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PubMed2006

Communication devices in the operating room.

PURPOSE OF REVIEW: Effective communication is essential to patient safety. Although radio pagers have been the cornerstone of medical communication, new devices such as cellular telephones, personal digital assistants (PDAs), and laptop or tablet computers can help anesthesiologists to get information quickly and reliably. Anesthesiologists can use these devices to speak with colleagues, access the medical record, or help a colleague in another location without having to leave a patient's side. Recent advances in communication technology offer anesthesiologists new ways to improve patient care. RECENT FINDINGS: Anesthesiologists rely on a wide variety of information to make decisions, including vital signs, laboratory values, and entries in the medical record. Devices such as PDAs and computers with wireless networking can be used to access this information. Mobile telephones can be used to get help or ask for advice, and are more efficient than radio pagers. Voice over Internet protocol is a new technology that allows voice conversations to be routed over computer networks. It is widely believed that wireless devices can cause life-threatening interference with medical devices. The actual risk is very low, and is offset by a significant reduction in medical errors that results from more efficient communication. SUMMARY: Using common technology like cellular telephones and wireless networks is a simple, cost-effective way to improve patient care.

Anesthesiology↗
PubMedDate not supplied

Perspectives on cardiovascular monitoring in 1977.

During the past several decades, cardiovascular monitoring has been used with increasing frequency. Measurement of pressures, flows, cardiac rhythm, and blood gases permits the physician and surgeon to apply physiological concepts for treating patients with disease. More complex surgical procedures are now possible. Higher postoperative survival rates have resulted directly from careful monitoring and treatment in the postoperative care units. Operations may be performed with greater safety because of cardiovascular monitoring in the operating room. The relationship between the respiratory system and the circulatory system in managing patients with disease and in patients who are postoperative has been elucidated by new monitoring techniques. The value of extending monitoring to ambulatory patients is just being appreciated, and techniques to do so have been developed. The future offers much promise for an improved quality of medical care, with advanced techniques in cardiovascular monitoring that will be developed for use in the very near future. It is our hope that this symposium will provide useful information for those responsible for selecting such systems in future years.

Arrhythmias, Cardiac↗
PubMed1998

Intraoperative magnetic resonance imaging with the magnetom open scanner: concepts, neurosurgical indications, and procedures: a preliminary report.

OBJECTIVE: Intraoperative magnetic resonance imaging (MRI) is now available with the General Electric MRI system for dedicated intraoperative use. Alternatively, non-dedicated MRI systems require fewer specific adaptations of instrumentation and surgical techniques. In this report, clinical experiences with such a system are presented. METHODS: All patients were surgically treated in a "twin operating theater," consisting of a conventional operating theater with complete neuronavigation equipment (StealthStation and MKM), which allowed surgery with magnetically incompatible instruments, conventional instrumentation and operating microscope, and a radiofrequency-shielded operating room designed for use with an intraoperative MRI scanner (Magnetom Open; Siemens AG, Erlangen, Germany). The Magnetom Open is a 0.2-T MRI scanner with a resistive magnet and specific adaptations that are necessary to integrate the scanner into the surgical environment. The operating theaters lie close together, and patients can be intraoperatively transported from one room to the other. This retrospective analysis includes 55 patients with cerebral lesions, all of whom were surgically treated between March 1996 and September 1997. RESULTS: Thirty-one patients with supratentorial tumors were surgically treated (with navigational guidance) in the conventional operating room, with intraoperative MRI for resection control. For 5 of these 31 patients, intraoperative resection control revealed significant tumor remnants, which led to further tumor resection guided by the information provided by intraoperative MRI. Intraoperative MRI resection control was performed in 18 transsphenoidal operations. In cases with suspected tumor remnants, the surgeon reexplored the sellar region; additional tumor tissue was removed in three of five cases. Follow-up scans were obtained for all patients 1 week and 2 to 3 months after surgery. For 14 of the 18 patients, the images obtained intraoperatively were comparable to those obtained after 2 to 3 months. Intraoperative MRI was also used for six patients undergoing temporal lobe resections for treatment of pharmacoresistant seizures. For these patients, the extent of neocortical and mesial resection was tailored to fit the preoperative findings of morphological and electrophysiological alterations, as well as intraoperative electrocorticographic findings. CONCLUSION: Intraoperative MRI with the Magnetom Open provides considerable additional information to optimize resection during surgical treatment of supratentorial tumors, pituitary adenomas, and epilepsy. The twin operating theater is a true alternative to a dedicated MRI system. Additional efforts are necessary to improve patient transportation time and instrument guidance within the scanner.

