Today's SurgiCenter - Supersizing Surgical Suites

Supersizing Surgical Suites
Envisioning an Integrated OR

By Kathy Dix

It seems common sense that purchasing equipment for a new or revamped operating room (OR) can be done most efficiently by acquiring every item at once and in integrated form. But what evidence exists to support this theory?

Overall, an integrated suite can improve safety, control, turnover, and profitability, points out Randy Tomaszewski, marketing director at Skytron. However, “There is always the detriment of cost. Not every facility can afford to have the technology to this level; they can plan for their future and integrate it as they go, or have one or two integrated suites, reserving the other suites for their general surgical and other types of cases that aren’t requiring this kind of intervention. And for some surgeons, the other detriment might be that they have to select a standardized system and they can’t always make everybody happy. Eighty percent of surgeons might be happy, or the technology might be tailored to only the top surgeons to keep them happy.

“The big thing is efficiency in the OR and better and more speedy control of various functions in the operating room,” says Tomaszewski. Simple changes such as putting all the “clutter” on booms allows those turning over the OR to avoid wiping down cords and cables, and eliminates the possibility of tripping over equipment on the floor. “It’s the cost of having employees miss work and [the cost to] repair equipment because something inadvertently dumped off the cart,” he adds.

Tomaszewski also offers the example of two vascular surgeons; one surgeon in the middle of a procedure needs his partner’s advice. The partner, who is seeing patients at the office, can go into her private office, pull up a surgery video online and offer counsel immediately rather than driving to the hospital and scrubbing in, Tomaszewski points out.

Economizing

When asked about the efficiency of acquiring an integrated system all at once rather than piecemeal, Jim Wetzel, group product manager at STERIS Corporation, responds, “I think it is more efficient; there are some systems in some companies that allow you to grow into the system. That’s one way of economizing but there are economies to realize by doing it all at one time. (By using one or two vendors for everything), that gets you a couple things: single-source responsibility for equipment, installation, and maintenance, and, if the facility works with the vendor closely, the vendor can help them realize just the equipment they need or the system they need now and then help them plan to grow capabilities in the future.

“Other things to be gained from a vendor point of view: a fully integrated suite is a relatively new concept; vendors want to use that place as a reference site to show their capabilities to other customers, and there are some economic tradeoffs when we do that, such as a quantity discount,” he says.

But the benefits extend well beyond simple cost. “The first benefit is a good operating environment for surgeons and their teams,” says Wetzel. “It touches on a lot of aspects: ergonomics and efficiencies. A system designed by one manufacturer or coordinated by one individual can assure good ergonomics for the entire surgical team; everything is in an appropriate position when it’s needed. Also, the side benefit for staff is efficiency — efficiency in patient care, avoiding staff fatigue, and so forth. Everything is at their fingertips.

“The integration part has a lot of benefits; also the integration with software systems offers a whole world of resources for the team. The system can be tied to the Intranet for managing data, and the data can be in many forms — in PACS (photo archiving communication system) images or other records, endoscopy images, lab results and so on. Healthcare is moving from an outcomes-based system to an outcomes-managed system, and in order to achieve desired outcomes, they need real-time information,” he adds.

“Real-time information requires some method or conduit of funneling that information where it’s needed when it’s needed,” Wetzel observes. “That starts in the OR, or in the critical care area; they need rapid access to this type of information. Some folks will claim that integrated suites do contribute to faster turnaround time. I shy away from a formal claim, though, because unless somebody has done some real hard-core time studies, it’s difficult to prove that sort of thing. I’ve seen with my own eyes how, even with a super well-organized integrated system, the way a facility practices medicine can defeat the potential improvements in turnaround time.

“When you integrate the OR suite with equipment that has multiple capabilities, you leave a lot of flexibility for the future in integrating new technologies. We like to say that we’re in the people business, but in actuality this is a technology-driven business,” Wetzel observes. “What you try to avoid is having customers paint themselves into a corner with limited technologies. Designing all-in-one suites well initially, and keeping them as flexible as possible for future technology, hedges against additional equipment investments.

“It really does start with a master plan, not just architectural, but a business plan, on behalf of the facility. If they plan out as well as they can to anticipate specialties, case loads, where the dollars will be coming from, what they anticipate in the future, it can help them design a suite that gives them the ‘open doors.’ This gives them flexibility for the future while meeting current expected needs. When they use an integration software or system, they need to be attuned to the fact that next year, when they start doing a different procedure, they will need a new piece of technology,” he says.

“The basic idea is to have essentially a controlled OR, with all equipment integrated together, and operated by touch or voice,” says Stacey Persky, marketing manager for surgical products at Olympus Medical. “Any information that’s within the OR can be disseminated to any monitor and can also go to a conference room, to send out to classrooms or auditoriums.”

Such an OR increases efficiency, gives control outside the sterile field to the circulator nurse over every piece of equipment, and gives the surgeon control from the sterile field, she points out.

