Building the OR of the Future
Healthcare information technology promises to improve hospital workflow, increase accountability, and ultimately deliver better patient care. Prominent examples include electronic medical records (EMRs) and telemedicine. While these tools remain a work in progress, there is no question that they have rapidly reshaped the way we treat patients. In just the last 15 years, EMR adoption in physician offices rose from 20 percent. to nearly 90 percent.
Operating rooms (ORs) represent a new frontier for technology implementation. More specifically, radiofrequency identification (RFID) can foster a model of automated supply chain and inventory management that advances patient safety and improves efficiency.
OR workflow relies on mistake-prone processes
Despite marked advances in surgical techniques (e.g. minimally invasive surgery), supporting workflow processes have changed little over time. For instance, the systems by which technicians select instrument trays, transport them to and from the OR, and manage sterile processing have remained largely constant.
Inside the OR, both patients and equipment are manually checked in and monitored. Prior to an operation, nurses use checklists to confirm the patient’s identity and the surgery for which they are present. And at the end of the case, they conduct instrument counts, physically accounting for sponges, sharps, and other instruments in order to decrease the risk of retained foreign bodies in the patient.
These practices are considered standard of care. Yet that standard has substantial room for improvement. Equipment-related errors are commonplace in the OR, including incomplete instrument trays, lost equipment, and failures in updating and using surgeon preference cards. One study in BMJ Quality & Safety found that a typical surgery had more than 15 errors, of which approximately one-quarter were equipment related.
Meanwhile, checklists and counts may prevent many mistakes but are far from error-proof. In the U.S. alone, there are an estimated 4000 surgical “never” events per year, referring to catastrophic errors such as operating on the wrong patient or performing the wrong surgery. An estimated 1,500 of these involve unintendedly leaving a foreign body inside the patient, most commonly sponges.
New technologies can reduce errors and improve efficiency
There is considerable interest in developing better strategies to reduce errors in the OR. These range from outsourcing staff to implementing electronic dashboards. Another promising model is to use RFID tags.
RFID technology uses radio waves to identify and track tagged objects. It does not require line-of-sight reading, in contrast to a barcode, making it possible to track large, packaged sets of disparate items.
Some of the earliest surgical use cases of RFID have been in detection of retained foreign bodies. Multiple studies have demonstrated a 100 percent detection rate of RFID tagged sponges that were placed intraoperatively. Moving forward, there are dozens of other applications, including:
· Patient armbands to confirm a patient’s identity the moment they are rolled into the OR
· Monitoring of instrument sets to ensure that kits are complete and adherent to surgeon preferences prior to being sent to the OR
· Location tracking to prevent loss of surgical tools
· Data collection on equipment use, breakage, and other instrument-level information
As the above examples illustrate, there are many advantages to reimagining surgical services with HIT. First and foremost, it lends itself to patient safety. Second, it improves equipment management, thereby addressing one of the biggest sources of unanticipated costs and inefficiency in many surgical departments. And third, it provides information that can be used to optimize purchasing and workflow decisions.
It is important to recognize that RFID technology will not replace perioperative human judgment and decision making. Indeed, there is a critical human component to designing use cases for new technology, analyzing the data, and managing quality improvement. Instead, the technology is a compelling complement that can make service providers in the OR even more effective.
Barriers to implementation are addressable
In spite of its potential, RFID use in ORs continues to face technological, regulatory, and commercial barriers. There are ongoing questions about tags’ ability to withstand sterilization cycles over time, interoperability of the IT system with existing EMRs, and the possibility of interference with other medical devices.
The tracking technology itself is not infallible. Studies have shown that the accuracy of RFID readers can decline in the presence of other electromagnetic fields or in certain physical environments. It is unsurprising then that the Food and Drug Administration (FDA) closely monitors RFID products.
Cost is another key barrier to use. A study of limitations on RFID uptake in hospitals found that the expense was the single biggest concern among administrators, with the estimated cost of launching a system rising into the millions of dollars.
These are legitimate concerns but they are addressable. For example, new tags have demonstrated that they can tolerate different forms of sterilization and concerns around interference can be mitigated. RFID technology will require further development and validation in healthcare settings. As that happens, it can have a transformational effect in the OR.
Akhilesh Pathipati is a resident physician at Beth Israel Deaconess Medical Center and Signature Healthcare Brockton Hospital.
Elizabeth Casey is Vice President of Surgical Services at Baystate Medical Center.
Alyssa Rapp is CEO of Surgical Solutions, a healthcare services company owned by Sterling Partners. She is also a lecturer in management at the Stanford Graduate School of Business and the managing partner at AJR Ventures.
