Star attractions
Because these integrated O.R.s are designed in large part to keep surgeons happy and productive, it’s important that the system be easy-to-operate and promote an ergonomic work environment. You’ll find systems with touch-screen, intuitive interfaces, voice activation and other features designed to make them easy-to-use for nurses and physicians as well as improve efficiencies in the O.R.

"Integration is not defined as to how many flat screen monitors a customer has in an O.R. but rather the objective of improving ergonomics," explained Spoljaric of the ConMed O.R.

To make its DOCS user-friendly, CompView draws upon its experience in the private business sector. "We come from the world of corporate America where you’ve got to CEO-proof the devices. The average CEO in America is not particularly versed in technology, yet they don’t want to look silly in a major presentation in front of their colleagues or board members," said White.

"At the end of the day, if they can’t become more productive because of the tools you provide them, then we’ve missed the mark. If you think about it in that sense, an O.R. to a surgeon is not a whole lot different than a high-end board room is to a CEO. They’ve got to have technology that is user-friendly, is intuitive, and makes them more productive. In the O.R., hopefully the case takes a shorter amount of time because they’re focused on the patient as opposed to the technology. I can’t tell you how many times in the last couple of years where I’ve been in O.R.s where there was a distraction based on technology or a lack thereof," continued White.

"If the system performs consistently in an easy-to-use manner, then the doctors and the nurses are going to be much more inclined to be happy with the system," agreed Stryker’s Anderson.

Another thing to keep in mind as you’re looking at integrated systems is that surgeons will also be looking for clear, high-definition images and camera systems to give them better visualization during minimally invasive surgeries.

Stryker matches the high-definition capabilities of its cameras, to its high-resolution monitor so that the surgeon "gets a very clear view of the inside of the patient’s body," said Anderson.

"True high-definition video and other digital imaging are the wave of the future which will enhance the clarity and functionality of the flat screen monitors we use even more so than currently," said Spoljaric.

Ultimately, the integrated O.R. will provide a network within which surgeons can do their best work, make quicker and more accurate diagnoses, and treat more patients in less time.

"It’s not only attracting surgeons, but giving them the equipment they need to get great patient outcomes," said Anderson.

Where to begin
If there’s one thing to keep in mind when planning an integrated O.R. – it’s the importance of planning, and of planning ahead to ensure future sustainability and to prevent costly re-dos.

"Any time you’re looking at a purchase, and these are major purchases, you want to make sure that things are compatible and that they perform consistently on a day-to-day basis," emphasized Anderson.

Vendors also stressed the need to include key players early in the planning process. "You have to start off with creating that team: the clinicians, the architect, the equipment planner, contractors, everybody who’s going to touch the project," said Berchtold’s Palmer.

"It begins with the user groups," added his associate Dunkley. "The end users have to have the initial input as to how they want the rooms to work, and what they want the rooms to do."

Palmer explained that gone are the days of being able to bring people in at the last minute to install a cabinet, boom or light, for example. "Today, because so many things are hinged upon other factors, we have to get in as partners as early as possible because what we’re doing on one side might impact what the other person’s doing on the other side," said Palmer.

At the most recent ASHE (American Society of Healthcare Engineering) conference, Palmer heard a speaker illustrate how a small and relatively inexpensive problem can turn into a much bigger and more costly problem if not addressed until final stages of construction. "If you start off with a $10 problem in the first phase, it becomes a $100 problem in the second phase, if you don’t catch it there it becomes a $1000 problem, if you don’t catch it there it becomes $10,000 and it just keeps growing. That’s why you’ve really got to plan it well first in order to stay on track and stay as close to budget as possible, so you don’t get hit with these surprises at the end," said Palmer.

When it comes to surprises, these vendors have seen and heard it all.

"There are several stories out there where there was little or no vision applied during the planning stage," said Dunkley. "They looked at only the cost value of planning for the future. If you do that today, that puts your facility at risk not only in terms of a diminished presence within your local area but it can also virtually put you out of business."

"We’ve heard so many horror stories, about facilities not anticipating this or that," echoed White. "One facility found asbestos in the ceiling and the whole project was delayed an extra 60 days. An O.R. manager said to me, ‘not only did it almost cost me my job, but it cost the hospital a quarter’s worth of revenue.’"

Beyond planning early with all of the key players, what can facilities do to ensure their integrated O.R. will be a success for years to come?

"They need to have vision as to what’s needed now and what might be needed later and they need to align themselves with vendor partners who have that same vision," said Dunkley.

To be sure, most vendors agree that if you’re looking at renovating or constructing an O.R., and you think you may want to integrate in the future (and you probably will), you should plan for that now.

