The Final Frontier: Meeting Image Demand in the OR

Historically, the OR has been one of the last departments to deploy PACS. In the early days of PACS, hospitals delayed OR deployment because technology was not ready to meet surgeons’ complex needs. But that has changed for facilities with insight, innovation and a good game plan.

“The OR [has been] the most difficult area to meet PACS needs,” confirms Michael Cloutier, manager, technical services at Catholic Medical Center in Manchester, N.H. Bobbi Miller, director of radiology at Toledo Hospital in Ohio, admits the OR was a PACS concern because some hospitals never succeed with the filmless OR.

But the era of the filmless OR has arrived. And with it, hospitals face a dizzying array of viewing options geared to the OR — carts and wall-mounted or boom-mounted displays of multiple sizes and resolutions, special mouses and keyboards for image manipulation and practical solutions that meet the needs of the sterile field.

Indeed, PACS is in the midst of a sea change with many sites pushing the OR to the leading edge of deployment. For starters, the technology to support digital image viewing in the OR exists. Secondly, many hospitals are learning from the missteps of pioneers. Ken Kelly, director of radiology at Jordan Hospital in Plymouth, Mass., says facilities can fail to achieve filmlessness through a lack of foresight. Institutions must blanket the floors, including the OR, with monitors for image viewing, says Kelly.

But monitor size, resolution and placement are just part of the filmless OR equation. The hospital must determine if new network drops are necessary and access the viability of wireless for primary viewing or redundancy. At the nitty-gritty level, the team needs to develop a system for handling CDs from outside institutions (and other PACS vendors).

This month, Health Imaging & IT visits with a few sites that have effectively deployed PACS in the OR to learn about their successes and challenges.


Step one: The surgeon survey

Everyone in radiology and IT knows that transitioning to digital imaging is a challenge. The OR is no exception. “It is a challenge to transition from looking at images on a viewbox located outside of the sterile field to viewing digital images that may be closer,” Barry Castle, PACS project manager at Oakwood Health System in Dearborn, Mich.

Hospitals use multiple tactics to sell surgeons on digital viewing and design a solution to meet their needs. At Delnor Hospital in Geneva, Ill., PACS Administrator Brian Daily held a monitor “bake-off” and surveyed the hospital’s 42 surgeons about their needs. Most decided on dual, cart-mounted NEC 2 megapixel (MP) color monitors and dual, cart-mounted Double Black Imaging’s WIDE 3 megapixel (MP) black-and-white monitors as the preferred option for viewing images stored on the Amicas Vision Series PACS.

Leslie Beidleman, PACS administrator at St. Vincent Hospital/Mercy Medical Center in Toledo, Ohio, used cookies and coffee to lure surgeons to a conference room to evaluate equipment. Jordan Hospital IT staff stepped into surgeons’ shoes, visiting the OR to gain a bird’s eye view of viewing needs and ensure that all angles and logistics such as navigating the logistics of the sterile field were covered in the digital plan.

The surgeon survey typically leads to a fairly uniform solution for viewing digital images: mobile carts (aka COWs or computers on wheels) or wall-mounted monitors, but boom-mounted displays are becoming increasingly popular. As the hospital assesses the pros and cons of various viewing vehicles, it must make another tough decision: monitor size and resolution.


Carts, walls and booms: Pros and cons at a glance

COWs can be placed anywhere in the OR, says Miller. Toledo Hospital relies on seven Philips Medical Systems Inturis PACS workstations mounted on AFC Industries carts. The hospital has encountered one challenge that points to the success of the approach. Surgeons kept stealing carts because the hospital didn’t fully anticipate image demand upfront. When Jordan Hospital underestimated its cart needs, surgeons continued to request film. The upshot is to complete a realistic estimate of the number of carts needed to serve ORs.

A few sites opt for a 1:1 ratio of carts to OR suites, but many find that they can manage with a ratio closer to the 1:2 range. Factors to consider include other viewing solutions; a hospital with a few wall-mounted displays needs fewer carts and the surgical mix as not all surgeries require images.

With proper planning, carts can serve as an enterprise solution. Daily of Delnor Hospital refers to the carts as POWs — PACS on wheels — rather than the conventional COWs and points out that the carts can be shared with other departments like pre-op, PACU and endoscopy — that is if the hospital has purchased a sufficient number and surgeons agree to share. Oakwood Health System bypassed turf battles by equipping each room with its own carts and using some 1.3 MP OR monitors as a PACS station.

Troy Apiti, PACS coordinator for St. Joseph’s Hospital in Tampa, Fla., points out that carts allow the enterprise to maximize its investment. “Carts don’t sit unused on a wall, and we can roll additional carts into ortho or neuro rooms when necessary.”

