Transcript Slide 1

Operating Efficiency and Safety in
Minimal Access Surgery
Alfred Cuschieri
Institute for Medical Science and Technology, Dundee
Scuola Superiore Sant’Anna di Studi Universitari, Pisa
Operating Room Efficiency and Safety
Governance
Teamwork
Communication
Standard operating procedures (SOPs)
Operational system
OR Design
Time and motion analysis
Stress
End of procedure scoring
Surgical Team Skills Based on CRM Model
System does not reduce authority/ accountability of Chief –
remains in charge
Chief encourages all team members to contribute their
knowledge and skills towards safe and effective execution of
intervention
Components of good team dynamics:
briefings
standard operating procedures (SOP)
check lists
environment that encourages constant team interaction
Empower junior staff to voice their concerns
Train senior staff to listen to perspectives of the rest of the team: honest
concern or need for clarification NOT insubordination/ doubts about leaders’
ability
Standard Operating Procedures and Check Lists in
Surgery
SOPs in surgery are the best practice guide lines based on
evidence-based research
Still permit individual technique but ensure that critical
steps are executed in a way that is documented to yield the
best outcome
Check lists ensure that everything that needs to be done,
actually gets done. Not ‘cookbook surgery’
Operational System vs. OR architecture
Operational System
OR architecture
Real time workflow process
Design considerations to maximize work
Patient and staff tracking system (RF
flow
identification tags)
Different interventional approaches require
Clinical decision support system
specific configuration/ layouts/ technologies
Asset management
Operating room cluster to replace ‘all
Measuring outcomes
purpose OR’
Communication and Technology within the OR
Common ground theory of team communication (Clark and
Schaefer 1989, Clark 1996)
Common ground: efficiency depends on the individual’s working
knowledge and/or assumptions about what other individuals
within a communication setting (team) know
Communication success is reflected by the lowest level of shared
knowledge (common denominator)
Established common ground (team knows all there is to know)
results in more efficient communication (less time/ fewer words)
and more successful outcome ( better task performance by team)
Caroline G.L. Cao ,
and Holly Taylor.
Effects of New
Technology on the
Operating Room
Team in Work with
Computing Systems
2004. H.M. Khalid,
M.G. Helander, A.W.
Yeo (Eds)
Time motion and
communication
study: remote
master-slave
surgical robot
(LaproTek) vs direct
lap surgery
Information need by the surgeon in order to complete operation
without robot
Caroline G.L. Cao , and
Holly Taylor. Effects of
New Technology on the
Operating Room Team in
Work with Computing
Systems 2004. H.M.
Khalid, M.G. Helander,
A.W. Yeo (Eds)
Time motion and
communication
study: remote
master-slave
surgical robot
(LaproTek) vs
direct lap surgery
Information need by the surgeon in order to complete operation
with robot
Nature of Motion Analysis
MA involves the study of patterns of movement
It draws conclusions on their efficiency based on
comparisons made between certain recorded angles and
paths of movement
Investigative technologies include:
cinematography and video recording
optoelectronic systems
goniometers
systems combining photocells, light beams and timers
Newer video software tracking system (Dundee)
Industrial MA is driven by need for information on:
enhanced productivity (profit)
improved quality
Motion Analysis &
Telemetric EMG for
research in grip
forces, muscle
recruitment and
fatigue
Telemetric electromyography
Motion Analysis in Minimal Access Surgery
Investigation of ergonomic flow in the OR
Evaluation of proficiency in execution of operations in the OR
Study of joint movements and muscle recruitment and work – coupled
with telemetric EMG
Research and development of instrumenation/ devices for
laparoscopic surgery
Investigation of muscle fatigue and the overuse syndrome in MAS
Training of residents in skills laboratories
Motion analysis of the abdominal wall during insufflation
Benefits of Time-motion Analysis in MAS
Identifying unproductive and unnecessary activity
during the surgical procedure itself
Improving OR layout and equipment design
Achieving better pre- and peroperative planning
Dundee Study
Time-Motion Studies During Laparoscopic Surgery
Theatre Time
i. Anaesthesia induction
ii. Surgical preparation
iii. Set-up
iv. Operative
v. Recovery
vi. Instruments cleaning
Components of theatre time
Recovery
11%
Operative
68%
Anaesthesia
induction
12%
Surgical
preparation
6%
Set-up
3%
Results
Activity of the surgeon
Cholangiogram
8%
Instrument
exchange
13%
Introducing
access ports
23%
Camera
cleaning
1%
Intra-corporeal
activity
55%
Results
Adjusting equipment set-up by circulating nurse
Machine
Frequency
Time (min)
Monitor
3 (4.75)
1.025 (0.96)
Gas insufflator
4 (1.75)
0.64 (0.43)
Diathermy device
3 (1.00)
0.6 (0.42)
Suction-irrigation
3 (2.75)
1.23 (1.49)
Camera control
2 (2.00)
0.74 (0.41)
Light source
4 (1.50)
0.56 (0.43)
Results
Activity of the scrub nurse
Time spent:
Preparing instruments
23%
Handing instruments
04%
Following the procedure on the monitor
21%
______________________________________
Total
48%
Frequency of preparing and handing instruments
8 (21)
33 (14)
Disruption in the OR: Motion Analysis Study
Surgical workflow: Uninterrupted continuation of a surgical process
within a specific observation period
Incidence of disruptive events: 114 episodes /h
intra-operative conversations: 71/h - 1% delay
instrument change: 41/h – 33% delay
