INSIDE THE CURRENT ISSUE

February 2007
Operating Room

Outpatient Connection

Patients who receive drug-eluting stents should continue antiplatelet medications

Patients who have had drug-eluting stents inserted to prop open blocked coronary arteries should continue to take medications to reduce the risk of blood clots for at least one year after the stent is inserted, a new scientific advisory recommends. The American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons and American Dental Association issued the joint advisory. It will be published in Circulation: Journal of the American Heart Association, Journal of the American College of Cardiology and Catheterization and Cardiovascular Interventions (CCI): Journal of the Society for Cardiovascular Angiography and Interventions. The medications clopidogrel and ticlopidine are in a class of prescription drugs called thienopyridines. Thienopyridines and aspirin are known as antiplatelet agents. They are begun before stent insertion to reduce the chance of clotting within the stent, which may result in heart attack or death. "Despite this benefit, antiplatelet therapy is sometimes prematurely discontinued within the first year after stent implantation," the advisory warns. This practice is potentially deadly. Stopping antiplatelet therapy too early after a stent is placed is the leading independent predictor of stent thrombosis – blood clots that frequently lead to heart attack and/or death. "Death rates due to presumed or documented stent thrombosis range from 20 percent to 45 percent," the advisory reports. "We want to alert patients and healthcare professionals that this is a serious medical issue; they shouldn’t even think about stopping antiplatelet therapy because it could result in heart attack or death," said Cindy Grines, M.D., chair of the advisory writing committee and a cardiologist at William Beaumont Hospital in Royal Oak, MI. "If a physician, dentist or surgeon feels that stopping these medicines is absolutely necessary, the patient’s cardiologist should be consulted, and the medications should be re-started as soon as possible. Patients are advised to postpone elective procedures if the physician or dentist doing it isn’t comfortable with continuing antiplatelet medicine." The advisory group also made the following recommendations: The physician should discuss the need for antiplatelet therapy with the patient. In patients not expected to comply with 12 months of thienopyridine therapy, a bare metal stent should be strongly considered; In patients who are likely to require surgery within 12 months of receiving a stent, a bare metal stent or balloon angioplasty with a provisional stent should be considered instead of routinely using a drug-eluting stent; Patients should be specifically instructed before hospital discharge to contact their cardiologist before stopping any antiplatelet therapy, even if instructed to do so by another healthcare provider;Healthcare providers who perform invasive or surgical procedures should be made aware of the potentially catastrophic risks of prematurely stopping thienopyridine therapy, and should contact the patient’s cardiologist to discuss optimal patient management.For the complete list visit www.americanheart.org.

Central control stations add brains, brawn to OR

But many facilities fail to harness true power

by Julie E. Williamson

It’s been said that humans use only 10 percent of their brains, leaving
behind a storehouse of untapped intellectual potential. Sadly, it seems the same can be said for some surgical departments that have invested in high-tech centralized control stations.

Although these control stations are essentially the brains of the integrated OR, capable of centrally commanding a wide range of OR equipment and functions at the simple touch of a button — from lights and tables to digital images and environmental controls — some facilities have yet to tap into their true power.

According to Russ Hardy, surgical integration marketing director STERIS Corp., Mentor, OH, an informal study revealed that roughly 70 percent of customers primarily use the control stations to operate their music systems and conduct simple video routing.

"They sky is really the limit on these control systems’ capabilities, but we’re not really seeing too many facilities using them to their [full potential] yet," he explained.

Numerous factors are contributing to the rather limited, even elementary, use of the systems, including inadequate facility infrastructure to accommodate some of the more advanced integration capabilities, and an inaccurate assessment of the features and functions required by the facility.

"Too often, people get hung up on having the very latest technology, but haven’t given enough thought to how they will actually apply it, or whether their current infrastructure will even support some of the more advanced functions," Hardy continued.

Smart systems, intuitive controls

STERIS Harmony Integrated OR

Hospitals wishing to board the surgical integration bandwagon and tie all their components to one easy-to-use, central control station may be surprised to learn just how far the technology can take them.

Aside from serving as the central control for the OR’s sound system, nurses can use the workstations to route a wide range of images; control picture archiving & communication systems; operate surgical lighting and digital recording and printing devices; and manage temperature and overhead lighting within the surgical suite. The systems can also facilitate teleconferencing and telemedicine, with control stations being used as telephones that link to speakerphones in video monitors and bedside microphones for hands-free communication. With the right technological infrastructure in place on both ends, these systems make it possible for healthcare professionals to communicate, share images and relay pertinent patient information to care partners in other departments, such as pathology, radiology or laboratory — either from within the same facility, across town or even globally.

While vendors offer their own version of centralized control stations, many are adopting an open architecture that lets staff operate other manufacturers’ equipment – a noteworthy benefit for facilities that want to explore the latest technology without being tied to just one vendor. Many manufacturers’ control stations share similar capabilities, although there are some subtle – and not so subtle – nuances. Smith & Nephew’s CONDOR Control System, designed as the nucleus of the company’s Digital ORs, allows medical staff to control devices, patient information, and even lighting and temperature of the operating room. The CONDOR technology makes it possible for a medical team to send commands to medical devices, digital cameras, image management systems and other components using voice commands and a wireless touch panel. It also enables real-time streaming audio and video of the procedure over the Internet to classrooms, offices and consulting surgeons in other locations.

Voice activation is a stand-out feature of Stryker’s Sidne system, a wireless device management solution that allows centralized control over devices in the OR. The system can integrate and operate surgical equipment and control the surrounding surgical environment.