Adolescent↗
PubMed2003

Coregistered intraoperative ultrasonography in resection of malignant glioma.

OBJECT: The authors present their experience with coregistration of preoperative imaging data to intraoperative ultrasonography in the resection of high-grade gliomas, focusing on methodology and clinical observation. METHODS: Images were obtained preoperatively and coregistered to intraoperative hand-held ultrasound images by merging the respective imaging coordinate systems. After patient registration and imaging calibration, the authors computed the location on the magnetic resonance (MR) space of each pixel on an ultrasound image acquired in the operating room. The data were retrospectively reviewed in 11 patients with high-grade gliomas who underwent ultrasonography-assisted resection at our institution between June 2000 and December 2002. Satisfactory coregistration of intraoperative ultrasound and preoperative MR images was accomplished in all cases. Ultrasound and MR image data were closely congruent. Preoperative setup and intraoperative use of the system were unencumbering. CONCLUSIONS: Based on these preliminary results, intraoperative ultrasonography is an attractive neuronavigational alternative, by which a less expensive and constraining imaging technique is used to acquire updated information. Optimal intraoperative guidance can be provided by the integration of this with other imaging studies.

Adult↗
PubMed1999

Emergency medical services for children: a general pediatrician's perspective.

The EMSC movement is still in its infancy, and there is much that remains to be done. The primary care pediatrician plays a major role in the EMSC system and should continue to advocate for efficient, high-quality pediatric emergency care. In summary, there are several ways that the office-based pediatrician can and should become involved with EMSC: 1. Pediatricians should emphasize safe and injury prevention at each health maintenance visit throughout a child's life. 2. Pediatricians should encourage all parents to become certified in BLS/CPR. Ideally, training in CPR should be provided during prenatal and childbirth classes. 3. Pediatricians should advocate for injury prevention and safety campaigns in their communities. They can also become involved with efforts to develop legislation dealing with issues in injury prevention and safety. 4. Pediatricians should ensure that all children receive the appropriate immunizations. 5. Pediatricians need to maintain office emergency preparedness. All office personnel should maintain certification in BLS as a minimum and ideally, PALS. Equipment used for pediatric resuscitation should be available and functional. Monthly mock codes should be scheduled to ensure that all personnel clearly know their roles and responsibilities in the event of an emergency. 6. Pediatricians should maintain their skills in emergency pediatrics. In addition, they should maintain certification in PALS. Continuing medical education (CME) workshops and conferences in emergency pediatrics are available throughout the year. Also, pediatricians can maintain their airway management skills by practicing endotracheal intubation in the operating room setting. 7. Pediatricians must become familiar with the prehospital care providers, EDs, and transport services in their communities. Association with a pediatric intensive care unit at a tertiary care center would also be beneficial. 8. Pediatricians must be available for consultation to local EDs. They must realize that, in many instances, they may represent the physician who is most experienced with caring for the critically ill or injured child. 9. Pediatricians can serve as medical advisors to the EMS systems in their communities. 10. Pediatricians should stay well informed on issues pertaining to EMSC.

Child↗
PubMed1993

[Hardware].

For effective management of clinical laboratory in spite of a shortage of medical technologists, we modified conventional analytical instruments on the market, and developed the automatic transport mechanism and the robotic analytical instruments to suit the operational needs of our laboratory. Consequently, we succeeded in designing a system in which the results for 89% of all the tests ordered were reported within 60 minutes after the time when the specimens were received at the laboratory. As a result of this laboratory automation system, medical technologists were spared from their routine work, and their expertise was now diverted to the other duties like examination for microbes in hospital facilities, evaluation for sterilization of surgical instruments, and maintenance of measuring apparatuses in the operating rooms. In addition, the technologists also became involved in preventive health activities for university personnel such as: periodical healthy check, and screening programs for adult diseases, and the like. Some became engaged in the health management programs for radiological department workers. Thus, the introduction of this laboratory automation system, enabled the medical technologists to cooperate in hospital operation activities and to contribute to the prevention of iatrogenic disorders.

