Andrew Frost -- Operating Theatre Integration New EfficienciesI’m Andrew Frost. Just give you a bit of an idea of my background. I started off life as an MDT4 many, many years ago. I’ve worked in the NHS as well as the industry for the main corporates and I am now working for NTS Health. I’ve been working there for 12 years. We’re a consulting company and we specialise as well, and we specialise in providing consulting into new builds, anything from original business case, right the way through procurement, equipping and installation and conditioning. We also get involved in asset management as well. We do quite a bit of asset management consulting. We’ve done quite a lot of work in hospitals across the country, looking at how environmental partners are working and trying to sort of find ways in which to improve their efficiency and the services they’re offering.

So, before I actually start on my presentation, just a little question. I see myself as an enabler and I think NTS Health as sort of enablers. We get heavily involved in design and development of healthcare facilities. The key to that is equipment. So out of interest how many of you here actually are actively involved in design, development, developing services in hospital from the word go? So one, two, three, oh dear, right! One of the problems is that services within healthcare tend to be very siloed. Biomed Departments tend to be on their own, so visibility at high level doesn’t tend to be particularly good, and I think that’s something that needs to change. I think one of the key players in developing services in the healthcare are biomed departments, and I think my little presentation today will help sort of make us see that, and also perhaps give you some enthusiasm to get more involved. I think it’s a tremendous opportunity.

So, I’m talking about theatre integration. And by theatre integration, it’s not just theatres, it affects quite a few areas, and I think one of the trends in working in health services you tend to look at your own area; you don’t look at the whole hospital as a whole. And quite often some solutions, technical solutions are being used in one area of the hospital that could actually solve a problem in another area of the hospital and nobody realises it, because they want to look surprised. I mean that’s what being involved in design development actually forces you to do. So what I’m going to do is talk about how integration within the operating theatre environment. And also it’s not just that. It’s areas like endoscopy, it’s areas like cath labs, intervention rooms, across the board, seminar rooms, teaching rooms, MDT rooms. How does that improve patient safety and efficiency? We’re going to look at some of the vendors and some of the technologies that are available. And also we’re going to look at a practical example, a case study of a particular new development, the new Papworth Hospital, which is actually sort of on the cusp of going live as we speak. They’re actually doing all the air tests in all the theatres at the moment and so it gives you a little bit of a story to put this all into context.

So, does any of this look familiar? I didn’t just make this up. These are real anecdotal things that I’ve come across as part of my consulting when talking to clinicians and talking in the context of developing a new theatre complex or whatever. Are you all aware of people storing patient data on sticks? Yeah, you’ve all come across that. What happens with GDPR when you need to delete that data and it’s sitting in the pocket of a consultant sitting in the carpark, it makes life difficult. Sellotaping printed pictures onto handwritten reports. This is in a hospital that has electronic patient records. So how does that get into an electronic patient record? Well somebody goes and scans it and it ends up in a database somewhere of scanned records. But in this day and age? With iPhones and everything, should we really be taking clinical pictures, printing them out on paper, cutting them out with a pair of scissors and sticking them on a piece of paper with a bit of Sellotape? I don’t think so. The other thing is how on Earth do you find it later when you want to refer back to a case as part of your treatment process.

The other thing also that happens, which is a bit scary actually from a patient safety point of view, got a surgeon, say an orthopod, orthopaedic surgeon, he’s sitting there with his knives and forks doing what he’s doing and he thinks oh I really would like to look at the image of the last scan that was done. So he has to put down his bits, walk across the theatre to a computer over here, look at the image, hold it in his head, come back and carry on. Now, all of us work on, probably have had experience of working on cars, we’ve all got a Hayes manual in one hand and the engine there in front of you and you’re sort of doing that. Surely that’s a more efficient way of working than actually having to sort of hold, learn the Hayes manual off by heart and then be doing what you’re doing. But there’s some cables. I guess you’ve been involved in connecting things to something else, used to be the life blood, a bit of coax and some DNC cables. Always being run over by trollies and being broken. And funny thing this actually came from the ODPs being shouted at that nothing works. You know what surgeons are like if a widget that is supposed to be connected to something doesn’t actually function.

