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PubMed2000

Virtual university applied to telesurgery: from teleeducation to telemanipulation.

UNLABELLED: PROBLEM/BACKGROUND: In order to improve patient care by minimal invasive surgery (MIS), we perfected a Virtual TeleSurgical University that allows for teleeducation, teleconcertation, surgical planning and telemanipulation, through new Virtual Reality and multimedia systems. TOOLS AND METHODS: The organization of this innovative school was federated around three major research programs. First, the TESUS program focused on the teletransmission of medical information, allowing for videoconferencing around the world and telementoring. Next, the WeBS-Surg program is a multimedia continuous surgical education system on internet, that allows for teleeducation and teleconcertation between world experts in MIS. Then, the MASTER program (Minimal Access Surgery by Telecommunications and Robotics) allowed the development of the third millenium Operating room. It included Virtual Reality systems that delineate automatically anatomical and pathological structures of a patients from him CT-scan, and that allow for an interactive surgical planning and force-feed-back simulation. It also included a telesurgical robot named Zeus controlled by surgeons through telemanipulation system. RESULTS: Tests and validation shows that all these systems improved all steps of the surgical procedure: preoperatively due to a better continuous education and a computer assisted surgical planning, and peroperatively due to teleconcertation, telementoring and telemanipulation systems. CONCLUSION: Revolutionary tools for minimal invasive surgery learning, planning and performing are all ready available. These tools represents the first prototype of the computer assisted tele-robotical surgery that will be the future of surgery.

Computer Simulation↗
PubMed1996

Laser Doppler vibrometer (LDV)--a new clinical tool for the otologist.

We describe a laser Doppler system (LDS) that can be used clinically for the measurement of tympanic membrane (TM), malleus and prosthesis head displacement in response to sound inputs of 80-to 100-dB sound-pressure level (SPL). It also has the potential for use in the operating room to perform measurements of prosthesis and stapes displacement. The information provided by such testing gives the otologist knowledge of TM and ossicular function that is unique in evaluating middle ear function; it should help select the best type of reconstruction in a given case and direct us toward new and better methods of TM and ossicular reconstruction. The results of umbo displacement measurements in 95 human ears are reported. Examples are provided of LDS measurements in representative ears and how they can be of help to the clinician. The potential of multisite TM-displacement testing is demonstrated in two temporal bones, including before and after partial ossicular replacement prosthesis (PORP) insertion.

Audiometry, Pure-Tone↗
PubMed2001

[General principles for the clinical organization and management of a surgical unit].

Because health-care costs and demand for services are both rising, appropriate management of resources is yet another essential consideration in efficient clinical practice. Surgical units, with their special features, are a particular focus of attention. Although it is possible to study the circumstances of each hospital individually, in fact surgical units often share the same management concerns. Currently, surgical units are often reorganized and provided with an Operating Room Committee, a Medical director or coordinator and operational protocols, such that the unit is considered a system rather than a sum of its individual parts. Work is goal-oriented, with starting and ending points, flexibility in use of surgical theaters, reserve capacity for unscheduled surgery, low cancellation rates and good output; the use of time indicators is considered essential. Other factors to bear in mind when managing a surgical unit are the universalization of information, which should be accurate and up to date, the involvement of teams such as that of anesthesia and recovery, scheduling that is realistic and tight, the appropriate design and use of circuits, and the use of techniques for continuous improvement and problem solving. Some programs, such as that of major outpatient surgery, orthopedic surgery and others may have special needs.

Operating Rooms↗
PubMed2000

[The operating room of the future].

Advances in computer technology will revolutionize surgical techniques in the next decade. The operating room (OR) of the future will be connected with a laboratory where clinical specialists and researchers prepare image-guided interventions and explore the possibilities of these techniques. The virtual reality is linked to the actual situation in the OR with the aid of navigation instruments. During complicated operations the images prepared preoperatively will be corrected during the operation on the basis of the information obtained peroperatively. MRI currently offers maximal possibilities for image-guided surgery of soft tissues. Simpler techniques such as fluoroscopy and echography will become increasingly integrated in computer-assisted peroperative navigation. The development of medical robot systems will make possible microsurgical procedures by the endoscopic route. Tele-manipulation systems will also play a part in the training of surgeons. Design and construction of the OR will be adapted to the surgical technology, and include an information and control unit where preoperative and peroperative data come together and from where the surgeon operates the instruments. Concepts for the future OR should be regularly adjusted to allow for new surgical technology.