Automation↗
PubMed2002

PET-guided three-dimensional treatment planning of intracavitary gynecologic implants.

PURPOSE: Positron emission tomography (PET) provides physiologic information that is not available from computed tomography (CT) or magnetic resonance studies. PET images may allow more accurate delineation of three-dimensional treatment planning target volumes of brachytherapy gynecologic (GYN) implants. This study evaluates the feasibility of using PET as the sole source of target, normal structure, and applicator delineation for intracavitary GYN implant treatment planning. MATERIALS AND METHODS: Standard Fletcher-Suit brachytherapy tandem and colpostat applicators were used for radiation delivery. After insertion of the applicator in the operating room, the patient was taken to a PET scanner, where 555 MBq (15 mCi) 18F-fluorodeoxyglucose (18F-FDG) was administered intravenously. Forty-five minutes later, three localization tubes containing 18F-FDG were inserted into the source afterloading compartments of the tandem and colpostat. A whole-pelvis scan was performed, and the images were transferred to a commercial brachytherapy three-dimensional treatment planning system. A Foley catheter was inserted into the urinary bladder while the patient was in the operating room. The regions of radioactivity in the three applicator tube image were contoured for reconstruction of the applicator, along with the bladder, rectum, and 18F-FDG-defined target volumes. A treatment plan was generated that included dose-volume histograms and three-dimensional dose distribution displays, allowing the physician an opportunity to determine if adequate target coverage and normal-tissue sparing had been obtained. For a more conservative approach, three-dimensional dose distributions and dose-volume histograms delivered with conventional source arrangements and loading could be observed. The accuracy of applicator localization from the PET images was verified using a water phantom containing two aluminum CT-compatible tandems. The PET-defined and CT scan applicator reconstructions were compared. RESULTS: Feasibility of using PET images for treatment planning of brachytherapy intracavitary GYN implants has been demonstrated. A phantom study demonstrated applicator reconstruction accuracy in the axial direction to be better than 2 mm. Reconstruction accuracy in the longitudinal direction (principally craniocaudal) was similar to the PET scanner's voxel size of 4.3 mm. CONCLUSIONS: Brachytherapy intracavitary GYN implant design has traditionally been based on patient tumor staging, palpation, and clinical experience. PET images have the potential to provide better spatial information about the relationship of tumor and normal structures to the applicator. This information can be used to optimize the delivery of radiation therapy treatments. Thus far, six patients have been scanned using this process.

Brachytherapy↗
PubMed1998

Continuing quality improvement procedures for a clinical PACS.

The University of California at San Francisco (USCF) Department of Radiology currently has a clinically operational picture archiving and communication system (PACS) that is thirty-five percent filmless, with the goal of becoming seventy-five percent filmless within the year. The design and implementation of the clinical PACS has been a collaborative effort between an academic research laboratory and a commercial vendor partner. Images are digitally acquired from three computed radiography (CR) scanners, five computed tomography (CT) scanners, five magnetic resonance (MR) imagers, three digital fluoroscopic rooms, an ultrasound mini-PACS and a nuclear medicine mini-PACS. The DICOM (Digital Imaging and Communications in Medicine) standard communications protocol and image format is adhered to throughout the PACS. Images are archived in hierarchical staged fashion, on a RAID (redundant array of inexpensive disks) and on magneto-optical disk jukeboxes. The clinical PACS uses an object-oriented Oracle SQL (systems query language) database, and interfaces to the Radiology Information System using the HL7 (Health Languages 7) standard. Components are networked using a combination of switched and fast ethernet, and ATM (asynchronous transfer mode), all over fiber optics. The wide area network links six UCSF sites in San Francisco. A combination of high and medium resolution dual-monitor display stations have been placed throughout the Department of Radiology, the Emergency Department (ED) and Intensive Care Units (ICU). A continuing quality improvement (CQI) committee has been formed to facilitate the PACS installation and training, workflow modifications, quality assurance and clinical acceptance. This committee includes radiologists at all levels (resident, fellow, attending), radiology technologists, film library personnel, ED and ICU clinician end-users, and PACS team members. The CQI committee has proved vital in the creation of new management procedures, providing a means for user feedback and education, and contributing to the overall acceptance of, and user satisfaction with the system. Well developed CQI procedures have been essential to the successful clinical operation of the PACS as UCSF Radiology moves toward a filmless department.