Many facilities avoid COWs because of space concerns. New York University Medical Center (NYUMC) of New York City opted for wall-mounted displays because carts consume too much real estate, says Chris Petillo, director of PACS. On the flip side, the OR already contains a hefty amount of boom-mounted equipment. It can be tough to find a spot for a PACS monitor.

Similarly, Catholic Medical Center, which relies on GE Centricity and Misys Radiology as its PACS and RIS solutions, placed two wall-mounted, 2 MP Barco Coronis monitors on Ergotron wall stands in its OR suites. Instead of placing a CPU in each room, the facility remote-located PCs in a central cabinet adjacent to its ORs; each OR has its own network switch and CAT 5 cable into the OR. The PC drives a wireless keyboard and mouse that allows users to walk around the OR.

Jordan Hospital opted to integrate 19-inch boom-mounted, medical grade monitors into its McKesson Horizon Medical Imaging PACS. OR staff can change images, log onto the HIS and view lab results from a monitor at an OR work desk.

Willamette Falls Hospital in Oregon City, Ore., also opted for the boom approach. “Walls don’t offer any flexibility,” sums PACS Administrator John Hart. Surgeons, however, weren’t satisfied with the 19-inch monitors on another boom. Hart worked with NEC and Ergotron to modify the boom to accommodate NEC’s MultiSync LCD3000 large-screen LCD display. “It’s hard to satisfy surgeons,” asserts Hart. The NEC configuration does the job because it provides easy and flexible access to patient images and information.


Anticipate exceptional needs

While most surgeons in most hospitals can agree (believe it or not) on a standard monitor size and configuration for viewing images in the OR, some specialists may require a solution tailored to their unique needs. This image-intense population typically consists of neurosurgeons and may include orthopedic surgeons.

Neurosurgery tends to add a layer of complexity to digital image viewing; neurosurgeons need to view multiple CT, MRI studies as well as static chest images, say Castle. Digital ORs have employed different approaches to meeting the needs of the entire surgical population.

When NYUMC scheduled an OR pilot of its Siemens Medical Solutions Magic Web PACS in 2005, the first hurdle arose early in the process. “When we asked surgeons about their needs, neurosurgeons wanted one monitor for every lightbox. This amounted to eight monitors per OR suite. It wasn’t really practical, so we decided to [temporarily] bypass neurosurgery and focus on general surgery,” explains Petillo.

The approach paid off. The wary neurosurgeons were eager to jump on the digital bandwagon after seeing their peers benefit from digital image viewing. The ultimate solution at NYUMC was a far cry from neurosurgeons’ original demands. The center dual-mounted 2 MP Dell 20-inch monitors to each OR wall and added a flip-up keyboard.

Neurosurgeons can be cheerleaders rather than naysayers. A group of neurosurgeons at St. Francis Hospital and Medical Center in Hartford, Conn., championed the transition to filmless viewing of images from its Fujifilm Synapse PACS in the OR. The hospital deployed single 1.8 MP off-the-shelf monitors on Anthro carts in 2002. “The size represents the largest piece of film we had, and it sufficed for neurosurgeons,” notes Radiology Manager Kathy Smith.

Some facilities develop hybrid solutions to meet the needs of different OR users. Take for example Oakwood Health System, which deployed Philips Medical Systems iSite PACS in May 2005. “The OR is a significant film user. We wanted to make sure [all] surgeons could view images online when we went live,” explains Castle.

The health system managed to meet its neurosurgeons’ needs by equipping two neurosurgery rooms with 3 MP Barco Coronis monitors and reserving those rooms for the most complex cases. Other ORs are equipped with cart-mounted 2 MP Barco Coronis displays.

Neurosurgeons aren’t the only tough customers. Delnor Hospital wall-mounted black-and-white monitors in two orthopedic surgery suites to supplement COWs.

Neurosurgeons and orthopods presented a united front at St. Vincent Mercy Medical Center, agreeing that neither single- or dual-mounted 1.5 MP flat-panel monitors sufficed. PACS Administrator Leslie Beidleman returned to the drawing board and equipped five surgery suites with wall-mounted, 40-inch 2 MP monitors to serve as a second OR display option for viewing images from its Kodak Carestream PACS; the specialists have accepted the new option ‘very well,’ reports Beidleman.

St. Joseph’s Hospital also deployed a hybrid solution to better meet the needs of super-users like neurosurgeons. While most of the hospital’s OR suites rely on Planar’s Dome Surgery Review Carts with dual-mounted 2 MP monitors to display images from GE Centricity PACS, neurosurgery rooms use 30-inch, wall-mounted Planar 4 MP monitors.


When bigger is better

At Delnor Hospital, most surgeons were impressed by the 40-inch NEC monitor, but decided on other solutions for day-to-day OR viewing. Catholic Medical Center also wavered between 42-inch plasma monitors and 9 MP monitors; however, its web product could not drive the entire monitor. As a result, resolution dropped or the image was displayed at the original resolution, but in smaller size.