Diagnosis, Computer-Assisted↗
PubMed2002

[Contribution of anesthesia to workflow operation].

The changes in our health care system caused by the introduction of DRGs make it necessary for us to abandon departmental process structures in favour of total hospital orientated process structures. An interdisciplinary approach is crucial to enable the most effective use of personnel and material resources. Future orientated information technology and organisational structures will enable us to process our patients effectively and efficiently from pre-admission to discharge. Anaesthesia has to be integrated into a patient management system for in- and out-patients. The essential matters for consideration are anaesthesia consulting hours, the common establishment of process structures for preoperative care, operation room management and postoperative patient care. Routine controls and analysis of the required teamwork reveal improvement potential and enable us to use the necessary control elements effectively.

Anesthesia Department, Hospital↗
PubMed1999

File management in a radiology department.

OBJECTIVE: The objective of this study was to assess the effectiveness of film management in a large urban teaching hospital. SUBJECTS AND METHODS: For 5 days in March 1998, individuals seeking access to imaging studies performed in the radiology department of a large urban hospital were questioned about their activities and were physically followed in an effort to characterize the efficiency and effectiveness of the department in servicing individuals not employed by the department. Activities in the department were recorded, and the times to visit completion and the failure rates were assessed. RESULTS: Of the 381 visitors to the department who were followed, 321 were hospital employees and 186 were physicians. The average total time spent in the department was 4 min, during which 2 min were spent viewing images or obtaining consultation. Physicians were in the department an average of only 7 min with 3 min for consultation and image viewing. During the 381 visits, we monitored 753 separate transactions, 693 of which were completed successfully. We found no instances in which a physician indicated that a patient's treatment would be delayed or altered because of film mismanagement and only one instance in which it was suggested that a study may have to be repeated. CONCLUSION: This study found a high level of efficiency and effectiveness in file room operations.

Filing↗
PubMed1999

Remote-rendered 3D CT angiography (3DCTA) as an intraoperative aid in cerebrovascular neurosurgery.

OBJECTIVE: To assess the viability and utility of network-based rendering in the treatment of patients with cerebral aneurysms, we implemented an intraoperative rendering system and protocol using both three-dimensional CT angiography (3DCTA) and perspective volume rendering (PVR). MATERIALS AND METHODS: A Silicon Graphics InfiniteReality engine was connected via a Fast Ethernet network to a workstation in the neurosurgical operating room. A protocol was developed to isolate bone and vessels using an appropriate transfer function. Three-dimensional CT angiogram images were volume rendered and transmitted to the workstation using a bandwidth-conserving remote rendering system, and were rotated, cut using clipping planes, and viewed using normal and perspective views. Twelve patients with intracranial aneurysms were examined at surgery using this system. RESULTS: Rendering performance at optimal operating bandwidths (50-60 Mb/s) was excellent, with regeneration of a high-resolution image in less than 1 s. Network performance varied in two cases, slowing image regeneration. Surgeons found the images to be useful as an adjunct to conventional imaging in understanding the morphology of complex aneurysms and their relationship to the skull base. CONCLUSIONS: Intraoperative volume rendering using 3DCTA is achievable over a network, can reduce hardware costs by amortizing hardware among multiple users, and provides useful imaging information during the surgical treatment of cerebral aneurysms. Future operating suites may incorporate network-transmitted three-dimensional images as additional sources of imaging information.

Aged↗
PubMed1986

Data storage and retrieval.