Computer Communication Networks↗
PubMed2005

Chronic exposure to anesthetic gases affects balance control in operating room personnel.

Exposure to anesthetic gases is known to alter certain structures and functions of the central nervous system. As the effects of long-term exposure on balance control mechanisms have been the subject of few investigations, these were evaluated in 53 operating room personnel exposed to anesthetic gases and in 53 non-exposed individuals. Balance control was assessed by static and dynamic posturography. Exposed workers had the worst static and dynamic postural performances, particularly in the eyes closed condition, suggesting increased dependency on vision and decreased use of proprioception. This poorer ability to modify the weight and to switch the different cues controlling balance suggests central information processing disorders. By impairing information and its central integration, exposure to anesthetics gases leads to inappropriate organization of sensorimotor stabilization strategies.

Adult↗
PubMed1986

A frameless stereotaxic integration of computerized tomographic imaging and the operating microscope.

A computer-based system has been developed for the integration and display of computerized tomography (CT) image data in the operating microscope in the correct perspective without requiring a stereotaxic frame. Spatial registration of the CT image data is accomplished by determination of the position of the operating microscope as its focal point is brought to each of three CT-imaged fiducial markers on the scalp. Monitoring of subsequent microscope positions allows appropriate reformatting of CT data into a common coordinate system. The position of the freely moveable microscope is determined by a non-imaging ultrasonic range-finder consisting of three spark gaps attached to the microscope and three microphones on a rigid support in the operating room. Measurement of the acoustic impulse transit times from the spark gaps to the microphones enables calculation of those distances and unique determination of the microscope position. The CT data are reformatted into a plane and orientation corresponding to the microscope's focal plane or to a deeper parallel plane if required. This reformatted information is then projected into the optics of the operating microscope using a miniature cathode ray tube and a beam splitter. The operating surgeon sees the CT information (such as a tumor boundary) superimposed upon the operating field in proper position, orientation, and scale.

Evaluation Studies as Topic↗
PubMed2005

Where the patient and technology meet.

From the back office to the operating room, technology is transforming hospitals, making them more efficient and able to deliver leading-edge care. But one area remains stubbornly low tech: the nonclinical, routine interactions with patients. From registration to food service, some pioneering hospitals are now using IT to improve the patient experience.

Admitting Department, Hospital↗
PubMed1995

Situation analyses of emergency obstetric care: examples from eleven operations research projects in west Africa. The Prevention of Maternal Mortality Network.

Situation analyses were conducted by 11 multidisciplinary teams in the West African Prevention of Maternal Mortality (PMM) Network, with technical assistance from Columbia University's Center for Population and Family Health. Data on the functioning and use of facilities were used to identify resource needs and management problems at facilities providing emergency obstetric care in Ghana, Nigeria and Sierra Leone. The researchers looked at the number and distribution of facilities, trends in utilization patterns, time from admission to treatment at facilities, functioning of referral systems, availability of essential supplies, staffing patterns, and staff perceptions of services. Research methods included patient flow studies, inventories of drugs and supplies, and retrospective reviews of hospital records. Qualitative information was also collected through interviews with staff. This paper summarizes the principal findings of the situation analyses. Normal deliveries fell markedly where users' fees were initiated. However, the number of women with complications seen increased at several of these sites. The lack of drugs and supplies at the facilities had an adverse effect on utilization of non-emergency services and on women's survival chances. Users' fees and unavailability of supplies contributed to unacceptably long waiting times between admission and treatment at most sites. These long waiting times were also found to be associated with higher case fatality rates. Staff-to-patient ratios at the sites improved or remained stable, and do not appear to be associated with changes in quality of care. Strategies to address the problems identified include: the establishment of small revolving fund schemes to ensure the availability of supplies; the creation of 24-hr pharmacy services; the establishment of on-call rooms for staff; and the improvement of staff attitudes and morale through various types of training activities. These situation analyses were useful for assessing health system factors contributing to maternal deaths. The information on complicated cases and on hospital functioning provided a marked improvement over previous studies limited to data on deliveries and maternal deaths. Low-cost techniques such as the patient-flow studies and drug and supply inventories provided valuable information which was easily intelligible to program planners. These types of studies are recommended for use prior to the development of projects designed to reduce maternal deaths.