So, when we talk about theatre integration and, how many of you have actually been involved in a theatre integration project? Like installation of an Olympus ENDOALPHA system or a Storz or a Stryker theatre or something like that. And they’re sort of referred to in that way: oh we want to Olympus theatre, oh we want a Stryker theatre, driven by very specific modalities. Well hopefully I’m going to try and destroy that concept a little bit today. But in principle that market’s been driven by the camera: oh we’ve got this nice camera here, this nice scope, this nice telescope, and I want to put it on my stack and sales guys from various big boys come along and say well actually we’ve got display and you put that bit in there, it’s on a nice mobile stand. You only get that image quality if you buy our display and you buy our scope, and it’s sold to the clinician and off you go and that’s installed. So the camera drove the solution to a certain extent.

The other thing to bear in mind is that there is a bit of a change, a force for change in terms of how theatres are being used and how data’s being used. There are quite a few talks over these two days talking about integration generally, data integration, how being able to run analytics on things actually improves what you’re doing, what you’re trying to achieve as an organisation. So from an operating theatre point of view more and more minimally invasive surgery is being used. And it’s not just the domain of laparoscopy. It’s finding its way into orthopaedics, into general surgery. There are more and more cameras popping up. And by cameras, I don’t necessarily mean just the cameras that are inserted into a patient. I’m talking about cameras, head cameras. We’re talking about sharing of knowledge, training, education, that type of thing. Also, there are more widgets around, which have an output that somebody wants to see somewhere else. So there’s an increase in the number of sources of information. So, by data, we’re not just talking about ones and zeros. We also are not just talking about images. So we have to have some mechanisms to pull that all together and manage it and distribute it in the way that we want to.

Now funnily enough the NHS has never been at the forefront of technology when it comes to design development of hospitals, but how many of you know what an HBN is? Deathly silence, oh one, two, again two, three and a half. So an HBN is a health building note. There are two documents that are really key to how you build a hospital: HTMs, which your friends in estates will know all about, the health technical memorandum, and the others are HBNs. So you can look at an HBN, they cover all departments. So if you were to open up a new outpatient for something, you can look at the HBN and it will tell what you should be doing, how it should be designed, what size it is, and so on and so forth. They’re usually about 10-15 years out of date and they don’t keep step with the technology, but it provides a baseline. And HBN26, which is the one about theatres, actually hints at theatre integration. It’s got a little bit, it’s recommendation. So it’s something as technologists we need to be aware of and we need to understand more about.

Just one final thing on that, the main drivers for doing all this is safety, ergonomics, meeting GDPR requirements, being able to do data management, reporting, and I think there’s a couple of other things to add onto that, which is sharing of information and distributing it around the whole hospital environment. So, I have a question, will an integrated theatre move away from being the specialised area that it’s come from historically? So, driven by endoscopy or driven by laparoscopy, will it become the standard for all normal general non-specialised operating theatres? My view is that it will. And the reason for that is that there is, as I already mentioned, increased use of cameras, there’s obviously new technologies, use of robotics. They’ve all got some sort of visual element that needs to be distributed around the operating theatre. Training, we’ve mentioned. One thing that’s intriguing: dash cam for theatres.

Now we don’t actually have that yet, but it’s standard practice in some European countries so that you record every operation. So you’ve got a record of exactly what went on. You can’t do that without some sort of integration solution. The other thing also is that a bit which you probably might not get that involved in and that is the need for reporting systems. So we’re not talking about being able to say well here’s this picture I took of this procedure and I stuck in a little reporting database and pushed a button and out comes a patient record that goes off into the EPR system or wherever and there we go; these reporting systems, certainly for endoscopy, are very specific. They actually report on the whole patient experience, the whole procedure, the whole process. So it’s more than just capturing pictures and storing them. But it makes it very difficult to do that if you don’t have some sort of integration solution in the room that you’re using.