Delnor Hospital did determine an ideal location for one 40-inch display and placed it in the surgical patient consult room to facilitate clinical consultations with patients and their families.


IT issues: Networking and more

It may be necessary to add network drops to link the OR with the PACS. “OR retrofits can be a challenge,” warns Apiti. For starters, ceilings are constructed of drywall rather than ceiling tiles, which make them more difficult to run cables. Plus, the OR ceiling is a high-demand spot with plenty of boom-mounted equipment.

Delnor Hospital added wired and wireless network connections into its OR suites as part of the digital deployment. The hospital uses Cisco switches with redundant supervisor and power modules to insure maximum uptime of the network.  “The wireless is insurance,” explains Daily. If the primary network is down, surgeons can view images wirelessly — albeit at a slower speed.

The slow speed of wireless deters many hospitals from relying on it for image viewing. St. Cloud Hospital in St. Cloud, Minn., has used its wireless network to view images in the OR. The advantages of wireless are safety and maneuverability, says Gene Fischbach, director of diagnostic imaging. St. Francis Hospital also relies on its 802.11b wireless network for OR image viewing. The OR circulator pre-loads images on the mobile workstation. “Speed is relative,” says PACS Administrator Paul Hennessey. “If the surgeon requires a different image, it can be pulled in the same amount of time as it takes to remove film from a jacket.”

Other IT challenges include access to historical images. At NYUMC, images are launched via an electronic medical record, but most hospital staff need images from the one or two previous days. Not the OR. Surgeons require historical images, so IT created two links in the EMR. The “view patient” link launches current images; the “view study” link retrieves older images.

Another NYUMC challenge centered on the limited number of web licenses throughout the enterprise. “All PACS monitors are designed to time out after 30 minutes. You can’t time OR studies, so we created a separate OR account with an eight hour time out,” explains Petillo.

Toledo Hospital found that transferring C-arm images from the OR to PACS was a challenge, so it created a centrally located OR PACS port to download C-arm images into the PACS.


Those pesky outside CDs

Outside CDs can present an OR headache on multiple levels. OR staff may not know how to search for the executable file to launch an image during surgery, or a computer may identify a potential virus and lock out users.

Some hospitals use a dedicated off-network computer for outside images. Willamette Falls Hospital placed a laptop in each OR. The laptop serves multiple purposes, says Hart. It’s used for incoming CDs; surgeons burn CDs with patients’ images and information right in the OR, and it provides a contingency plan with surgeons working off a worklist on the laptop. St. Vincent Hospital is configuring its OR PCs to handle different executables and plans to acquire CDs from local hospitals to evaluate which executables it needs in advance. Delnor Hospital uses KPACS software to create DICOM import and export files on incoming and outgoing CDs.


Closing advice

Ready to start on an OR-PACS project? Exper-ienced project managers offers some final words of wisdom.

• Involve the OR management team as early as possible. Educate them about the benefits and allow physician leadership to stand by reasonable decisions, says Petillo.
• “Don’t skimp in the OR. It’s not an area for cutbacks,” recommends Castle.
• Don’t expect OR staff to become computer experts; look for solutions that are easy to use, says Kelly of Jordan Hospital. For example, a patient care inquiry (PCI) integration between McKesson and Meditech enables surgeons to use the same password to view images and reports.  
• Don’t assume one size fits all, says Hart. Off-the-shelf components can be modified to better meet surgeons’ needs, and the hospital can implement multiple solutions — like a mix of COWs and wall displays or different monitors.
• Put items in the budget even without buy-in from the surgeons because once they see the benefits of PACS, they will want it and want it fast, says Beidleman
• “There are a lot of options for viewing images in the OR. Be sure to analyze the usability of different solutions,” advises Apiti.
• Follow up with surgeons who continue to request film to determine how to meet their needs or educate them about digital viewing, says Kelly. Sometimes, clerical staff continues to request film even when surgeons don’t need it.
• “Consider adding image viewing capabilities to ancillary surgical areas such as the anesthesiologists’ lounge,” adds Beidleman.
• Envision the surgical suite of the future as you equip the OR. Vendors are developing new solutions to better meet image demand in the OR. For example, St. Cloud Hospital recently deployed GE Healthcare’s 9900 Elite portable surgery C-arm with new features specifically geared to the filmless OR such as movable monitors.

The era of the filmless OR has arrived. In fact, there may be more options for viewing digital images in the OR than anywhere else in the enterprise. Developing a solution requires input and buy-in from surgical staff as well as a thorough IT assessment of the current OR network and various options for transmitting and viewing images in the OR. Although the choices can seem overwhelming, the project is well-worth the investment as a filmless OR represents one giant leap toward the filmless enterprise.