Africa, Western↗
PubMed2001

The palm as a real-time wide-area data-access device.

Handheld wireless technologies offer great promise in helping to improve healthcare. However, it is not clear whether off-the-shelf wireless networking will work as well within medical centers as this technology works outside of the medical center. Therefore, we evaluated the coverage of wide-area wireless technology within two representative academic medical centers. The study determined the rate of connectivity by testing both the Palm VII and the Minstrel V modem in a set of locations typically frequented by house staff in their daily activities. Within one hospital, connectivity was 59% for OmniSky service, and 78% for Palm.net. The second hospital's connectivity was over 93% with both devices. Differences in connectivity were likely due to the number of rooms visited with externally exposed walls, the suburban versus urban location of the academic medical center, and the relative location of service transponders. When examined by the Johns Hopkins Clinical Devices Laboratory, both devices were found to operate without interfering with other hospital equipment.

Academic Medical Centers↗
PubMed1996

Picture archiving and communication systems and vascular surgery: clinical impressions and suggestions for improvement.

The purpose of this study was to determine the acceptance and clinical utility of a large scale picture archiving and communication system (PACS) for vascular surgery. Questionnaires and one-on-one interviews were conducted with physicians and nurses in the department of vascular surgery at the Baltimore VA Medical Center where PACS has been in routine, hospital-wide use for more than 2 1/2 years. The perceptions of the clinical staff were assessed to determine the efficacy of PACS in comparison to the conventional film based alternative for the practice of vascular surgery and suggestions for improvements were solicited. There was consensus among the vascular surgery staff members that the use of PACS enhanced their clinical practices, both in and out of the operating room (OR). Vascular surgeons heavily rely on image display in the OR as a "road map" to help determine their operative approach and to guide their surgery. PACS offers unique intraoperative imaging capabilities including rapid image retrieval and improved archival, cine review, the ability to modify image contrast, and the ability to obtain direct quantitative measurements of the degree of vascular stenosis. The increased accessibility and availability of images throughout the hospital enables improvement in time management and in patient care.

Baltimore↗
PubMed1988

Models for costing patient care services, Part 3. Costing operating theatre procedures.

This is the third of a series of papers describing the development of costing models for use in the Clinical Information System (CIS) at the Clayton Campus (formerly the Queen Victoria Medical Centre) of the Monash Medical Centre (MMC) in Melbourne. The first two papers in this series described the costing of diagnostic laboratory services and organ imaging services. This paper describes the development of a model for costing operating theatre procedures.

Accounting↗
PubMed1988

Planning and documentation. Addressing patient needs in a day surgery setting.

Day surgery has reduced the time allowed for patient contact, but it has not reduced the need for assessment, planning, and delivery of patient care. Day surgery, however, has shifted some responsibility from nurses to patients and their families. Our goals in developing a preoperative assessment plan were to ensure consistent and thorough patient assessment; enhance problem identification and guide appropriate interventions; provide evaluations based on the needs of the day surgery patient; assist patients and families in assuming increased responsibility for postoperative care; provide achievable and manageable documentation of patient information gathered in a compressed amount of time; and facilitate communication between the patient and the health care team. We feel our assessment documenting system meets these goals and allows nurses and patients to adapt to the changes in traditional roles both parties experience when day surgery procedures are performed.

Ambulatory Surgical Procedures↗
PubMed1996

Temporal physiologic patterns of shock and circulatory dysfunction based on early descriptions by invasive and noninvasive monitoring.

