View as “PDF version”
Patient Safety Tip
of the Week
March 17, 2020 Video Recording in the OR
For over a decade we’ve argued for
proactive use of video recording, particularly in the OR. Video recording can
be used constructively to assess communication and teamwork in the OR. It can
be used evaluate OR door opening and closing, which may be factor contributing
to surgical site infections. It can help quantitate interruptions and
distractions that occur during procedures and identify some of the reasons for
those interruptions and distractions. It can be used to determine compliance
with Universal Protocol, surgical timeouts, surgical checklists and whether parties
were truly active participants in those important processes. It can help
determine whether all parties are actively participating in sponge/instrument
counts. In our March 2019 “Another Use for Video Recording” we
showed how it has been used to demonstrate compliance with key steps in
specific surgical procedures. And it can obviously be used to assess and
improve performance in medical education and training.
So we were pleased
to see a recent article in HealthLeaders on Northwell
Health’s use of such technology Cheney
2020.
Northwell Health has employed OR black box technology since early 2019laparoscopic cases of urologic and colon surgery. Those were chosen for
pilot projects because there is a digital feed from the camera used during the
laparoscopic surgery and because there were physician champions for the
project.
So, what’s recorded? There are video feeds from the
laparoscopic camera and video of the OR staff, audio of the OR staff, and
physiological data from various OR monitors.
Northwell’s primary
purpose has been to use the integrated data to help improve OR teamwork and
communication. They use it proactively to improve coordination in the OR. They
have used it for one of our examples above – to identify distractions and
interruptions and, especially, people entering and leaving the room. But it’s
also used in their quality improvement and educational activities.
Interestingly, Northwell has also used it to cover some of the aspects we
discuss during post-procedure “debriefings”. For example, they might identify
issues related to equipment availability or other problems with equipment or
supplies.
It also has a role in teaching programs. They can look to see if a
resident’s performance improved over a 4-month rotation, to evaluate the
success of the teaching program. Our March 2019 “Another Use for Video Recording” noted
a study (van de Graaf 2019)
that showed systematic video
recording was better at capturing the essential steps of some laparoscopic procedures
than was the narrative operative report.
Our first 3 columns listed below recommended use of video
recording as one means of improving compliance with surgical timeouts or
elements of a safe surgery checklist. In fact, Overdyk
et al. (Overdyk 2016)
demonstrated that real-time feedback from video recording conferred a 3.37-fold
increased odds of time-out compliance versus no feedback, and 2.75-fold and
2.4-fold increased odds of compliance with the sign-in and sign-out components
of the WHO surgical safety checklist, respectively. It also led to some improvements
in efficiency (shorter OR turnaround times for scheduled cases).
In our March 17, 2015 Patient Safety Tip of the Week “Distractions
in the OR” we recommended video/audio recording in the OR with subsequent playback
for all parties in a constructive fashion so they can see how well (or not so
well) they communicated and how distractions and interruptions interfered with
their communications. Jung et al. reported their
first-year analysis of the operating room black box study (Jung
2020). They conducted a prospective cohort study in 132 consecutive
patients undergoing elective laparoscopic general surgery at an academic
hospital during the first year after the definite implementation of a multiport
data capture system called the OR Black Box to identify intraoperative errors,
events, and distractions. They found that auditory distractions occurred a
median of 138 times per case and that at least 1 cognitive distraction appeared
in 64% of cases. Medians of 20 errors and 8 events were identified per case.
Both errors and events occurred often in dissection and reconstruction phases
of operation. Technical skills of residents were lower than those of the
attending surgeon.
Some formal studies have demonstrated
that such use of video/audio recording can in fact, reduce interruptions and
distractions. Bergstrom et al. (Bergström 2018) found that audio-video recording during
laparoscopic surgery in a Swedish study reduced irrelevant conversations in the
OR. Irrelevant conversation time fell from 4.2% of surgical time to 1.4% when
both audio and video recordings were made. No differences in perioperative
adverse event or complication rates were seen but, again, sample size was too
small to assess those outcomes.
People entering and exiting the operating room, with consequent door
opening and closing, has been identified as a factor potentially exposing
patients to surgical infections. In our November 24, 2015 Patient Safety
Tip of the Week “Door Opening and Foot Traffic in the OR” we noted some low-cost methods that might
assess such events, but we also noted that video/auditory recording might identify
not only the frequency of such events, but also the reasons for such events.
We’ve often recommended doing video/audio recording in the OR and then
play it back for all parties in a constructive fashion so they can see how well
(or not so well) they communicated and how distractions or interruptions
interfered with their communications. Teodor Grantcharov, MD, creator of surgery's
'black box' and senior author on the Jung study, noted in an interview that
they’ve shown that coaching surgical teams with black box data reduces the rate
of surgical errors by 50%. (Grantcharov 2019).