Fortunately, intuitive touch screens and controls, which are vital for maximizing efficiencies and utilizing system capabilities, are becoming common fixtures on today’s control stations. "Systems must be intuitive and easy to use, or they won’t be used to their full potential," said Steve Palmer, director of marketing for Berchtold Corp., adding that OR nurses and other potential users do not want to navigate through elaborate and potentially confusing drop-down menus.

The touch screen on Olympus’ EndoALPHA, the centralized OR control panel for the AlphaOR, makes it easy for nurses to operate all equipment from the sterile field, including the insufflator, electrosurgical unit, TV camera and light source. Frequently used functions are accessible from the main screen and display layouts for all equipment are both simple and uniform. Complete on-screen instructions are also provided, allowing anyone to quickly understand and operate the system. A remote control with one-touch operation is also available so the surgeon can personally operate all equipment from the sterile area. Buttons are illuminated so their functions can be easily discerned, even in a dimly lit operating room. Voice navigation is also available for hands-free operation. What’s more, EndoALPHA allows electronic management of data and images, eliminating the need for hospitals to store paper files which is often expensive, inconvenient and susceptible to human error.

"We provide our customers with digital record keeping capabilities to electronically capture, store, access, and display patient information, which makes data and image management easier and more efficient," said Julio Monroy, assistant product manager, surgical, Olympus Surgical & Industrial America Inc. "All of these features are designed to reduce costs by improving efficiencies so the customer can find true value in the product.

The Storz Communication Bus, the brain behind Karl Storz Endoscopy-America Inc.’s OR1 integrated operating room, features a "Realistic User Interface" to aid efficiencies and help take the guesswork out of the OR set-up process. "If a doctor says he needs the lights and insufflator turned on, for example, the on-screen RUI shows the nurse an actual picture of what the device looks like, as opposed to just the name of the device," explained Devon Bream, director of sales and marketing, KSEA. Through the SCB, the system delivers centralized command of all surgical equipment, lasers, surgical tables, room and operating lights, digital documentation, and data storage, and also features advanced teleconferencing technology.

Some systems are taking ease of use and efficiency a step further by allowing users to preset programs. STERIS’ control system makes it possible to preprogram physician presets. If a physician needs a video routed to a specific monitor, or prefers working with the lights dimmed, for example, the nurse can simply press a button on the intuitive touch screen display and be ensured that the physician’s requirements are instantly met.

"The control system can also be preset for specific procedure types that require different room set-ups and image routing," said Hardy, explaining that endoscopic images can be preset and routed to one monitor, while PACS can be displayed on another.

Karl Storz’s SCB can be programmed with as many as 20 customized physician presets, and allows for one-touch operation. Olympus’ EndoALPHA includes as many as 100 electronic preference cards, allowing a facility to preset surgeon settings for quick and efficient set up prior to every procedure.

The integrated touch screen on the Nurse’s Assistant OR Control System by CONMED Integrated Systems also makes procedure set-up a snap. Circulating nurses who use the system can program surgeon preferences, easily switch video signals, activate equipment, restore monitor settings, and set nurse station and room light levels. Telemedicine and teleconferencing, and PACS/DICOM/Digital Interfacing are also possible.

Surgical staff can also count on built-in safeguards with their control systems. Skytron’s SkyVision OR Integration System, for example, features a touch panel display that offers instant response video confirmation before critical images and clinical data are routed and displayed for the surgeon and surgical team.

Thoughtful planning

Despite the far-reaching capabilities of today’s centralized control stations, nurses and physicians must understand that the systems’ more advanced functions are not automatic.

Karl Storz OR1 featuring the Storz Communication Bus

Sources agreed that the key to making the most of the technology – and the investment – is to have a thorough understanding of the facility’s framework and infrastructure limitations. If the hospital is old and outdated, and hasn’t undergone necessary renovations or construction to accommodate component integration and future add-ons, the control station’s capabilities will be vastly limited, they explained.

"It’s important that facilities conduct a thorough assessment and analysis of what they would like the system to do and what infrastructure changes will be needed to accommodate those functions," said John Nies, product manager, TELETOM Equipment Management System, Berchtold Corp.

Most vendors offer consultative services, oftentimes, free of charge, to help their customers meet their current goals, while also planning for future upgrades and expansion. Being equipped with an adequate number of conduits, for example, means facilities can quickly and easily pull additional cabling and incorporate new technology and capabilities when it’s needed, without having to tear out walls and ceilings.

Delaying vendor selection until the eleventh hour – right before construction and renovation are nearly complete — is another big mistake, pointed out KSEA’s Bream.

"People want to wait until the very last minute to pick their vendor because they want to be sure that they are getting the latest and greatest technology," he explained, adding that because technology is always evolving, delaying the process is futile. "Choosing a vendor is something that really should be done in the design phase. If you wait until all the walls are closed up, it’ll be too late. You won’t have the infrastructure in place to meet needs now or in the future."

Being realistic about current and future integration goals is also important. Although laying the foundation for expansion is essential from an efficiency and budgetary standpoint, facilities may be able to substantially curb upfront expenses if their current needs are minimal.

"If you’re in a [sophisticated] endoscopy suite it may be necessary to have more high-level system capabilities. But some facilities just aren’t going to need as much. Why pay for what they don’t need?" asked STERIS’ Hardy.

The good news is customers with more limited system requirements do have access to more suitable, cost-effective solutions.

"If a smaller surgery center only wants to route a couple images to a laptop monitor, for example, they don’t have to buy that [sophisticated control station]. There are smaller solutions that are only the size of a laptop that can do the job just fine," Bream said. "Again, if they want to keep their options open for the future, which is always a good idea, all they have to do is ensure that the infrastructure is in place. A modular approach that lets you use what you need now, while easily adding on later, is the way to go."