In the past, most investigators failed to consider time relationships in their studies of circulatory problems. Because of this, data obtained in middle- or late-stage shock during organ failure are often presented as being characteristic of specific shock syndromes. Even "early" studies are not physiologically early, but instead have often come to mean early after ICU admission or early after life-threatening hypotensive events. The hypotensive episode represents decompensation of protective circulatory mechanisms, not the beginning of circulatory dysfunction. Early monitoring demonstrates that circulatory changes do not start with hypotension, but with the precipitating event, i.e., hemorrhage, trauma, surgery, or sepsis. When monitoring is started after hypotension, the first half of the problem is missed. It is, therefore, appropriate to focus on the earliest period of circulatory dysfunction with noninvasive methods to evaluate pathophysiology, to predict outcome, and to propose therapeutic protocols to improve outcome. Invasive monitoring is generally accepted as the "gold standard" for critically ill patients. The pulmonary artery flotation catheter has translated information to the bedside previously only available in cardiac catheterization laboratories, forever changing the way we treat ICU patients. Newer high-tech hardware and software innovations in the impedance method give more accurate and reliable cardiac index (CI) measurements that now satisfactorily agree with thermodilution in most clinical conditions. Minor disparities are more than made up for by the continuous online display of data. This impedance device, combined with pulse oximetry and transcutaneous oximetry, provides a feasible, noninvasive hemodynamic monitoring system that can be applied in a manner similar to electrocardiogram electrodes in the emergency department, operating room, ICU, hospital floors, and doctor's offices. More importantly, noninvasive monitoring provides a continuous, online, real-time display of hemodynamic data needed to titrate therapy rapidly and expeditiously. This is a major advantage, since therapy is more effective if given prophylactically or early and then titrated to optimal goals. Noninvasive monitoring provides a powerful method for objective evaluation of early, rapidly changing circulatory dynamics beginning with the precipitating event. This gives a new and different view of circulatory failure, exceeding the boundaries of our old concepts of shock based on blood pressure, subjective symptoms, and imprecise signs. Data of survivors revealed increased cardiac function (CI and oxygen delivery) shortly after surgery, trauma, and sepsis; this response is needed to meet the increased metabolic demands defined by the increased oxygen consumption. Nonsurvivors have limited responses to the added metabolic demands of external stressors. Therapy should augment naturally occurring compensations, but it must be given promptly within appropriate time limits.

Hemodynamics↗
PubMed1998

Risk of blood contamination of health care workers in spine surgery. A study of 324 cases.

STUDY DESIGN: The relative risk of blood contamination during spine surgery was studied using data collected from 324 procedures. OBJECTIVES: To analyze demographic factors that predict blood-borne pathogens in the population of spine surgery patients, study the rates and patterns of blood contamination in health care workers (i.e., skin-penetrating incidents and nonpenetrating surface skin contamination from patients' blood) and compare those risks with those in other surgical departments, and analyze the effectiveness of barrier systems worn by the surgical team. SUMMARY OF BACKGROUND DATA: The Centers for Disease Control and Prevention has reported 49 health care workers infected by the human immunodeficiency virus through occupational exposure. Several studies have noted the risk of blood contamination in various surgical departments, but the relative risk during spine surgery has not been determined. METHODS: This year-long survey included 9795 cases, or 60,789 health care worker--patient contacts, of which spine disorders comprised 324 cases (2234 health care workers and patients). Data collection forms were designed and inservice training conducted with operating room staffs. Information regarding type of case, staff position (surgeon, assistant, scrub nurse, circulator), protective clothing worn, length of operating room time, blood loss, incidence of blood spills, was recorded, among other data. RESULTS: Prevalence of human immunodeficiency virus in patients in the overall series was 0.19% versus 0.93% in spine patients. The rate of HCW contamination in the overall series was 7.76%, of which 0.92% resulted from skin-penetrating incidents. Contamination in spine surgery occurred in 31.86% of cases, of which 1.23% were the result of skin-penetrating incidents. CONCLUSIONS: Health care workers in spine surgery have a statistically significant overall higher risk of blood contamination than do those in other surgical departments. The increased risk occurred with blood contacting intact skin. There was no higher risk for skin penetrating injury. Analysis of data suggests that health care workers always should wear double gloves, forearm-reinforced gowns, and eye protection.

Blood-Borne Pathogens↗