January 2012

Operating Room

Outpatient Connection

Two out of three medical students do not know when to wash their hands

Only 21 percent of surveyed medical students could identify five true and two false indications of when and when not to wash their hands in the clinical setting, according to a study published in the December issue of the American Journal of Infection Control, the official publication of APIC - the Association for Professionals in Infection Control and Epidemiology.

Three researchers from the Institute for Medical Microbiology and Hospital Epidemiology at Hannover Medical School in Hannover, Germany collected surveys from 85 medical students in their third year of study during a lecture class that all students must pass before bedside training and contact with patients commences. Students were given seven scenarios, of which five ("before contact to a patient," "before preparation of intravenous fluids," "after removal of gloves," "after contact to the patient’s bed," and "after contact to vomit") were correct hand hygiene (HH) indications. Only 33 percent of the students correctly identified all five true indications, and only 21 percent correctly identified all true and false indications.

Additionally, the students expected that their own HH compliance would be "good" while that of nurses would be lower, despite other published data that show a significantly higher rate of HH compliance among nursing students than among medical students. The surveyed students further believed that HH compliance rates would be inversely proportional to the level of training and career attainment of the physician, which confirms a previously discovered bias among medical students that is of particular concern, as these higher-level physicians are often the ones training the medical students at the bedside.

Aging stem cells may explain higher prevalence of leukemia, infections among elderly

Human stem cells aren’t immune to the aging process, according to scientists at the Stanford University School of Medicine. The researchers studied hematopoietic stem cells, which create the cells that comprise the blood and immune system. Understanding when and how these stem cells begin to falter as the years pass may explain why some diseases, such as acute myeloid leukemia, increase in prevalence with age, and also why elderly people tend to be more vulnerable to infections such as colds and the flu.

Specifically, the researchers found that hematopoietic stem cells from healthy people over age 65 make fewer lymphocytes — cells responsible for mounting an immune response to viruses and bacteria — than stem cells from healthy people between ages 20 and 35. (The cells were isolated from bone marrow samples.) Instead, elderly hematopoietic stem cells, or HSCs, have a tendency to be biased in their production of another type of white blood cell called a myeloid cell. This bias may explain why older people are more likely than younger people to develop myeloid malignancies.


Smart surgical suites set new operating standards

by Jeannie Akridge

Berchtold/Philips Hybrid OR

Whether they’re called hybrid, integrated, universal, or simply "smart", these advanced operating rooms give surgeons new flexibility by coupling traditional surgical capabilities with the latest imaging modalities. Access to X-ray, CT, MR and other diagnostic equipment typically found in interventional radiology suites and cath labs can help lead to improved outcomes as well as operating efficiencies.

According to a report by Millennium Research Group, the OR integration market will see an average growth of approximately 15 percent per year through 2015.1 "As they become more popular, hybrid ORs also increase demand for new hybrid-compatible versions of such products as surgical tables and equipment booms, while increasing the complexity and cost of integrating devices. Growing demand for advanced operating room equipment that can promote OR efficiency and patient safety will be a major driver of the $2.4 billion United States video and high-tech hardware device market," said the report.

"Over the last 5 to 7 years integrated hybrid rooms have become more common," observed Jeff Dunkley, director of design, BERCHTOLD Corporation. "Integration is defined as a room in which all the different equipment is designed to work together in harmony with each another – and with the staff; thus providing better patient care and more efficiency in those rooms. Hybrid is defined as a room serving both diagnostic and surgical functions in the same location." 

"The challenge in making this work successfully revolves around integrating traditional cath lab imaging equipment with operating room equipment," Dunkley continued. "If designed properly the integrated hybrid suite will cut costly patient transfer from cath lab to OR then OR back to cath lab (and even a return trip from cath lab back to OR in some cases). The patient is diagnosed, then treated, then examined post operatively all in one location."

"We are seeing a movement toward multidisciplinary and minimally invasive (MIS) approaches that synergize the benefits of imaging and surgical sciences," said Robert Popilock, senior market development manager, Surgical solutions, STERIS Corporation. "Many hospitals are working under a paradox; to reduce procedure times for the most challenging patients without sacrificing service quality, while also dealing with tremendous pressure to decrease costs and improve quality indicators such as complication and infection rates for these types of patients. The ability to perform image-guided MIS procedures under the safety net of a sterile environment becomes highly desirable."

