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Anesth Analg 2008; 106:554-560
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e3181606f01
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ECONOMICS, EDUCATION, AND POLICY

The Use of Distributed Displays of Operating Room Video When Real-Time Occupancy Status Was Available

Yan Xiao, PhD*, Franklin Dexter, MD, PhD{dagger}, Peter Hu, MS*, and Richard P. Dutton, MD*

From the *Department of Anesthesiology and Program in Trauma, University of Maryland, Baltimore; and {dagger}Division of Management Consulting, Departments of Anesthesiology and Health Management and Policy, University of Iowa, Iowa.

Address correspondence to Yan Xiao, PhD, 22. S. Greene St., T3R85, MD 21201. Address e-mail to yxiao{at}umaryland.edu.

Abstract

INTRODUCTION: On the day of surgery, real-time information of both room occupancy and activities within the operating room (OR) is needed for management of staff, equipment, and unexpected events.

METHODS: A status display system showed color OR video with controllable image quality and showed times that patients entered and exited each OR (obtained automatically). The system was installed and its use was studied in a 6-OR trauma suite and at four locations in a 19-OR tertiary suite. Trauma staff were surveyed for their perceptions of the system.

RESULTS: Evidence of staff acceptance of distributed OR video included its operational use for >3 yr in the two suites, with no administrative complaints. Individuals of all job categories used the video. Anesthesiologists were the most frequent users for more than half of the days (95% confidence interval [CI] >50%) in the tertiary ORs. The OR charge nurses accessed the video mostly early in the day when the OR occupancy was high. In comparison (P < 0.001), anesthesiologists accessed it mostly at the end of the workday when occupancy was declining and few cases were starting. Of all 30-min periods during which the video was accessed in the trauma suite, many accesses (95% CI >42%) occurred in periods with no cases starting or ending (i.e., the video was used during the middle of cases). The three stated reasons for using video that had median surveyed responses of "very useful" were "to see if cases are finished," "to see if a room is ready," and "to see when cases are about to finish."

CONCLUSIONS: Our nurses and physicians both accepted and used distributed OR video as it provided useful information, regardless of whether real-time display of milestones was available (e.g., through anesthesia information system data).

Surgical patient flow is enhanced by careful scheduling before, and necessary adjustment on, the day of surgery.1 Adjustment on the day of surgery, including adding cases or moving cases between operating rooms (ORs), requires real-time information.1 Managers of ORs and other OR staff resort to labor-intensive processes to obtain OR status information, such as frequent voice-based communication and walking through surgical suites.2 Such communication activities may be interruptive in OR3,4 and other settings.5,6 There is an increasing interest in automatic means to obtain and disseminate OR status awareness.7–9 These means include accessing patient monitoring data to automatically identify OR occupancy,10 tracking patient locations through wireless tags,11 and paging nurses automatically with notifications of patient status.12 Technology in these examples may lessen the burden of obtaining real-time accurate information of OR status, such as the times of patient entry and exit.10,11 However, the majority of communications of OR charge nurses are for anticipating events of individual cases, such as equipment needs and the timing of preparing patients for surgery.2

Live color video images of OR activities can provide direct visual cues to OR activities without the need to physically visit each OR. Examples of such visual cues include draping, lighting, and equipment arrangement. Video may be complementary to automated information when staff can confirm discrete events ("seeing is believing") to overcome potential distrust of automation.13 When displayed in different locations, OR surveillance video may be viewed by OR staff of all job categories to help their work.

However, there are significant questions about deploying distributed OR video. We report a study in two surgical suites that addressed four questions about the acceptance of distributed video and reasons for using these systems.

The first question was "Will OR staff accept the presence of distributed video?" The use of distributed video in ORs is novel. OR staff (including surgeons) may object to the use of video, perhaps because of the perceived loss of privacy, even though the privacy impact of video depends on image quality, updating frequency, and other variables of video,14 as well as whether the video is archived. Some facilities have, or plan to have, surveillance video of ORs displayed at a centralized location (e.g., the OR control desk). Managers at these facilities could add displays of the OR video throughout the surgical suite. However, distributing the video may cause concerns over job monitoring.15

The second question was "Will OR staff use OR video?" Studies of technology adoption in health care have shown innumerable examples of computer technology being installed but not used.16–18 Some facilities have patient tracking systems through real-time electronic nursing documentation, anesthesia information system, or radio frequency identification technology.11 Adding OR video may seem superfluous given the availability of discrete OR event information.