The entire face of modern medical and surgical practice is being significantly affected by the application of technologic developments to the practice of surgery--developments that will tie together such areas as information management and processing, robotics, communication networks, and computerized surgical equipment. The achievements in these areas will create a sophisticated, fully automatic system that will assist the plastic surgeon in many aspects of work, such as regular office activities, doctor-patient interaction, professional updating, communication, and even assistance during the operational process itself. It will be as simple as dialing a telephone today. When it is necessary to consult with other colleagues, a combined vocal and visual consulting network in other medical centers as well as consulting computerized expert systems will be available all day and night as part of the communication services. The plastic surgical expert systems will store valuable information, based on the knowledge of the best human experts, on any important subtopics and will be accessed in a very friendly way. This will be an invaluable tool for the residents in training, for emergency room work, and for just getting a second opinion, even for the more experienced practitioner. All the electronic mail, professional magazines, and any other required professional information will flow between central and personal retrieval systems. The doctor, at a desired time in the privacy and comfort of his or her own home or office, can read the mail, make required changes to suit his or her needs, and store, send back, or distribute information, all in a speedy and efficient manner. The simulation of a planned surgery will give the surgeon the ability to prepare and will prevent difficulties during complicated procedures through the luxury of a dry run, without any sequelae if certain expected outcomes fail to materialize. The preprogrammed control of sophisticated surgical equipment and the use of robotics would generate new operational possibilities for more complicated surgeries, which are now prevented owing to the surgeon's physical limitations. Information urgently required during the operation as a result of an unexpected situation will be available immediately from storage and retrieval systems, and real-time vocal and visual consulting with expert colleagues, often in remote locations, will bring the operations process itself to a new era.(ABSTRACT TRUNCATED AT 400 WORDS)

Artificial Intelligence↗
PubMed2006

Problem-solving capacity for vitreoretinal diseases in a university health center.

PURPOSE: To evaluate the effectiveness of the tertiary care delivered to patients with vitreoretinal diseases in a defined urban population; to substantiate the planning and allocation of resources in order to improve the tertiary eye care delivery system in a specific area. METHODS: Data were collected from consecutive first-time patients between June 1, 2003 and July 31, 2004 in the Department of Ophthalmology, State University of Campinas, São Paulo, Brazil. Problem-solving capacity values were calculated for vitreoretinal surgery and photocoagulation. Data were entered into the Statistical Package for the Social Sciences (version 10.0). RESULTS: Of the 7500 patients referred to the Department, 641 were deemed suitable for analysis. The diagnoses analyzed were retinal detachment (26.0%), diabetic retinopathy (21.0%), and vitreous hemorrhage (7.7%). The median ages were 52, 59 and 57.5, respectively. Of all patients referred for retinal detachment, 26.5% were inoperable. The values obtained for the problem-solving capacity (PSC) showed that 38.1%, 33.0% and 93.5% of those eligible for an ophthalmic intervention (for retinal detachment, vitreous hemorrhage and diabetic retinopathy) had obtained treatment. The main reason for not giving treatment was the unavailability of operating room time and photocoagulation time (87.1%). CONCLUSIONS: This was the first study of tertiary eye care service performance in Latin America. Sight-threatening conditions such as retinal detachment and diabetic retinopathy are not thoroughly covered by the health system in this area. Various ways to reduce the problem are considered. The study has provided valuable information on planning high-complexity eye services in the population in question.

Academic Medical Centers↗
PubMed1998

Diagnosing community-acquired pneumonia with a Bayesian network.

We present the development and the evaluation of a Bayesian network for the diagnosis of community-acquired pneumonia. The Bayesian network is intended to be part of a larger decision support system which assists emergency room physicians in the management of pneumonia patients. Minimal data entry from the nurse or the physician, timely availability of clinical parameters, and high accuracy were requirements we tried to meet. Data from more than 32,000 emergency room patients over a period of 2 years (June 1995-June 1997) were extracted from the clinical information system to train and test the Bayesian network. The network performed well in discriminating patients with pneumonia from patients with other diseases. The Bayesian network achieved a sensitivity of 95%, a specificity of 96.5%, an area under the receiver operating characteristic of 0.98, and a predictive value positive of 26.8%. Our feasibility study demonstrates that the proposed Bayesian network is an appropriate method to detect pneumonia patients with high accuracy. The study suggests that the proposed Bayesian network may represent a successful component within a larger decision support system for the management of community-acquired pneumonia.

Adult↗
PubMed2006

Progress in sinonasal imaging.