The dreaded IT pops up. IT departments are starting to become quite savvy when it comes to putting in a better infrastructure for hospitals. There’s a growth in obviously the use of sophisticated PAX systems, EPR solutions. Some of you might be involved in implementing a new electronic patient record system. Anyone involved in that? Like Lorenzo or Cerner. I think one over there. That’s something else which is going to come and hit you between the eyes before too long, and also being able to provide things like a vendor neutral archive. Because all this data needs to go somewhere, it needs to go and be stored somewhere.

So for sure you can pay your PAX company to increase the storage but that costs a fortune. So trusts are starting to build their own vendor neutral archives. If you’ve got a vendor neutral archive, you’ve got somewhere to stick all this information that you’re capturing, all these videos, all these stills and so on that you’re taking into something that can then be linked into the patient records. So that when you’re looking at someone who’s in outpatient clinic, you can say well that was what it looked like before I did my stuff and that’s what it looks like now after I’ve done my stuff and look at the difference – which is very difficult to do if that image is stuck on a piece of paper in a scanned record somewhere.

One thing I’ll just mention very briefly and that’s MDT rooms. Anyone know what an MDT room is? Anyone ever heard of an MDT room? Right, there’s one. So MDT room, multidisciplinary team rooms, very important in hospitals. They’re the life blood of the hospital. In fact sometimes they’re more important than the theatres are, especially for centres that are used as referrals centres, because it’s where patient cases are discussed. And you’ll have in that room, which is basically like a bit seminar room, access to all the visual and data information you need on a patient. So you might have three or four displays. You might have a microscope. You might have the need to communicate with video conferencing with another hospital down the road, and also to have communications with other parts of the hospital as well, so you can get a full pathology, for example, so on and so forth. So you’ve got a complete holistic view of what’s going on with the patient.

So this, although that sort of technology is there, connectivity is key to make it all work. An example of that, related is that in theatre, if you take a sample and send it off to pathology, the pathologist looks at something under a slide and then might ring up the theatre and say oh yeah I’ve found XYZ, isn’t it better if they can just take an image of what they’ve seen from the microscope and pipe it down into theatre so the surgeon can actually see it? So my message is that I think that integration is actually going to become the de facto standard.

So what is it exactly? Well it’s a layered thing. At its very basic level, it’s AV management and control, so you need a system to control that. Layered onto that you’ve got all the connectivity to make it work. You’ve got this thing called instrument control, which is something that’s very brand specific. If you have an Olympus theatre, it enables you to control the various devices on your stack remotely. If you were to wheel a Storz stack in, you couldn’t do it, it wouldn’t work, so it’s very brand specific. So that’s why it’s optional for specific types of areas. And then we have full bi-directional IT integration, which is the layer that sits on top of that. So you’ve got your foundation on the left over there, and you build upon that your connectivity and instrument control, and then you’ve got your full bi-directional integration – which means that rather than just viewing a PAX image, you can actually annotate an x-ray or whatever and store it back up into the PAX system. Or, as you move further to the right-hand side, then obviously the cost goes up and up and up, so it depends on how much money you want to spend.

So who and what does it impact? Well, the key to this is room design. If it’s not designed right, you haven’t got the right pendants, you haven’t got the right suspension systems, and you haven’t allowed for putting monitors on walls and that type of thing, then you’re going to run into trouble when you try to implement a solution. But I see clinical engineering generally being quite heavily involved in room design and the hardware: what’s the nuts and bolts that are actually going to make this work; who are you going to go and buy it from; what sort of solution do you want? And the thing is that it’s very rare for a clinical department to actually say oh yeah I want one of those. What you’ve got to do is understand what everybody needs for that theatre, different surgeons or whatever, knit it together and then you can write a specification for a solution that will actually meet what they want to do.

In the IT domain, that’s where all your documentation archiving goes, all your vendor neutral archives. Integration with other systems, being able to send, take information from various disparate applications and pipe it down into theatres. So if someone sees something on a screen then you can actually, the whole integration system’s interfaced into it and you can achieve that. So basically this is a bit of a busy slide, but what you’ve got, so taking an operating theatre as an example, you’ve got various separate theatres, which is where your integration hardware sits. And then up in the clouds you’ve got your IT department, some might argue IT departments are always up in the clouds, but with the various databases, applications and things that you’re actually using as a hospital. And as the user you’re able to access everything from within that cloud.