The third question was "Who uses OR video?" OR staff other than charge nurses may not find the video useful, which would undercut the rationale of distributed video.

The fourth question was "What will OR video be used for?" When timings of patient entering and exiting OR are available, video may provide complementary information that is otherwise unattainable through electronic sources such as anesthesia information systems.

To answer these four questions, we surveyed OR staff’s acceptance of an OR video system and their perceived reasons for usage. We analyzed usage logs of a distributed status video system in which OR status information (e.g., patient entrance into and exit from the OR) was available in real time.

METHODS

Settings and the Video System
Installation and operational use of the video system was approved by the administration, legal, and human resources counsels of a 90-bed trauma hospital and, later, an adjacent 665-bed tertiary hospital.

The video system was custom-developed to show in a single display live OR color video from all ORs, along with OR occupancy status (Fig. 1). Real-time information of OR occupancy was obtained automatically by using a previously published algorithm analyzing networked vital signs from OR patient monitors.10 Based on occupancy status and times of status changes, users could determine which ORs were occupied, elapsed time since patients entered individual ORs, and elapsed time since patients exited ORs. Live OR color video was intended to show the presence of radiology imaging devices, position of the surgical bed, presence of padding devices ("bean bags"), and general activities.


Figure 132
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  		Figure 1. The block diagram of operating room (OR) video display system with real-time OR occupancy data. More details of the design were described in Ref. 19. The original cost of video cameras and video network installation was estimated at $2000 per OR. The image processor with necessary video components cost about $3000. The video projector at the trauma suite cost about $2000. The incremental cost of adding each of the four distributed display unit was about $1500.

 

Addressing Privacy Concerns
Potential concerns over OR video were addressed by reducing video quality and limiting access to the video displays.15 Installation was accompanied by an educational program.

  1. The OR video was only used in real-time. The video was not recorded.
  2. OR audio was not used.
  3. The quality of video images was degraded through a blurring and pixel re-sampling algorithm19 to balance between privacy and information access.
  4. Cameras were used only with wide angle lenses (Fig. 2), which generally did not provide enough detail to produce recognizable images of patient’s faces. Faces of OR staff could only be discerned if the individual was not wearing a mask and was directly facing the camera at a close proximity.

  5. An on-off switch for the video camera was provided inside each OR to turn off the camera at the discretion of the OR staff. Charge nurses were asked to report occurrences of the cameras being switched off.
  6. Extensive discussions with OR staff in private, group educational meetings and trial periods were used to address any staff concerns over privacy and patient confidentiality, and to communicate the purposes of the system.
  7. Restrictions were placed on access to video images. The two suites studied had different implementations of video access restrictions.


Figure 232
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  		Figure 2. A sample video image from the video display system in the tertiary suite. The resolution of displayed video, shown here, was 246 x 168 pixels. The original resolution (100%) captured by cameras was 352 x 240 pixels. When combining the video with knowledge of who has been assigned to an OR, their role (e.g., anesthesiology resident), and the individuals’ body habitus, sometimes identification of a staff member could be made. However, the image shows that individual staff members could not be identified with the video alone.
 
The trauma hospital had more than a decade of experience with the use of video technology (e.g., recording trauma resuscitations).20 This experience led to an open attitude towards distributed video among the staff members. A video projector was used to continually display video and occupancy status on top of the OR white board located in a corridor which was restricted to and frequented by OR physician, nursing, technical, and housekeeping staff (Fig. 3, left).21 However, the image quality was reduced to just 5% of the full resolution to prevent accidental identification of individuals.


Figure 332
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  		Figure 3. The video system as implemented in the six operating room (OR) trauma surgical suite (left) and in the 19-OR tertiary surgical suite (right). In the trauma suite, both OR video (processed for specific levels of quality) and occupancy times were projected on top of the OR board. The OR board was located in a corridor restricted to OR staff only. In the tertiary suite, 19 inch liquid crystal display units were installed at the OR control desk, anesthesia workroom, physician workroom, and the pre- and postoperative care unit for an ambulatory service. Access to the video was through a badge reader mounted beside the display.