Surgeon position change: 2/h – 44% delay
Nurse duty shift: 1/h - 12% delay
Phone/ Page: 3/h – 3% delay
Extraneous: 2/h
Disruptive events caused 4.1min delay/case/h and corresponded to
6.5% of procedure time
Zeng et al Surg Endosc 2008, 22: 2171-7
OR operational strategy
Surgical Service Strategic
Development
•Assess demand and resource requirements
•Plan for OR expansion
•Continued professional development of Staff
OR Governance , Policy &
Management
•Restructure governance mechanisms
•Identify operational management requirements
•Develop measurement and monitoring systems 
•Communication 
Anaesthesia and Staffing
Needs
•Identify anaesthesia resource options
•Restructure anaesthesia relationships
•Team work based on CRM 
OR Operational
Performance Improvement
•Reduce OR turnover time
•Increase OR utilization
•Increase available block time
•Maximize staffing resources
OR Supply Chain and
Management
•Product standardization
•Inventory reduction
•Value analysis programs 
•Aged receivables management
Apgar Neonatal Score
The Apgar score was devised in 1952 by Dr Viginia Apgar
(anaesthetist) as a reproducible method of assessment of the health
of newborn babies
The Apgar score is determined by evaluation based on five criteria (on
a scale from zero to 2): Appearance, Pulse, Grimace, Activity,
Respiration) then summing up the five values thus obtained
Max Apgar score (best condition) = 10
Revolutionized neonatal care
Apgar, Virginia (1953). A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anesth. Analg. 32 (4):
260–267
Surgical (Apgar) Outcomes Score
A 10-Point Surgical Outcomes Score*
0 points 1 point
Estimated blood loss (ml) > 1,000 601-1000
Lowest mean arterial bp
< 40
40 - 54
Lowest heart rate /min
> 85
76 - 85
2 points 3 points
101- 600
≤ 100
55 - 69
≤ 70
66 - 75
56 - 65
4 points
—
—
≤ 55†
Surgical score sum of the points for each category in the course of a procedure.
†Occurrence of pathologic bradyarrhythmia, including sinus arrest, atrioventricular
block or dissociation, junctional or ventricular escape rhythms, and asystole
also receive 0 pts for lowest heart rate.
Thirty-day Outcomes for 767 Patients Undergoing General
or Vascular Surgery, in Relation to Surgical Scores
Surgical score
Major complication/death Relative risk
n % (95% CI)
p Value*
0-2
4
3
75
20.6 (8.550.0)
0.0001
3-4
25
14
56
15.4 (7.233.1)
0.0001
5-6
123
20
6
4.5 (2.09.8)
0.0001
7–8
395
25
6
1.7 (0.83.8)
0.16
9 – 10
220
8
4
1
c-statistic 0.72.
*Chi-square test. Patients with scores of 9 or 10 served as the reference group
—
30-day mortality and major complications for 767 patients undergoing general or
vascular surgery, in relation to surgical scores. *p 0.0001 for an association
between surgical score and major complications/ death
Stress in Laparoscopic Surgery
Physical – morbidity
Mental – fatigue syndrome
Psychological – cardiac bio-signals of stress
Beat-to-beat variability (MSSD) reflects changes in vagal activity
Pre-ejection period (PEP) beta adrenergic activity
Average heart rate (HRA)
Visual
Morbidity Involved
Nerve Injuries
17 case reports of digital nerve injury (neuropraxia,
axonotmesis
Back/ neck/ shoulder pain and arthralgia
Mental Stress
Surgical fatigue syndrome
Visual disturbances
Survey Lawther et al (2002 Surg Endosc)
Respondents
50 surgeons
Morbidity reported:
finger numbness (40%) unilateral (45%), bilateral (25%). Median
duration 9 hours
Factors involved
magnified operative view
difficult dissection (tight grasp syndrome)
lengthy procedures
Correlations reported
case load – symptomatic group performed significanly more
operations annually
no correlation with years of practice
Body and Grip Stance of the Surgeon
Predominant stance of surgeon during laparoscopic surgery:
static upright position with abducted arms
Same muscle groups are activated for long intervals of time
Position of surgeon does not alter
Magnified view exaggerates transmitted movements/
tremors – surgeons tend to grip instruments tighter than is
needed to achieve fine instrument control
STG Smart Arm Rest for MAS
Operating From Images (Late Perception)
Interpretation:
Image is first identified (snap shot) by saccades
Image is then scanned by slow-pursuit eye movements with fixation/
refixation by ocular muscles
Manipulation:
Scans the picture and eye tracks the tips of the instruments
Display:
Nature
Position and distance from surgeon
Image quality
Effect of position of ‘image display’
on execution time Hanna et al
Execution time (s)
80
p<0.0001
60
40
Rt/HL
Rt/EL
F/HL
F/EL
Rt/HL
Lt/EL
Location of image display system
Rt = right, HL = level of hands, F = in front, EL = eye level, Lt = left
Effect of position of ‘image display’ on
task quality) Hanna et al
Knot quality score (%)
35
p=0.08
30
25
20
Rt/HL
Rt/EL
F/HL
F/EL
Lt/HL
Location of image display system
Lt/EL
STG Sterile Screen Projection System
Recognised Immediate Needs for a Modern OR
Integration of various technologies into physical layout of
OR
OR design optimises work flow
Optimal OR size -70m2 (650feet2), flexible to support new
technologies as they emerge
Clutter-free work space around patient and operating team
Ceiling mounted utilities
Integrated data and communication systems
Key Issues
Modern or future OR?
Generic or dedicated OR?
Single room OR or Interventional OR Cluster?
Increased safety in OR - technology vs. human factors?
Useful vs. status OR technologies ?
How do we assess OR functionality?
Consider patient and surgeon welfare
Time and motion and ergonomic studies needed to improve
efficiency without compromise of safety
Safe operational systems – the players not just the theatre