"If they’re considering integration in the future, they should consider pre-wiring their rooms for that possibility. It costs a lot less now than it does in the future during new construction. If you’re doing new construction at least run the conduit lines, even if you’re not going to actually implement integration now," said Broder. "One of the big areas that SkyVision saves hospitals money is in the cost of conduit," he added. "[Skytron] only needs to run one cable back and forth from the monitor to the system. Other companies will want to run several redundant cables which necessitates a larger piece of conduit, takes more labor to install, costs more and can make booms harder to move."

Berchtold is releasing a 3-D interactive planning tool for its sales team that gives them the ability to sit down in front of a customer, and in a real-world 3-D environment create a "virtual" room in which they can view and compare features. "You now have a tool in front of a person who really understands planning that can really enhance and speed up the process," said Palmer.

ConMed offers a "Checklist for New and Renovated Smart O.R.s", on its website, (www.conmedis.com). The checklist details four phases of O.R. renovation and construction: Pre-planning, Pre-Construction, Construction and Post-Construction, and presents several key questions that a facility should ask itself before embarking on any surgery suite project.

Spoljaric gives the following bit of advice for materials managers involved in planning for an integrated O.R. "The purchasing or materials management department should anticipate longer lead times for procurement, planning and installation of equipment for an integrated O.R.

"ConMed begins early with educating the staff and project principles as to the importance of planning and design, and typically prior to the PO being issued we will have already submitted our evaluations and O.R. layout recommendations to the O.R. staff for their review and approval," he continued.

CompView’s alternative to hanging equipment booms and ceiling infrastructures, the NuBoom, itself costs slightly less than traditional ceiling booms, but the real cost savings are found in the installation, said White. "The NuBoom will create a paradigm shift in how people think about upgrading their O.R.," said White.

He explained that the NuBoom can be installed in less than five days, with as few as two or three planning meetings and as few as two key players (typically the O.R. manager and the facilities manager), and no need for a certified structural engineer to sign off on the project. White also pointed to the costs associated with shutting down an O.R. for renovation, which he estimated could range from between 30 to 45, even 60 days. At an estimated cost of $25,000 a day net for the hospital’s largest profit center, a conservative 30-day O.R. shutdown amounts to $750,000 in lost revenue. At the same time, the NuBoom can be installed in rooms with ceilings as low as about 8 ft. Most vendors will agree that a 9 ft. ceiling height is the lowest height they can work with to install ceiling booms.

Anderson cautions that facilities should also consider performance records and service options post-construction. Depending on a facility’s needs Stryker offers remote servicing options, in addition to providing on-site technicians for facilities with multiple integrated O.R.s.

Skytron’s SkyVison enables true remote diagnostic capabilities. This allows a Skytron technician who may be located in Grand Rapids, MI or Chicago, to pull up the integrated O.R. on their computer, and then be able to route those images from their station to diagnose if it’s the fault of the camera or the scope, the monitor or the scaler, then re-route those images through a different source, said Broder. He gives the example of a monitor that wasn’t working properly because electricians had inadvertently cut the power wire to the monitor. "Nobody could see that in the room because it was above the ceiling. Remote diagnostics allowed technicians to diagnose the problem and assist in routing images to other monitors to continue with surgery," he explained.

Stryker is also looking at integrating remote diagnostic capabilities into its system in the near future.

Open architecture and modularity
One way to put the odds in your favor when it comes to predicting the future needs of your surgical staff and forecasting trends is to look to products and systems that operate on an open architecture system.

"What makes integration systems valuable is if they’re open architecture, meaning that you can work with anybody’s camera system, you can work with anybody’s scope system, anybody’s PACS system, microscope, etc., said Broder. "That’s a truly open architecture system." If you’re working with one vendor’s camera system today and newer, better technology comes out tomorrow, you won’t be stuck using outdated equipment with SkyVision, he explained.

"In our world where we come from dealing with the Boeing(s), the Intel(s), the Microsoft(s) of the world, they demand [open architecture]," explained White of CompView.

"You have to have flexibility and modularity in your products today. You can’t just have a fixed-type product, because the [equipment] that we provide the conduit for is changing," agreed Berchtold’s Palmer. "You’ve got to have creative ways from a vendor standpoint, to be able to help deliver the product but also to do it effectively and efficiently over the life of the product. We’re talking about something we’re going to put in the ceiling that’s probably going to be there for about 15 years."

"The technology curve is moving so fast, that you almost have to snapshot it every six months at a minimum to get a perfect picture of what’s available today," said Dunkley. "What Berchtold is trying to do is provide enough open architecture to that superhighway as it were, so that they can do anything on it they need to do in the foreseeable future."

"Miniaturization of equipment makes it possible to use space more efficiently. Paradoxically, while equipment is getting smaller, displays such as plasmas and medical grade LCDs are getting larger," said Spoljaric. "People are getting excited about 32" high-definition LCD displays in the surgical field that will be available next year."

Just a few things on the horizon for the O.R. suite of the future: fiber optics, robotics, RFID, and enhanced telemedicine capabilities.