 

In contrast, the OR staff in the 19-OR tertiary suite did not have the extensive experience with video and the OR desk area was not restricted. Division chiefs of anesthesia, surgical, and nursing services were contacted individually about the planned video system. Several of them visited the installation in the trauma suite. About 1 yr after the video system was operational in the trauma suite, computer displays were installed at the following four locations of the tertiary suite: the OR desk, the anesthesia workroom, the physician workroom (used mostly by surgeons), and the pre- and postoperative care unit (Fig. 3, right). By swiping their identification badges, OR staff could access the video for all ORs (Fig. 3, right) for 2 min at a time. Access logs were kept for auditing purposes. Video quality was set to 3% of the full resolution (64 x 44 pixels) for all OR staff except charge nurses and attending anesthesiologists, who were shown video at 50% resolution (Fig. 2). The incremental cost attributable to the distributed video at each viewing site was approximately $1500 for a desktop PC and a badge reader (Fig. 1).

Acceptance and Usage Studies
After the video system was operational in the trauma suite for 2 mo and after IRB approval, we conducted an anonymous survey of all OR staff to assess their concerns (Table 1) and their reasons for using the system (Table 2). They were also asked whether their concerns increased or decreased after the 2 mo of use.


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  		Table 1. Survey Questions of Specific Areas of Concerns Among Staff Working in the Six Operating Room (OR) Trauma Surgical Suite (1 = "no concern whatsoever," 2 = "a little concerned," 3 = "somewhat concerned," and 4 = "very concerned")

 

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  		Table 2. Survey Questions of Perceived Usefulness of Video Among Staff Working in the Six Operating Room (OR) Trauma Surgical Suite (1 = "no use whatsoever," 2 = "a little useful," 3 = "somewhat useful," and 4 = "very useful")

 

Access logs and OR occupancy data, detected by the vital sign algorithm,10 were collected in the two surgical suites. Data from scheduled workdays were analyzed. Each video access was identified by the job category of the following users: anesthesiologist, charge nurse, OR nurse, surgeon, or "other" (e.g., the anesthesia technician). In the trauma suite, data collection was over three consecutive weeks, 2 yr after installation. During the 3-wk study period, the video system was modified so that the video was on for 2 min only when staff swiped their badges, after which the display would be off. In the tertiary suite, data over six consecutive months from the four video access stations were collected after 4 mo of operational use.

Data Analysis
Question 1: "Did OR staff accept the presence of distributed video?" About half (63 out of the estimated 120 OR staff) responded to the survey. We tabulated levels of reported concerns by means, medians, and quartile deviations of the survey in the trauma suite (Table 1). Additionally, the following signs of rejection of the system were studied:

  1. any reported complaints,
  2. episodes of turning off video cameras,
  3. administrative actions limiting or stopping the use of video, and
  4. incidence of OR nurses resigning 6 mo before and 6 mo after installation.

Question 2: "Did OR staff use the video even when data were available in real-time for which ORs were occupied and for how long?" To estimate minimal amount of usage, we calculated the 95% lower confidence bounds on the mean daily accesses using Student’s t-distribution.

Question 3: "Who uses OR video?" We tallied the number of unique users based on job categories. The lower 95% confidence interval (CI) was calculated for the percentage of days over which users of a job category accessed video most frequently among users of all other job categories. Confidence intervals were calculated using the method of Blyth-Still-Casella (StatXact-7, Cytel Software Corporation, Cambridge, MA). Differences among anesthesiologists, OR charge nurses, and surgeons in video accesses over time of day were calculated by analyzing accesses and occupancy in 30 min periods, for 5904 periods (123 scheduled work days x 48 time periods per day). The differences in the distribution of video accesses over time of day were tested by the Kolmogorov-Smirnov method (StatXact-7). Only data from the tertiary suite were used for this question, because we wanted to use timing of usage to infer why the video was used. The tertiary suite had an end of the workday with few cases starting.1,22 In contrast, the trauma suite had add-on cases throughout 24-h periods.