So if you want to take a picture during your operation, you want to be able to edit it and upload it into a patient record, that’s sort of enabled with the IT solution that sits above it. So I guess if you look at who has responsibility for what, clinical engineering would be involved in what goes on in theatres. Obviously the cloud stuff is all IT. So, effectively, in terms of efficiency in theatres, integration is a key element to make sure you get the right information at the right place at the right time.

So who are the vendors? Well they fit into two camps. Historically it was very much brand driven. Then you started to see vendor neutral providers appearing on the market. And now I think that virtually all suppliers now could consider themselves as vendor neutral. So it doesn’t matter whether you’re a Storz, a Stryker or an Olympus, apologies if I’ve missed anyone off, but it tends to change on a daily basis. Now, when you actually look at those vendors and you look at the technologies that are driving then, and you’ve got sort of the names that all know and love, MAQUET, Arthrex, Storz, Sony, Miravara, Stryker, and you actually look at the technology that’s actually sitting behind it, 50% of these suppliers all use the same platform. It’s usually Barco-driven. And displays on the whole are either Barco or Sony. There are cheaper displays out there, but you cut your cloth accordingly.

So if we look at some practical examples of how we achieve this integration. This is actually from the Met project. This is the design of their current orthopaedic theatre. Now I don’t know how many of you actually ever look at 1:50 drawings. It’s exciting stuff really. But if you don’t recognise the icons, what you’ve got there are a couple of pendants either side. But you see the lines that are drawn in red, those are suspension arms. So in the middle you’ve got your operating lights. And to the left and to the right you’ve got a little red arm with a green thingy on the end of it, well that’s the display. If you look north onto the wall there, you’ve got your surgeons panel. And you’ve also then got your AV integration panel to the right-hand side, and control panel. So what that gives you is a large 52” display that’s up on the wall and a little touch control panel which enables you to do, very simply there’s my input, I want it to go to that display. And these displays are managed in such a way you can have picture in picture, picture and picture, or put them in quad mode or whatever. So you could have physiological measurements from your patient monitoring on one bit of the screen. You can have a PAX image. Somebody wheels in an ultrasound machine, you plug it in and you have an ultrasound image, so on and so forth. And you can route that to any of the displays around the room.

One thing I would say as far as integrated with PAX and legacy systems, there’s a very cheap way of doing that, which is very simply to take the output of a PAX review PC and route it through into the system so that gives you your PAX image. The next level up of actually having bi-directional communication with your PAX system, so you can annotate on your AV integrated system and that takes a lot more integration and that is a more costly solution. So anyone heard of Brainlabs? Right, have you come across Brainlabs Buzz? That’s a system which really does revolutionise the way in which theatres work in terms of data integration as opposed to just video integration. But you can’t have that unless you’ve got your AV routing and management in there as a baseline to start with. So that’s like an add-on. You can add that on later on.

So if you look at a couple of architectures. It depends on what your trust is doing and what the project is. This is an example from Olympus, which very simply and succinctly shows what an AV integration system is. You’ve got various data sources on the left, goes through into a big box, and then you can then route it through to various output devices, various displays and so on. What I would say if you’re involved in these projects the first thing I’d think of is future proofing. Don’t go down the route of a copper-based solution, go for fibre. Because although there aren’t very many 4K devices, 4K imaging is the domain of surgical imaging using telescopes. Endoscopy hasn’t quite caught up yet. They’re still HD quality and 3D. But it won’t be long before 4K comes to endoscopy as well. And of course around the corner there’s 8K. And you aren’t going to do that on copper. So go for a fibre-based system and uncompressed video over IP is the way to go.

This is a real installation. This is the new Papworth Hospital. And it might look like one of those flow diagrams that you get about Brexit in the newspaper as to what happens next, but it’s actually relatively straightforward. You’ve got your various input sockets that you have, which would be on pendants or on the wall. Top right-hand corner you’ve got the big display that goes on the wall that you can put stuff on. And then on various suspension arms you’ve got displays that can be moved around into the patient area. The biggest argument I have is normally with IT who say how much for one of those displays? I can get you one for £70 or something from Dixons. And you say oh no, is it a surgical grade display, it’s in the surgical area. And then that puts a different price bracket on things.