“The bottom line behind an integrated suite is improvement in both the efficiency and the efficacy of the OR,” agrees John Konsin, vice president of marketing at Smith & Nephew, Inc.’s endoscopy division.

“Three or four years ago, a prominent surgeon came to visit us, and he said, ‘You know, John, one of my biggest problems is turnaround time for an OR,’” Konsin recalls. “This surgeon will do anywhere from five to ten cases without any problem in a given day. He found himself being held up in his own surgery center waiting an extra 5, 10, 15 minutes between cases for the room to turn over properly.”

The surgeon needed an arrangement that would enable his OR to flow more smoothly and push cases through more efficiently. “The idea of getting all of the endoscopic and other surgery-related equipment off the floor, off the carts and onto suspended booms means less carts to move and allows those people to make an operating procedure a success,” Konsin says. “It allows them to clean up that room and turn it over a lot faster.”

Another benefit of the integrated OR is that it allows for centralized control of equipment in the OR. “That equipment can include the OR table and the lights surrounding it, as well as any of the manufacturing-specific equipment that controls light settings for endoscopic cameras, shaver systems, the way images are captured, etc.,” he adds. “The central control frame helps in a couple different ways. It helps with setup, because before a procedure, one member of the staff can go to a touch panel inside or outside the OR and set all the equipment to the surgeon’s preferred settings.

“Another way it helps is during the procedure, when the surgeon or member of staff can adjust multiple settings on the equipment very quickly as a result of the centralized control panel. And everything is easier to move during the procedure itself, whether it’s the light or the patient on the table, or equipment that has to be moved during the procedure. Talk to anybody who has worked in a traditional OR; when you load 100 to 400 pounds on a cart, I don’t care how good those casters are — that’s a lot of weight to move. The way they’ve built these booms, the leverage point is such that you can move it with one hand,” he says.

“Another subtlety that improves the efficiency of the OR is that during the procedure, surgeons will capture images of the procedure and also capture audio transcription of what they’re doing. Depending on the company or options you choose, you can have a fully automated surgical information management system that integrates into the rest of the surgery center. Or you can ask for something a step or two improved from what you have. There are lots of options in terms of how automated you want to get,” says Konsin.

“There’s multimedia networking, which allows you to bring in X-ray images or ultrasound images, and you display it on live monitors with grayscale quality or color image quality instead of old-fashioned light boxes, to show both still and moving images. One benefit of an ultrasound is that you see a real-time image of the blood flow. There is also surgical information management — capturing what happens during the procedure and making a document out of it for reimbursement purposes or to give the patient something to take home to review, or for general filing purposes,” he adds.

“Efficacy is a little bit harder to talk about. Because surgeons have more control of the operative environment, they have fewer distractions, so they believe that the surgeon is getting a better outcome because of a more relaxed staff, less equipment problems, more control of equipment,” he says. “I think over time we’ll be able to document that; at this point in time, the benefits of efficiency are so well understood and so desirable for surgery centers, that they are willing to make this kind of investment up front without waiting for evidence of efficacy improvements.”

Konsin adds, “There’s another benefit that we heard of. If you’re starting up a surgery center and you have an integrated suite, and a candidate comes to town whom you want to add to your practice. He or she is being wooed by a hospital down the street. One of the first things you do is walk him into your brand new integrated suite and say, ‘This is where you’ll work.’ It has vast appeal for surgeons who are being recruited.”

From a marketing perspective, these integrated suites are also valuable in presenting the ambulatory surgery center (ASC) to the healthcare consumer in the best possible light; the technology can be used to drive inpatient traffic to the ASC.

When asked why not every ASC has a high-tech integrated suite yet, Konsin responds, “Because this is a competitive environment and not everyone has the money to do it right away. I think eventually all ORs will be integrated suites. It’s just a matter of time. I’m sure there’s administrators looking at ORs that are 20 years old, and asking, ‘Is it cost effective for me to tear down this OR and build a brand-new one in the same spot, or is it better for me to open up a new surgery center as an adjunct to a hospital and put all new equipment into it?’ Most new surgery centers going up are obviously examining and evaluating this technology. They go in and they plan their OR for the future, deciding what they want it to be two years from now, but we’ll start with this initially and over time build in more capability. They’re putting in some of the basic infrastructure initially, and then allowing more advanced features and options to be added later. That’s a good way to reduce upfront costs, which can be as high as $300,000.”

If an ASC goes this route, starting with the basic building blocks and then adding more equipment over time, the construction will include support for booms and light sources, and appropriate wiring and cabling for future use, so that when the time comes to integrate new pieces, nothing has to be torn down and replaced. Konsin compares it to high-end new home construction, which inevitably includes wiring for sound, for video, for fiber optic connections, assuming that the owners will eventually add many higher-tech options.