Question 4: "What was the video used for?" We tabulated perceived usefulness of the video system for different reasons for use. We also analyzed usage logs to infer the reasons why the video system was used. Without looking at the video, users knew which ORs were occupied from the real-time display of the times of patients’ entrance into and exit from ORs.10 The reasons studied were in two categories. First, we tested if staff accessed video more when more ORs were occupied, meaning that they used the video when there were more intraoperative activities to facilitate (e.g., equipment needs). Spearman’s rank correlation coefficient was used to test the association between the numbers of ORs occupied for at least part of a 30-min period and the number of video accesses during the period. Second, we tested if staff accessed the video frequently even when no cases were starting and ending. We studied the trauma suite because it had sufficiently few ORs that it was feasible to separate time periods with case starting or ending from periods without. The video access and OR occupancy data were analyzed in 30-min periods, for 720 periods (15 scheduled work days x 48 30-min periods per day). The lower 95% CI on the percentage of periods without a case starting or ending was calculated (StatXact-7).

RESULTS

Question 1: "Did OR staff accept the presence of distributed video?" The video system was generally accepted by the OR staff as evidenced by:

  1. The distributed video has been in continuous use in the trauma suite for 54 mo (since February 2003) and in the tertiary suite for 37 mo (since July 2004).
  2. There have been no reported complaints about the video system.
  3. There have been no administrative actions limiting the use of the system. On the contrary, we received occasional urgent requests to maintain the video system, such as replacing burned-out projector lamps and adjusting drifting OR cameras.
  4. In the trauma suite, the cameras were switched off five times during the first 2 mo of installation and only once since. In the tertiary suite, the cameras were switched off 18 times for unknown reasons during 37 mo of study.
  5. In the trauma suite with 52 full-time nursing and technical staff, two staff resigned during the 6 mo before installation of the system. There were no resignations in the 6 mo after the video system installation. In the tertiary suite with 111 full-time nursing and technical staff, there were four resignations before installation, and six resignations after installation.

The survey at the trauma suite provided further supporting evidence of acceptance of the video system. None of the 63 trauma OR respondents reported increased concerns over using the video after the initial 2 mo of usage. Twenty-three reported diminished concerns after the initial usage. Levels of concerns reported in the survey of the trauma suite staff were low overall (Table 1). Even the highest ranking area of concern, "video compromising patient’s confidentiality," had the median response of "a little concerned." The median response was "no concern whatsoever" in the surveyed area of "video influencing how you do your job in OR."

Question 2: "Did OR staff use the video even when data were available in real-time for which ORs were occupied and for how long?" The video was accessed for all 15 consecutive workdays studied in the trauma suite, with 151 ± 5 (se) accesses per day (lower 95% CI >141), totaling 302 ± 10 min of activation time per day. It was accessed for all 123 consecutive workdays studied in the tertiary suite, with 25 ± 1 accesses per day (lower 95% CI >23), totaling 50 ± 2 min of activation time per day.

Question 3: "Who uses OR video?" In the trauma suite, OR charge nurses were the most frequent users for all 15 days (Table 3). In the tertiary suite, anesthesiologists were the most frequent users for more than half of the days (71 of 123 days, 95% CI >50% of days). Most (78%) of the anesthesiologists’ accesses were made from the anesthesia work room. There were significant differences in accesses by time of day in the tertiary suite (P < 0.001). The OR charge nurses accessed the video when the OR occupancy was the highest (Fig. 4, left panel). The anesthesiologists accessed it when occupancy was declining at the end of the workday and few cases were starting (Fig. 4, right panel).


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  		Table 3. Accesses by Different Roles and Unique Users of the Video in the Two Operating Room (OR) Suites

 

Figure 432
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  		Figure 4. Accesses of operating room (OR) video over time of day by anesthesiologists in their workroom and by charge nurses at the OR desk. Data were for 123 consecutive scheduled workdays in the studied 19-OR tertiary suite. The right panel displays a subset of the data in the left panel to show the relationship between accesses by anesthesiologists and the number of cases starting.

