What is a SMART Operating Theatre and why do future hospitals need it?

Towards the operating theatre ‘black box’: the integration of smart technologies in the operating theatre will allow us to identify key issues and reduce the incidence of never events.

Over the past 25 years, operating theatres have moved from being simple, clean procedure rooms to becoming complex multimedia smart rooms. This has been driven, in part, by innovation in minimally invasive surgery – as instruments are manipulated inside of the body cavity, this requires multi-media to guide and visualise the surgery. More recently, we have also seen hybrid theatres that allow imaging during the procedure, along with robotic surgery.

Modern operating theatres have a proliferation of equipment, with multiple monitors showing multiple images. In addition to the need for pre-operative images such as MRI scans, ultrasound and CT scans, there is increasing demand for greater data sets, including vital signs and a variety of other information on the progress of the operation. Against this backdrop of smart technology is the increasing requirement to capture and integrate this data into the electronic patient record.

However, as operating theatres become smarter, we need to avoid the danger of ‘technology overload’ – i.e. providing more information than the clinician can absorb. There is also a risk, with so many complex devices in the operating theatre, that some do not function properly and are overlooked.

Technology overload also means that clinical teams do not make use of all of the pre-operative images or data sets available. Some teams leave new technology switched off and stick with ‘traditional approaches’, while some equipment quickly fails or falls into disuse.

Teams also struggle to create a complete record of the patient journey through the operating theatre.

The challenge is to use technology that adds to our lives, rather than adding to the burden of our workload. Smart operating theatres can help with a combination of:

• Easy and intuitive integration of multiple images and data sources (i.e. integrated operating theatres).

• The clinical team are guided through the procedure with supportive information.

• Adoption of smart IoT building technology to automate mundane equipment/building functions. (For example, the lights come on when you enter the operating theatre without having to touch a switch.)

This technology could also capture data and event logs to enrich the patient record. Currently, the patient record is typically populated with data on drug allergies, how the patient was ventilated, their vital signs and even some video content from the minimally invasive cameras during the procedure. However, it would be useful to know more about what is happening in the operating theatre. What is the temperature of the room, for example? In the event of an infection, it may be possible to understand whether the temperature in the room contributed to perioperative hypothermia, a known risk factor for surgical site infection.

In the event that the patient does not recover post-operatively it would also be useful to be able to investigate whether there were any issues with the oxygen supply during the operation. It is also possible to ‘lock in’ best practice and expertise – for example, by automating settings, it could be possible to prevent a member of the theatre team turning down the temperature of the theatre to adjust the environment to their own comfort levels, which could put the patient at risk It is also possible to introduce guidance – in neurosurgery, for example, smart technology could be used to guide other surgeons on the depth of insertion of probes and the order of key activities during the procedure. This can be introduced via screens during the procedure. Furthermore, it is possible to provide automated condition monitoring to maintain equipment availability and reduce support costs.

Challenges:

While the operating theatre is becoming more complex in terms of technology, the smart operating theatre could help reduce the burden through automation. But what are the new challenges involved in introducing these technologies?

We are moving from the simple operating theatre, which we understand and is based on traditional engineering, to operating theatres based on complex interconnected devices that we are less familiar with. Adding to the challenge is the fact that integrated, hybrid and smart theatres rely on multiple systems and multiple vendors – including video systems, building management systems and medical equipment systems. They require a high degree of interconnection. This results in mixed technologies and mixed communications protocols. It is complex to plan, expensive and risky. They are difficult to maintain and support as they involve so many different vendors and, to add to the challenges, the knowledge to overcome these issues lies within pools of separate and exclusive knowledge domains. This is fundamental to why many projects fail. Many new technologies are led by the clinical domain. MedTech businesses, particularly in the field of endoscopy, tend to be clinically focused and are not inclined to integrate with building engineering, while the clinicians tend to focus on function without detailed technical specification. On the other hand, the engineering domain often lacks familiarity with operating theatres. Leaders in smart infrastructure and IoT tend to be nervous of hospital contracts and see operating theatres as high-risk projects. There is a reluctance to apply new smart building technologies, and this is hampering adoption.

This ‘disconnect’ between the clinical and engineering domains creates ‘islands of technology’ and ‘islands of knowledge’. Laparoscopy systems, vital signs equipment and scanners all have different output formats and communications protocols, yet there is a lack of understanding around the requirements for integration. The problem of ‘islands of technology’ is even worse in the engineering domain – for example, medical gases use relay contacts or BacNET; HVAC uses analogue or BacNET; PCs and PACs uses Ethernet; while power distribution uses BMS. All of these systems need to be ‘plugged together’ and into the control panel. This requires sufficient connectivity, so the control panel is capable of connecting to any system.

No single person has all of the knowledge across these complex ‘islands of technology’ and projects tend to lack leadership, therefore. So, who should lead these integration projects? Surgeons simply want the images on the screens and are not technical; IT often get charged with the project as it looks technical, but video is not the same as computer data and requires a different knowledge set; the builder, on the other hand, is not accustomed to these specialist technologies; while health estates don’t want the headache but expect that they will be left to deal with it.

Ultimately, smart operating theatre capability will be a journey not a project. We should look for opportunities to progressively upgrade capability – always looking ten years ahead, to the long-term vision, and encouraging common data and communications platforms. ‘Technology islands’ need to gradually converge, but this process is likely to take a decade or even longer. To tackle these technology islands for the smart, integrated operating theatre, we must extend compatibility and integration to all image and data sources in the operating theatre. This will mean that any new cameras, scanners, laparoscopes and vital signs machines can be accommodated in the future.