics, Intravenous↗
Re-engineering hospital emergency rooms: an information system approach.
The efficiency and effectiveness of hospital emergency rooms depend on the effectiveness of the information and communication system as well as on the physical facility itself. Describes the role of information technology in the design of contemporary ER systems. A computerized information board is one system that can enhance the operation of an ER facility. Describes the structure of this system, as well as its integration with other computerized systems. Also describes design features that may help to reduce ER delays/frustration. Because many types of professionals are involved in the daily operations of an ER facility, their input to the design is essential. For this reason, also describes a group decision-making process.
Decision Making, Organizational↗
The registration and scheduling processes.
The entry of patient information via a computer registration system eliminates the manual and repetitive handling of patient information in many different operations. Present scheduling systems range to the very sophisticated that not only smooth peaks and valleys but also eliminate examination conflicts and unnecessary, similar, and duplicate examinations to increase departmental productivity using the existing radiographic rooms and technologic staff.
Appointments and Schedules↗
Method for the quantitation of myocardial perfusion during myocardial contrast two-dimensional echocardiography.
This article describes the hardware and software components of two systems designed for quantitative analysis of data obtained during myocardial contrast two-dimensional echocardiography. One system is meant for off-line analysis of data, whereas the other is designed for on-line analysis, especially in the operating room. The algorithms used for data transfer, selection of appropriate frames, data alignment, derivation of time-intensity plots, and curve-fitting and parameter generation are described in some detail. It is hoped that this information will be of use to others who work in the field of myocardial perfusion imaging.
Algorithms↗
Staff selection for an ambulatory surgery unit.
Major changes in the care delivery system affect the selection of the professional nursing staff for an ambulatory surgery unit. The skills required are diverse and dynamic. Selecting the right applicant requires not only knowledge of the interview process, but also acute observation and communication skills. The use of a matrix system helps to organize the process as well as to quantify and qualify the information gained.
Ambulatory Surgical Procedures↗
Statistical method for predicting when patients should be ready on the day of surgery.
BACKGROUND: Previously, mathematical theory was developed for determining when a patient should be ready for surgery on the day of surgery. To apply this theory, a method is needed to predict the earliest start time of the case. METHODS: The authors calculated a time estimate such that the probability is 0.05 that the preceding case in the patient's operating room (OR) will be finished before the patient is ready for surgery. This implies there will be a 5% risk of OR personnel being idle and waiting for the patient. This 0. 05 value was chosen by considering the relative cost valuation of an average patient's time to that of an average surgical team based on national salary data. Case duration data from a surgical services information system were used to test different statistical methods to estimate earliest start times. RESULTS: Simulations found that 0.05 prediction bounds, calculated assuming case durations followed log-normal distributions, achieved actual risks for the OR staff to wait for patients of 0.050 to 0.053 (SEM = 0.001). Nonparametric prediction bounds performed no better than the parametric method. Having patients ready a fixed number of hours before the scheduled starts of their operations is not reliable. If the preceding case in an OR had been underway for 0.5 to 1.5 h, the parametric 0.05 prediction bounds for the time remaining achieved actual risks for OR staff waiting of 0.055 to 0.058 (SEM = 0.001). CONCLUSION: The earliest start time of a case can be estimated using the 0.05 prediction bound for the duration of the preceding case. The authors show 0.05 prediction bounds can be estimated accurately assuming that case durations follow log-normal distributions.
Appointments and Schedules↗
The Anesthesia Simulator Consultant: simulation plus expert system.
The Anesthesia Simulator Consultant was designed to provide anesthesiologists the opportunity to practice the management of anesthesia-critical incidents. The program simulates the operating room environment in a graphic display on the screen of a personal computer. Physiologic models predict the patient responses and an automated record-keeping system produces a detailed summary of the case. An expert system provides interpretations of patient information, differential diagnosis, and treatment for abnormal patient conditions. The coupling of the simulator, recorder, and expert system creates a unique self-study and evaluation environment.
Anesthesiology↗