Konsin explains that surgery center directors who have a good idea of the cost per OR minute can show cost effectiveness over time. “Consider the fact that the room is being turned over three to five minutes faster. With 500, 600 or 700 cases per year, you’re going to more than pay for the extra $100,000 to $200,000 premium in a short period of time. If you can put one more procedure in there per day, do five ACLs instead of four, that’s going to help pay for it. And then if you do turn it over faster and you’ve got the shorter procedures, I would say you’d be able to shut down the OR sooner during the day and turn your attention to patients in post-op recovery before they leave the surgery center that day.

“As for the surgical information management, I think over time you’re going to see some huge benefits in that regard too. You might have a requirement for a lot of outside help during the year to help organize patient records and files. You might be able to cut down on overtime or not hire as many temps to get that under control,” he adds.

The momentum is building even for such expensive suites, Konsin points out, saying, “The cost savings are so obvious, administrators don’t need major studies. When people ask us to help them, they’re not asking for loads of documentation on its cost-effectiveness. Actually, the benefits that I’ve shared with you just leap off the page.”

From Hospital to ASC

“I would say that manufacturers designing a surgical suite tend to be driven by a clinical specialty, or build it as a generic suite,” says Doug Garrabrant, North American sales manager for BrainLAB. “Various vendors in (a specific specialty) have selected a host of technologies that will complement the surgery, adding some additional efficiencies, and even adding technologies that will impact patient care. What we’ve done at BrainLAB is similar to other vendors, in building the OR of the future, but we’ve built our OR around brain surgery, and specifically brain tumor resections.”

The goal was to create an OR that would not only help with workflows and efficiencies, but that would impact clinical goals and the patient outcome, says Garrabrant. “One of the key elements is being able to see the tumor, and knowing that you have removed as much as you physically can; this directly impacts patient survival. We take a high field MRI and have integrated it into our OR, so not only are we building a state-of-the-art OR, we have given the surgeon the ability to define how well they’ve done surgically at the time of surgery.”

Asked if this type of technology would be cost-effective for an ASC, Garrabrant replies, “It’s difficult to measure. The cost to build the OR is approximately $5 million, but the cost to the patient and the healthcare system is greatly reduced, because reoperation rates in adults can be reduced by 20 percent in adults and 30 percent in pediatric patients, one study has shown. That’s a significant savings to the healthcare system, with regard to not having to do repeat operations. I don’t know that we have a full understanding of cost; cost is always a moving figure, and reimbursement is constantly changing. We can measure cost in patient care or we can measure it in real dollars; there seems to be a true disconnect. You have one group really concerned about dollars and cents and delivery, and then you have another subset concerned with patient care and outcome, and unfortunately, they don’t always seem to go hand-in-hand. It seems to be more the insurance companies and the people reimbursing for the procedures; I think administrators tend to be on the side of clinicians, but administrators also have to operate in the real world, with a bottom line they have to be concerned about, and if the facility goes out of business, it doesn’t do anybody any good.”

Garrabrant adds, “From a surgery center perspective, I think by moving imaging into these OR integrated suites, it will allow for (in the future) other types of treatment. If you were putting an electrode into a tumor and lesioning that tumor, and seeing results real-time, that’s a procedure that is today an inpatient procedure. With the advent of technology, it may find itself working into the surgery center arena.”

The first BrainSUITE has just been purchased by Staten Island University Hospital in New York, says John D’Anna, MD, senior vice president of strategic planning for the hospital. Although the suite is not yet integrated, D’Anna can easily assess the potential benefits. “This is a real-time, MR (magnetic resonance)-guided surgical suite. It is still a relatively new thing in neurosurgery.”

In neurosurgery, it is often difficult to distinguish a brain tumor from the brain itself; thus, the MR-guided suite uses real-time imaging during the procedure to denote where the tumor ends and brain matter begins. Typically, a patient would get a follow-up MR post-surgery, at which time the surgeon would note extra tumor material and the necessity for a reoperation. The MR-guided suite allows for immediate results while the surgery is still in progress, which allows the surgeon to make adjustments.

“There are one or two companies that make an intraoperative MR product. There are multiple companies that make intraoperative navigational products in neurosurgery,” says D’Anna. This was the first time the two technologies have been merged and made available to the public.

Although cost-effectiveness of this product in particular cannot be ascertained yet, D’Anna says, “Our biggest analysis is that this is such a big leap in technology that it will draw surgeons and ultimately patients to us that we might not have gotten before. ROI (return on investment) really is based on driving volume to the hospital that we didn’t otherwise get before. We believe that it is technology that is cutting edge, that ten years from now everybody will have something similar to this, but it’s our nature to get out in front of these technological innovations before our competitors do.”

Higher quality of care provided by integrated suites in general is a “no-brainer,” D’Anna says. “You could purchase all these individual components and try to put it together, but obviously, intuitively [integration] makes more sense. If a company is offering a coordinated integrated suite, it’s going to be better technologically and therefore better for quality of care.”