He notes that the black box captures video and audio recordings of everything
that happens in the OR, including what steps were completed, how well the team
communicated, and includes physiological information from patient monitors and
the physical environment of the room, including ambient temperature, decibel
levels and how many times the door is opened. He notes that it's designed to
identify near misses, understand the risks involved and proactively mitigate
those risks. But he notes this isn't just about targeting errors and
near-misses. They use the data to study successes in great detail,
so they can identify and reinforce positive behaviors. They use the information
to coach surgical teams on ways to improve their performances, using the
analogy of how sports teams study videos and stats to enhance how they play.
Unfortunately, too
many surgeons and hospital attorneys are loathe to use video recording even when it is
clearly being done for quality improvement activities and even when the
recordings would be destroyed immediately following their use in quality
improvement activities. It might take very clear cut statutes in every state to protect such
recordings from the legal discovery process for us to convince more
organizations of the value of video recording.
So how did Northwell
get around those fears of litigation? First, everything is de-identified. The
cameras even blur the faces of the OR team! And second, the focus is to look at
system issues, not individual human issues. They also note that de-identifying
the data also protects patient privacy.
Several of the
studies in today’s column note that design of the systems or studies had the purpose
of looking at team performance and not individual performance, and that this
was a critical step in recruiting the support of all OR stakeholders.
There are ethical considerations for video recording in the
operating room. Prigoff et al. (Prigoff
2016) discussed these and recommended
the following guidelines:
- Creation of a video/audio recording should have a clearly stated
purpose. This may include educational, research, quality improvement,
patient request, or others.
- Any patient undergoing a procedure that may include recording should
be made aware and properly consented. This includes, but is not limited to,
the purpose of the recording, the intended audience, and the parts of the
procedure recorded.
- Patients, faculty, and staff should be notified that a recording
will take place during the procedure and given the opportunity to opt-out.
- If editing is required for visual accuracy or timeliness for a
presentation, the alterations should be clearly disclosed to the audience.
- All recordings should be protected with the same security and
scrutiny that the hospital and physicians use for patients’ medical records.
Northwell has not
yet published any outcome data that can be attributed to their OR black box
program. Likewise, several studies that have demonstrated improvement in
process measures have not been of sufficient sample
size to assess actual patient outcomes.
So, what does all this cost? It’s not for the faint of heart! Northwell’s
OR Black Box equipment costs $100,000 per operating room according to the HealthLeaders article. They also analyze all their data
centrally, so that lessons learned can be shared among multiple hospitals in
their system. The total cost of implementing the less sophisticated remote
video auditing in the Overdyk study (Overdyk 2016)
had three cost components: one-time video equipment cost of approximately $4000
per camera; one-time remote video auditing set-up and onsite consulting
training fee of $7500 per OR; and an remote video auditing service charge of $40/day
per OR. So, there is probably a whole spectrum of implementation components and
costs.
Nice job, Northwell!
We wish we could convince more hospitals to adopt this approach. Hopefully,
other hospitals will see the benefit of video recording and black box integration
that you’ve experienced and implement it at their facilities.
Some of our previous columns discussing video recording:
September 23, 2008 “Checklists
and Wrong Site Surgery”
December 6, 2010 “More
Tips to Prevent Wrong-Site Surgery”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
March 2012 “Smile...You’re
on Candid Camera!”
August 27, 2013 “Lessons
on Wrong-Site Surgery”
March 17, 2015 “Distractions
in the OR”
November 24, 2015 “Door
Opening and Foot Traffic in the OR”
March 2019 “Another
Use for Video Recording”
References:
van de Graaf FW,
Lange MM, Spakman JI, et al. Comparison of Systematic
Video Documentation With Narrative Operative Report in
Colorectal Cancer Surgery. JAMA Surg 2019; 154(5): 381-389
https://jamanetwork.com/journals/jamasurgery/fullarticle/2720695
Overdyk FJ, Dowling O, Newman S, et al. Remote video
auditing with real-time feedback in an academic surgical suite improves safety
and efficiency metrics: a cluster randomized study. BMJ Qual Saf 2016; 25: 947-953
https://qualitysafety.bmj.com/content/25/12/947
Jung JJ, Jüni P, Lebovic G, Grantcharov T. First-year Analysis of the Operating Room
Black Box Study. Annals of Surgery 2020; 271(1): 122-127 Published Ahead of
Print June 18, 2018
Bergström,
H., Larsson, L. & Stenberg, E. Audio-video recording during laparoscopic
surgery reduces irrelevant conversation between surgeons: a cohort study. BMC
Surg 2018; 18: 92
https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-018-0428-x#citeas
Grantcharov
T. Real-time OR Monitoring Leads to Better, Safer Surgery. QA with Teodor Grantcharov, MD, PhD,
FACS, creator of surgery's 'black box' and believer that data doesn't lie. Outpatient
Surgery Magazine 2019; April 2019
Prigoff
JG, Sherwin M, Divino CM. Ethical Recommendations for
Video Recording in the Operating Room. Annals of Surgery 2016; 264(1): 34-35
Print “PDF version”
|
|
http://www.patientsafetysolutions.com/