Imaging of sinonasal structures has evolved from standard radiographs to the much more complicated and informative techniques used today. The plain radiograph was useful when the surgical techniques practiced were primarily aimed at the maxillary and frontal sinuses. With a better understanding of the mucociliary clearance of the nasal cavity and the paranasal sinuses, the surgical technique was shifted to the ethmoid sinuses and became more focal, thus needing a better understanding and display of the intricate morphology of the nasal cavity and paranasal sinuses. Polytomography was a step above plain radiographs and was first used in the display of the regional anatomy for the development of functional endoscopic sinus surgery. Polytomography was quickly replaced by computed tomography, as this imaging technique provides a much more detailed view of the sinonasal architecture than does polytomography. Magnetic resonance imaging has also shown usefulness in imaging this morphological area, as it provides better soft tissue resolution, but it does not allow good visualization of bony structures. Newer computer systems with software capable of reconstructing the digitized information into a 3-dimensional display further enhance our understanding of the regional morphology and afford an improved means of correlating the imaging and endoscopic information. Furthermore, stereotactic navigation systems allow surgeons the ability to visualize the endoscope-instrument tip position, as instruments are actively being used during surgery, on the computed tomographic and/or magnetic resonance images. There is a persistent trend toward reducing the size of the imaging equipment to render it more mobile (computed tomography) and adapt it for operating room use.

Chronic Disease↗
PubMed2004

A virtual reality based navigation system for endovascular surgery.

Endovascular surgery provides a minimally invasive solution for the treatment of aortic aneurysms. Fluoroscopic guidance involves X-rays exposure and loss of space information. We have developed a navigation system allowing real-time visualisation of the endovascular tools in a 3D model of the vessels without any radiation exposure. A modified endoprosthesis is equipped with a magnetic sensor tracked by the Aurora magnetic localizer. The registration step uses 2.5D ultrasonography to replace pre-operative CT data in the Operating Room referential. The Virtual Reality based navigation system shows the location of the endoprosthesis inside a 3D CT model of the aorta. Endovascular procedure benefits from a reduced radiation exposure.

France↗
PubMed2001

Reducing family members' anxiety while waiting on the day of surgery: systematic review of studies and implications of HIPAA health information privacy rules.

STUDY OBJECTIVE: To investigate changes that most surgical suites will need to make in the process of giving reports to family members on the day of surgery by the compliance date (April 14, 2003) of the privacy regulations of the Health Insurance Portability and Accountability Act (HIPPA) of 1996. DESIGN: Systematic review of the medical literature on ways in which providing information to family members changes their anxiety. MEASUREMENTS: The endpoints of the controlled studies included Spielberger State Anxiety. The observational studies reported percentages of family members with a specific concern. MAIN RESULTS: An in-person progress report can reduce family members' anxiety, but this is not always. A personal approach is superior to providing pagers or a phone call. Observational studies suggest that family members want information specific to their relative, particularly if the case is running later than expected. Statistical methods exist to provide such an estimate of the time remaining in surgical cases. CONCLUSIONS: Surgical facilities should strive to provide in-person progress reports to family members while their relatives are undergoing surgery. To satisfy HIPAA regulations, the staff and physicians who talk to family members in the waiting room will need to determine first if the patient has agreed to the release of information. As hospital information systems are updated to assure that this process is HIPAA-compliant, facilities can also incorporate the relevant statistical methods.

Anxiety↗
PubMedDate not supplied

Wireless local area networking for linking a PC reporting system and PACS: clinical feasibility in emergency reporting.

Although local area networks (LANs) are commonplace in hospital-based radiology departments today, wireless LANs are still relatively unknown and untried. A linked wireless reporting system was developed to improve work throughput and efficiency. It allows radiologists, physicians, and technologists to review current radiology reports and images and instantly compare them with reports and images from previous examinations. This reporting system also facilitates creation of teaching files quickly, easily, and accurately. It consists of a Digital Imaging and Communications in Medicine 3.0-based picture archiving and communication system (PACS), a diagnostic report server, and portable laptop computers. The PACS interfaces with magnetic resonance imagers, computed tomographic scanners, and computed radiography equipment. The same kind of functionality is achievable with a wireless LAN as with a wired LAN, with comparable bandwidth but with less cabling infrastructure required. This wireless system is presently incorporated into the operations of the emergency and radiology departments, with future plans calling for applications in operating rooms, outpatient departments, all hospital wards, and intensive care units. No major problems have been encountered with the system, which is in constant use and appears to be quite successful.

Emergency Service, Hospital↗
PubMed1992

Automated situational analysis for operating room anesthesia monitoring.

The hospital operating room (OR) is an environment that requires up-to-the-minute, reliable information on a patient's state. Data is usually provided by a heterogeneous mixture of independent monitors that, due to their isolated nature, give complex and sometimes erroneous presentations of a patient's state. This complex presentation introduces the possibility of operating room personnel overlooking data items that indicate certain pending patient states, such as cardiac arrest. A computer based system that collects the various monitor data, summarizes its content, and provides concise discourse on a patient's state (including potential life threatening situations), would be beneficial.