"With more complex procedures and the use of advanced imaging, the surgical suite is rapidly changing, increasing the need to access patient data and clinical images in real time during many surgical procedures. This has driven the integration of OR suites into the overall hospital data and patient environment," said Walt Hoffman, group marketing manager, Hybrid OR Therapy, MAQUET. "And, with more complex procedures, hybrid procedures, involving several medical specialties, each with their own equipment and imaging needs, has given rise to the Hybrid OR, in which each specialty can perform their part of a complex procedure in a single room using all of the products and functions they would have in their own dedicated specialty room. All of these specialty devices and equipment must function together seamlessly, sometimes for the first time."

MAQUET Hybrid Vascular OR

Steve Palmer, director of marketing, TRUMPF Medical Systems, commented, "The definition of a hybrid room can vary dramatically, but it essentially brings high-end imaging and surgery together in the same room so that surgical and diagnostic procedures can be done in sequence without delay. What we are seeing is many larger hospitals are renovating to include at least one Hybrid OR. Common surgical specialties include Neurological, Cardiovascular, and Electro-physiology."

"Another way to look at this is in terms of operating suites that are flexible or universal," added Palmer. "Because technology and surgical procedures continue to evolve rapidly, hospitals don’t want a room that’s dedicated to one specific discipline. They want to be able to use these rooms with as many disciplines as possible. So, use for other disciplines is possible right now if the rooms are planned correctly."

Matt Weismiller, president, BERCHTOLD, described key advantages for surgical outcomes by bringing imaging into the OR. "The surgeon can visualize the target more effectively using imaging technology," said. "Even today, specific neurological and cardiology procedures cannot be done without surgical imaging. As surgical techniques continue to advance, especially non-invasive techniques, imaging will allow surgeons to fully visualize the target and the quality of the completed procedure without the complications associated with an open surgical site."

With imaging equipment at their fingertips, "benefits for the surgical team include the fact that success of the procedure can be better validated before completion of the case," said Palmer. "Also, since timeframes are condensed (by eliminating waiting, delays and multiple procedures) so care can be delivered more efficiently and with less staff stress and fatigue."

"For patients, the hybrid OR can minimize the chance of a required subsequent surgery," he added. "Not only the patient, but his or her loved ones can be spared the stress and risk or additional procedures."

Finally, "the hospitals benefit from faster processing times for patients. Also, improved staff satisfaction, retention and recruitment of better surgical talent by offering the latest most sophisticated technologies are considerable benefits."

Smartly equipped

What does it mean to have a truly "smart" OR? What minimal functionality should it have and what type of equipment is needed?

"A ‘smart’ OR starts with data integration," explained Hoffman. "During a surgical procedure, the surgeon needs access to previous patient procedures, tests, and images, while continuously monitoring the patient’s current clinical status. This requires the ability to access a variety of images – from x-rays to ultrasound to CT to MR -- in both still and video formats, often simultaneously on multiple monitors. It is not uncommon for two, four, and even eight monitors to be displaying data from multiple sources to different medical specialties and OR staff."

"All of this data must be coordinated in order to avoid procedural delays and provide the best patient care," he continued. "The keys to success are high-grade medical display monitors, the ability to play and distribute multiple test results and images from various hospital data systems, the ability to control systems to coordinate the rapid access and switching of data sources and displays, and cameras and computer drives that can capture data and images from the current procedure for future review and use."

Dunkley described Berchtold’s vision for a smart OR. "Creating a ‘smart’ OR would involve bringing digital technology and control to the surgical suite – and to the surgical table if requested. The circulating nurse can monitor and, in some cases control, the various surgical modalities from a conveniently located control station within the room. That control/nursing station would use touch screen panel technology, thereby greatly reducing or completely eliminating their need to physically locate and touch pumps, insufflators, light sources, camera controls, etc. The ‘smart’ OR has all been integrated and wired together through the ceiling and boom arms in order to work in harmony. Additionally, a versatile touch screen monitor can be located from the ceiling and, after being sterilely wrapped, conveniently positioned for the surgeon – thereby allowing them direct control of these devices from the surgical table. If this ‘smart’ room is designed properly it can save and create enough time to do one extra case per room per day. There is a tremendous increase in revenue and ROI derived from that," he added.  

