Black boxes within the operating room: improving quality of care and patient safety

What is that this post about?

• Black boxes record video, audio, and data from multiple sources within the operating room, equivalent to cameras, microphones, patient monitoring equipment, and medical devices.
• By providing visibility into multiple simultaneous processes within the operating room, black box data will be used to enhance safety and efficiency, train staff, and onboard recent nurses.
• Data will be used for retrospective evaluation of specific events or aggregated evaluation to detect patterns and changes in practice over time.
• Black box data was used to enhance and standardize operating room processes equivalent to tissue sample handling, communication during shift changes, and preoperative patient positioning.
• The information is non-personally identifiable and will likely be deleted inside 30 days.
• The goal is to seek out what went well and learn from it, to not point fingers.
  

associate vice chairman for perioperative services at Duke University Hospital, with whom he recently spoke ALL about her hospital’s use of black boxes in operating rooms (ORs) to standardize key processes to enhance safety and efficiency, train current staff and hire recent nurses.

OR black boxes, manufactured by Canadian company Surgical Safety Technologies (SST), are modeled on the concept of black boxes utilized in airplane cockpits to record flight data and have thus far been adopted by a small variety of hospitals in the USA, Canada and Europe.

The black boxes record video and audio from 4 cameras and multiple surface-mounted microphones, in addition to data from patient monitoring equipment and medical devices equivalent to laparoscopic cameras and an anesthesia machine.

“Every data point captured by medical devices within the operating room will be incorporated into an information evaluation algorithm,” McKenzie says. Given the wealth and variety of information collected by the black box, there are undoubtedly some ways to make use of it to enhance safety and standardize work and communication inside the team within the operating room.

While this data will be invaluable for retrospective evaluation of a facet of a selected event, it’s equally often analyzed in the combination to detect patterns and changes in practice over time with the goal of using quality improvement tools to enhance patient care.

Improving the evaluation of complex processes.

In health care, says McKenzie, “we regularly learn retrospectively, counting on recall and perception. We all know recalls are subject to errors and incomplete information – including lack of timeliness, inaccuracies, hidden bias and unawareness of contributing aspects. . . The operating room is a really complex environment, paying homage to an orchestra, with parallel processing and multitasking amongst many team members.”

Black boxes provide what McKenzie calls transparency, using image, audio and data evaluation to offer a more objective view of the simultaneous tasks performed by different team members.

This is not about “pointing fingers” or assigning blame, she says, as she repeated to doctors, nurses and other staff, but about team members retrospectively “taking a look at the complete environment” to achieve insight into how one can improve the patient’s condition. care. Patient and staff details are blurred, their faces and torsos are blurred, and their voices are modified. Data is deleted after 30 days unless used on a de-identified basis for aggregate evaluation.

Improving quality through transparency.

Says McKenzie: “The goal is for team members to review de-identified video and data to make informed decisions and gain insight into effectively managing and developing best practices.” From this wealth of information, you possibly can give attention to one small step and get a more objective picture of what is really happening and where the differences are.

For instance, information from black boxes helped make clear the steps for team members handling tissue samples in order that the suitable samples were sent to the suitable destinations. It has also been used to review communication when nurses rotate between shifts during a procedure or when, for instance, a staff member eats a meal during a procedure and someone replaces him.

“Now we have done observations and we’ve got a checklist of things we search for information to be included on this handover. Then we found a tool to make use of and trained people on that tool.” She said staff welcomed the introduction of a standardized handover tool as a technique to reduce differences in practice that may result in gaps in sharing key information.

In one other example, information collected by the black box is used to standardize the patient positioning process before surgery in accordance with evidence-based standards to avoid skin injuries or nerve damage that may debilitate the patient while increasing the patient’s care and length of stay. The goal, McKenzie says, “is to do every little thing we are able to to ensure we follow the principles [the standards] . . . or if there’s a difference to grasp why.”

Black box video as a tool for training and implementation of nurses.

The potential productivity gains from such quality improvement projects seem obvious and proceed to be measured at Duke. Such data-driven examination of key operating room processes, McKenzie says, can also be invaluable in the case of onboarding recent nurses into the operating room.

“It’s a singular specialty and nurses [who are interested in it] I not have experience within the operating room or nursing schools. Many universities have eliminated it from their curricula… The college has no clinical rotations, so we’ve got to be creative in training recent people and onboarding recent employees effectively and standardized.”

To this end, black box videos provided instructive examples of steps related to interruptions in surgery for patient positioning, sample transfer, and surgical site preparation, in addition to surgical safety checklists and post-OR debriefs.

Finding examples of best practice to learn from.

“Often once we take into consideration a black box scenario,” McKenzie says, “we take into consideration something that did not go the way in which we expected. The reverse can also be true. Sometimes we discover it. . . our response to a selected situation was exactly what it must have been, every little thing was done accurately and the suitable people reacted accurately. . . . “The black box data will be used as a tool to share best practices within the operating room when teaching and onboarding recent staff.”

Although installing black boxes in operating rooms requires a big initial investment of time, McKenzie says evidence of their value and recent ideas for his or her use in clinical practice will proceed to emerge as they grow to be more widely utilized in other hospitals, making a larger evidence base.