So to give you some idea surgical grade 4K display usually in the region of £10,000 each. So three displays in one theatre, you know, that’s £30,000 before you’ve even done anything else. The big wall display can be a commercial grade display, you know, a couple of thousand pounds, because they’re normally behind a screen. So you can display your iPhone through the system. So you’ve got music, so you’ve got speakers, you’ve got AV there audio part. So you’ve got your ability to video conference as well, you have microphones. Some of this stuff, what people don’t realise is that some of this principle is there, inherently, in a cath lab. If you look at a cath lab or an interventional system, it is an integrated system in its own right, because you’ve got all the various toys that are plugged that go through to displays. You’ve got the clinicians wandering round with wireless microphones talking to each other and talking back to control room, etc. etc. All this sort of principle is there and established.

So what happened in Papworth? Well, just very quickly, this was a project that was back to front. So they built the hospital, then installed all the architectural systems, all the pendants and lights, and then tried to figure out what they were going to do with it. And the problem was that every clinician wanted something slightly different. No one had actually sat down and actually wrote out a spec to actually say well we think you need an integrated system here. So we had the challenge of trying to install a solution, well, let me rephrase that. We had to prescribe a solution which would meet all of their differing clinical needs into a PFI hospital that had been completed to do something that it wasn’t designed to do.

So, although they’d had the foresight to install arms to hang displays on, they were loosely called PAX displays, and nobody really had got their heads round how they were going to get a PAX image from somewhere, i.e. a PC, onto those displays, other than just pulling a piece of wire. And it never ceases to surprise me actually as to where some of the drivers for this nebulous sophistication in theatres actually comes from. And the actual driver, one of the key drivers was actually really simple, it was about having the ability to repeat the output from a patient monitor on a display up on the wall. And the reason why that was so essential was because of the sorts of procedures that they do, the surgeon needs to look at the physiological measurements continuously during doing what he’s doing. And if it’s something low down, like an anaesthetic machine or whatever, he can’t do that. Because you’ve got profusionists in the way, you’ve got all sorts of clobber. And if you’ve ever been into a cardiac theatre in full tilt, then you’ll see that you can barely see the patient; it’s just a sea of green, of stuff that they’ve got all around them.

So we had to design and develop some sort of on-wall module to put onto the wall that didn’t upset the PFI consortium. And in that wall we got the facility to put in your on-wall display, put in your control panel. And I don’t know how many of you have got the older Olympus ENDOALPHA systems or the Storz OR1s, but you know the big 42 unit racks that you have sitting outside the theatre, or a big box in the theatre, have you seen those? Well that all disappeared. That all goes into that in-wall solution. So you don’t have to have anywhere to put the big racks and the switches and everything.

So, just to make you feel happy and comfortable, I just thought I’d show a picture of some input sockets which are mounted on all the pendants, so all the pendants have the same sockets. One key thing is that don’t go down the route of being tricked into thinking oh everything has to be fibre in terms of connectivity, otherwise you have to put an encoder on every device you want to plug into the system, which is very expensive. The system should be versatile so that you can plug in more traditional SDI signals or whatever directly into the system and the conversion’s done in the background. So you’ve got quite straightforward connectors there. The one that’s most intriguing is the one in the bottom left, which is a Neutrik’s connector. So, if you’ve got a stack, you put an encoder on the stack, one cable, you plug it into that socket there and everything’s connected; the system automatically recognises what’s been plugged in and formats everything so that you get the right display, the right image on the right display and so on.

So I think I’m nearly done now. So that is actually the finished solution as of last week. There was a bit of a rush to go through. In Papworth, there were five theatres, one hybrid theatre, one hybrid cath lab theatre and five cath labs, which were done as part of the project. And the advantage of that is that once it’s actually in the building it has all sorts of hidden benefits for the rest of the hospital in terms of access to information.

Thank you.

 

Andrew Frost's presentation at the EBME Expo: Operating Theatre Integration New Efficiencies