Popilock, STERIS, contended, "If we define a ‘truly smart’ OR as one that enhances decision-making confidence, improves procedural efficiency and creates a safer, more efficient environment, then it is essential to have an ideal marriage of fixed and portable imaging equipment such as c-arms, traditional surgical devices, and optimal surgical lighting. To make it completely smart requires the addition of an integration system capable of routing essential information (live and reference fluoroscopy, endoscopy, HD surgical field cameras, TEE, vitals, hemodynamics, etc.) to any location within the room in user-defined single and multi-image formats."

According to Melissa King, senior marketing associate, Integration, Stryker, "A truly ‘smart’ surgical suite would be equipped with an integration control system, a digital capture device, and a boom for dedicated medical equipment. In a ‘smart’ OR it is essential to have the ability to control all of the video signals and audio throughout the room as well as the medical devices located in the room, for instance the Endo camera, the insufflator, and the surgical lights, all from a centralized touch panel via an intuitive user interface. The ability to conference throughout the hospital and abroad is essential as well. The boom assists in cable management in the OR as well as supports OR workflow and efficiency."

Stryker/Philips hybrid OR

Stryker recently introduced a new high-definition monitor, the WiSe HDTV Flat Panel Monitor, the first wireless 1080p flat panel in the medical field, described King. "Uncompressed HD is transmitted wirelessly to eliminate cable clutter and potential costly repairs to traditional flat panels. WiSe HDTV will deliver optimal surgical images with unsurpassed resolution, brightness, and optical clarity while providing freedom to move the flat panel anywhere within the OR. The 1288 HD, Stryker’s third generation high definition 3-Chip camera, delivers an unsurpassed 1080p resolution with optimum depth of focus, and edge-to-edge clarity and sharpness for surgeons. It also features an intuitive touch screen, fully programmable camera head buttons and the ability to control the L9000 LED Light source from the camera head."

Jeff Saunders, project engineer, TRUMPF, described minimum requirements for an integrated OR to include: "at least three lights, an equipment boom, a monitor boom. The trend for the monitor is to have one large (54" screen) where the staff can divide the screen as required: i.e. if the surgeon only wants to see 2 images the screen is split in half, if the surgeon wants to see 4 images, then the screen splits into quadrants."

According to Palmer, imaging components of a hybrid OR include floor and ceiling mounted C-arms, MRI, and CT scanners.

Integral operations

Bringing imaging, video, data capture capabilities and more into the traditional OR environment requires seamless integration of a variety of equipment.

David Church, boom & lights product manager, for Stryker, commented, "Advanced operating suites today are moving towards being fully integrated in order to support the complexity of advanced surgical procedures. By integrating the various components of the operating room, users can operate these components from a single interface increasing efficiency. This integration is crucial with hybrid ORs as hospitals see these suites as a solution to constraints on space, as well as the need for an environment which fosters the ability to create new ways of performing complex procedures."

"The primary objectives of integration are to improve decision making, align the surgical team to better anticipate procedure needs and drive efficiency, and to create a less stressful environment," described Popilock. "This is accomplished through making mission-critical information available table-side for physician viewing, room wide for surgical team viewing, and remotely for education and peer support. The ability to integrate music can also create a more pleasant atmosphere."

Integration systems that are based on an open architecture format offer maximum flexibility for future upgrades.

"Open architecture means that you are prepared to implement any future technology from any viable source," Dunkley explained. "Just because you’ve chosen a certain manufacturer, and their technology today, does not necessarily mean that you will want to choose that same manufacturer and their technology five years from now."

STERIS Harmony iQ Integration System

Harmony IQ systems from STERIS are scalable, open architecture multi-format integration systems capable of concurrently routing a diverse set of signals in their native and high-definition formats to a variety of small, large, and whole wall displays, described Popilock. "This functionality is available at the time of purchase or through field upgrades that do not require rebuilding of the entire system."

Stryker’s SwitchPoint Infinity 3 Control System (SPI3) features an integrated surgical checklist, customizable room presets, and centralized operating room control. "Hospitals also have the ability to bridge the distance between sites across campus or locations abroad via the integrated ConnectSuite IP conferencing platform," said King.