Anesthesia↗
PubMed1999

An expert system for monitor alarm integration.

OBJECTIVE: Intensive care and operating room monitors generate data that are not fully utilized. False alarms are so frequent that attending personnel tends to disconnect them. We developed an expert system that could select and validate alarms by integration of seven vital signs monitored on-line from cardiac surgical patients. METHODS: The system uses fuzzy logic and is able to work under incomplete or noisy information conditions. Patient status is inferred every 2 seconds from the analysis and integration of the variables and a unified alarm message is displayed on the screen. The proposed structure was implemented on a personal computer for simultaneous automatic surveillance of up to 9 patients. The system was compared with standard monitors (SpaceLabs PC2), using their default alarm settings. Twenty patients undergoing cardiac surgery were studied, while we ran our system and the standard monitor simultaneously. The number of alarms triggered by each system and their accuracy and relevance were compared. Two expert observers (one physician, one engineer) ascertained each alarm reported by each system as true or false. RESULTS: Seventy-five percent of the alarms reported by the standard monitors were false, while less than 1% of those reported by the expert system were false. Sensitivity of the standard monitors was 79% and sensitivity of the expert system was 92%. Positive predictive value was 31% for the standard monitors and 97% for the expert system. CONCLUSIONS: Integration of information from several sources improved the reliability of alarms and markedly decreased the frequency of false alarms. Fuzzy logic may become a powerful tool for integration of physiological data.

Blood Gas Analysis↗
PubMed2005

Assessing team performance in the operating room: development and use of a "black-box" recorder and other tools for the intraoperative environment.

BACKGROUND: The objective of this research was to develop a digital system to archive the complete operative environment along with the assessment tools for analysis of this data, allowing prospective studies of operative performance, intraoperative errors, team performance, and communication. Ability to study this environment will yield new insights, allowing design of systems to avoid preventable errors that contribute to perioperative complications. STUDY DESIGN: A multitrack, synchronized, digital audio-visual recording system (RATE tool) was developed to monitor intraoperative performance, including software to synchronize data and allow assignment of independent observational scores. Cases were scored for technical performance, participants' situational awareness (knowledge of critical information), and their comfort and satisfaction with the conduct of the procedure. RESULTS: Laparoscopic cholecystectomy (n = 10) was studied. Technical performance of the RATE tool was excellent. The RATE tool allowed real time, multitrack data collection of all aspects of the operative environment, while permitting digital recording of the objective assessment data in a time synchronized and annotated fashion during the procedure. The mean technical performance score was 73% +/- 28% of maximum (perfect) performance. Situational awareness varied widely among team members, with the attending surgeon typically the only team member having comprehensive knowledge of critical case information. CONCLUSIONS: The RATE tool allows prospective analysis of performance measures such as technical judgments, team performance, and communication patterns, offers the opportunity to conduct prospective intraoperative studies of human performance, and allows for postoperative discussion, review, and teaching. This study also suggests that gaps in situational awareness might be an underappreciated source of operative adverse events. Future uses of this system will aid teaching, failure or adverse event analysis, and intervention research.

Cholecystectomy, Laparoscopic↗
PubMedDate not supplied

Physiologic monitoring systems.

Physiologic monitoring systems, which monitor vital physiologic parameters so that clinicians can be informed of changes in a patient's condition, typically consist of several distinct components, including a central station, bedside monitors, and ambulatory telemetry transmitters and receivers. For this study, rather than focusing on how each component performs individually, we evaluated how the entire system functions as a whole to better parallel the acquisition practices followed by most hospitals. We evaluated systems from eight suppliers, focusing primarily on adaptability, alarm implementation, and human factors design. We included only systems that offer (1) a central station that can concurrently receive information from bedside monitors and ambulatory telemetry transmitters, (2) one or more bedside monitors that can be used in critical care and intermediate care areas, as well as during transport, and (3) ambulatory telemetry monitoring. We rated the evaluated systems based on their capabilities for each of six applications: critical care unit, emergency department, intermediate care unit and general medical/surgical floor, operating room, postanesthesia care unit, and transport. We found that many of the systems are suitable for some applications, but are unable to meet the requirements for others.

Computer Systems↗