 

Question 4: "What was the video used for?" The trauma OR staff found the video very useful to see if cases are finished, to see if a room is ready, and to see when cases are about to finish (Table 2). Staff and case assignment decisions were perceived to be less useful reasons (Table 2). The video was actually used heavily in the middle of cases. Specifically, of all 30-min periods during which the video was accessed in the trauma suite, many had neither a case starting nor ending (45%, n = 522, 95% CI > 42%). The video was used most often when many ORs were occupied (Spearman’s rank correlation 0.70, P < 0.001).

DISCUSSION

Privacy concerns over the use of video are well documented.14,23 Our experience suggests that potential privacy concerns and other reservations to a distributed OR video can be addressed. In our view, the use of badge readers, automatic timeouts,24 and manipulation of image quality15 were likely important components for addressing privacy concerns.

The routine use of the video by OR charge nurses (Fig. 4) supports OR video and display units at OR control desks, even when real-time OR event information such as patient’s entrance and exit times are available. Since information on individual cases has limited impact on increasing the efficiency of use of OR time,1,25 much of the benefit likely is intangible (e.g., providing breaks for residents at appropriate times).

The use of video does not replace the need for discrete data to detect OR status and events such as those obtained through patient identification technology,11 networked physiological monitors,10 and anesthesia information systems, supplemented by real-time reminders.26 OR video works particularly well to support individual cases (e.g., deciding whether now is safe and convenient to give a colleague a break). The details of the activity within the OR are useful and may have implications for patient safety (e.g., there are two individuals at the head of the bed hanging blood and moving hurriedly). Our finding of frequent video usage in the middle of cases highlights that OR nurses are using video heavily for anticipating and coordinating intraoperative events, especially the use of equipment.2 The anesthesiologists used the video in the tertiary suite mostly at the end of the workday, perhaps for assessing which personnel were going to finish on their own and which would require relief.

The video was accessed six times more often in the trauma suite than in the tertiary suite. This was probably because all of the elective cases were scheduled in the trauma suite on a to-follow basis, and around 50% of the cases were nonelective, with low predictability of case durations. Also, many patients required anesthesia transport to/from intensive care units. Surgeons with pending cases were interested in assessing progresses of preceding cases.2 Another possible reason for more frequent video access in the trauma suite (Fig. 3, left) was that the video display was more convenient to the OR staff.27 Convenient placement may reduce cognitive burdens as staff could integrate information about real-time OR activities from the video with considerations about staff assignment from the OR board. The arrangement may also support group decision making when they stand side-by-side in front of OR video and the OR board.21

Future studies of distributed video could further examine the effect of video blurring on reducing privacy concerns and the specific benefits of accessing video. Additional surveys asking why the systems were being used would probably not be helpful, as we have previously shown that clinicians have limited insight into why they use and how they use OR management tools.28 Although the video may have been used by some clinicians because they did not trust the real-time OR occupancy display (e.g., seeing is believing), this explanation is inadequate as 45% of the video usage at the trauma suite occurred during times when no cases were starting or ending.

In summary, surgical suites that already have, or plan to install, surveillance video cameras should consider the addition of distributed video displays with degraded images. The current study in a 6-OR trauma suite and a 19-OR tertiary suite demonstrated that distributed video displays were well accepted and used regularly and extensively by nearly all OR staff.

ACKNOWLEDGMENTS

We thank Jake Seagull, Colin Mackenzie, Steve Seebode, Hao Hu, and Young-Ju Kim for their assistance in technological implementation and in data collection. Drs. Douglas Martz and Timothy Gilbert commented on earlier versions of the manuscript. Julie Ray, Debra Cooksey, and Darlene Carco provided logistic support of the study.

Footnotes

Accepted for publication October 19, 2007.

Supported, in part, by National Science Foundation (# 0325087) and US Army (#W81XWH-02-2-0057). Opinions do not necessarily reflect the official positions of the sponsors. FD is Director of the Division of Management Consulting, which is a Division of the Department of Anesthesia. He receives no funds personally other than his salary from the State of Iowa, including no travel expenses or honorarium, and has tenure with no incentive program.

Dr. Franklin Dexter, Section Editor for Economics, Education, and Policy, was recused from all editorial decisions related to this manuscript.

Partial results were presented as posters in American Society of Anesthesiologists’ Annual meetings in Las Vegas, NV on October 27, 2004 and in Atlanta, GA on October 25, 2005.

Reprints will not be available from the author.

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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press