MAQUET’s OR integration system allows data and images in all commonly used formats (e.g., HD-SDI, CVBS and VGA) from up to 12 sources to be displayed on up to six monitors simultaneously. At the same time, the system saves images from the current procedure, either with DVD or USB drives or in standard DICOM formats, to the hospital’s PACs system, Hoffman explained. "The MAQUET OR Integration system is compatible with a hospital’s existing LAN and internet networks, even allowing transmission of live cases to doctors’ offices or to training centers. These capabilities are all controlled through an intuitive touch screen that is easily and readily accessed by the OR staff and that is also used to control OR room lights, Magnus table position, and other accessories commonly seen in the OR."

"Most importantly, the MAQUET OR Integration System is upgradeable so additional features, displays, and storage systems can be added as surgical procedures continue to evolve at a rapid pace with new, unforeseen demands," explained Hoffman.

Booming business

Ceiling-mounted equipment management systems, commonly known as "booms" are the physical strongholds that house the ever-growing equipment needs in the advanced OR. They keep equipment and cables out of the way and off the floor, and feature moveable arms that allow for flexible positioning within the room. Newer boom systems allow for a great deal of versatility and modularity to accommodate changing needs.

"In a ‘smart’ OR, anesthesia, perfusion, endoscopy, surgical headlights, and other critical equipment can be housed on supply heads and equipment management systems that can be easily and conveniently located by the circulating nurse – allowing equipment to be brought in and out of play as needed." described Popilock of the benefits of the STERIS Harmony Equipment Management System.

"Today’s operating room environment is one of fast paced technological change. For an institution to maximize their return on investment, OR booms must provide the flexibility to meet that change," said Rollie Kitchens, global TELETOM product manager for BERCHTOLD. "Berchtold’s latest generation of the TELETOM Equipment Management System does exactly that in a number of ways. First, the system is entirely modular. Berchtold’s OR booms can be configured to meet the exact needs of the hybrid operating room today, service placements can be easily adapted if the need develops, and if future technology dictates the need for additional capability, TELETOM can be readily re-configured to meet the change. Depending on the needs of the institution, that may translate into adding a layer to the existing boom in order to gain additional service capacity, attaching additional monitors to support increasing video needs, or gaining more lighting capability. The new line of TELETOM OR booms adapts quickly and cost-efficiently due to the unique, highly flexible, modular design of the boom and its equally flexible, optional TC-ready suspension system. Making additions to the system doesn’t require gaining access above the ceiling, or making changes to the ceiling mount which translates into minimizing OR down time, and the associated loss in revenue."

MAQUET’s Ceiling Supply Units (CSUs) extend to nearly 8 feet to allow for versatile positioning of equipment, noted Hoffman. "With many different medical specialties utilizing a Hybrid OR suite, it’s critical that equipment be readily available when needed by a particular surgeon and that it be out of the way when not needed."

"With more OR staff supporting different specialties, the ability to easily to move instruments and equipment in crowded OR speeds the surgical procedure," Hoffman added. "CSUs are ideal for fast deployment while eliminating power cords and cables from the OR room floor. This facilitates cleaning, leading to faster OR room turnover, less delay between cases, and a better overall return on the smart OR room investment."

Church, Stryker, noted, "In a Hybrid OR environment, there is a great need for monitor, boom and lighting mounting solutions that work in conjunction with the imaging systems. Larger room dimensions, filled with a considerable amount of equipment, create a challenge for management solutions to have the capacity and modularity for a variety of needs."

Stryker’s FLEXiS boom systems feature a six-sided design that allows for supply of additional gas/video/data services in a smaller footprint; multi-functional rails that allow for adjustability and numerous placement possibilities for shelves and accessories; and various service head sizes and boom arm length options, described Church.

TRUMPF robotic surgical suite at Kennedy Medical Center, Washington Township, NJ

TRUMPF’s TruPort allows all sides and the entire length of the support head to be used and easily customized to meet specific staff and patient needs on a case-by-case basis, and offers modularity to accommodate future processes, procedures and technologies, described Palmer. "Do-it-yourself" simplicity helps improve ergonomics, while reducing service calls, operating room downtime and maintenance costs.

In addition to supporting any laparoscopic or endoscopic equipment required during a procedure and serving as the primary source of providing medical gas and electrical support to the surgical field, "the greatest benefit to TruPort in the hybrid environment is the ease at which we can change the configuration to support new equipment and procedures," said Saunders. "As these rooms become more common place, the spectrum of procedures performed in these rooms will grow. Having equipment that can easily accommodate advancements in technology and diverse procedures is essential."

Future forward suite design

Diligent pre-planning is paramount to creating a surgical suite that not only works for today but can also quickly adopt to accommodate new surgical techniques and modalities.

"An eye should always be kept on what new technology is coming around the corner. Because your hospital may be forced to adapt to it in the near future in order to remain competent and competitive," said Dunkley. "Insure that all of your vendor partners are on that same future proofing and open architecture page. The hospital does not want to paint themselves into a fatal technology corner today, in order to merely adhere to the old bundling and contract compliant concepts of yesteryear."

"We understand that the only constant in the ‘smart’ or hybrid OR is change," he added.

"The science of smart surgical suites is in its adolescence," remarked Popilock, STERIS, The most significant advancements will be based on sound end-user insights. For this reason, it is essential for industry professionals and their clinical partners to forge strong relationships and maintain communication about initial experiences, existing challenges, and key clinical drivers. If we understand their in-use cases and the insights behind them, we can evolve in more meaningful ways."

Imaging technology is one area that’s sure to advance, noted Weismiller. "Many of today’s imaging devices are excellent for use in the OR, and will continue to improve as the requirements for new procedures are better understood. But much of today’s imaging technology was developed for diagnostics, as opposed to interventional processes. The future holds smaller and lighter systems with even better performance that will work effectively in an interventional setting with a surgical team. Today, the physical hybrid OR and the workflow are driven primarily by the imaging device; in the future the imaging device must be tightly integrated into the process and the surgical environment."

Manufacturers with complementary imaging technologies such as Siemens, Philips, GE Healthcare and others, have partnered with surgical suite vendors to offer "package" integrated hybrid OR solutions.

"To avoid incompatibility between equipment from different sources, hospitals should partner with manufacturers that can offer systems that are as complete as possible," advised Hoffman. "When hospitals must work with different manufacturers, they should choose companies that have established partnerships with each other, even to the point of offering a single construction project price and integrated drawings and design."

Modular, adaptable pre-fabricated room systems offer an innovative approach to future proofing an OR suite.

For example, MAQUET’s customizable VARIOP system offers pre-fabricated wall components, windows and doors, and floor and ceiling panels, reducing construction time. "VARIOP represents a unique construction approach to the ‘smart surgical suite,’ offering all the components to design and construct the OR room itself," said Hoffman. "The panel design, provides access to electrical, medical gas, and cabling systems without the need for tools. And the sealed panels facilitate cleaning, making room turnover quick and efficient."

"The TRUMPF ModuBuild medical construction system, offers efficient, flexible room construction, using integrated components including the substructure; walls; ceiling, windows, doors and ventilation connections," said Palmer. "In addition to streamlining construction and significant hygienic benefits, ModuBuild serves to help future proof the OR. Its modular stainless steel panels – powder coated to the hospital’s color of choice - allow easy access inside the walls. This allows service, modifications and future changes in equipment and wiring, including upgrades and expansions, to be accomplished quickly and cleanly."

Ultimately, an investment in advanced surgical suite technology makes good business sense, concluded Church, Stryker. "An advanced hybrid OR suite can help to recruit top-notch surgeons and help to market the hospital to potential patients, so successful implementation is imperative. Hospitals will obviously need to identify an imaging system, boom and lighting solutions that work with, and around, the imaging system and integration equipment that is robust enough to grow with the needs of the OR. However, hospitals should also keep in mind that it is not only the equipment that ensures success of the project. Experience in room design and implementation of other advanced surgical suites is also a benefit to this process. Vendors that have this experience are more able to mitigate the risk of potential issues and help ensure the successful completion of a hybrid OR design project."


1. Millennium Research Group, "US Markets for Video and High-Tech Hardware Devices 2011", May 2011.