Bringing Images into the OR

Successfully integrating digital images into the operating room is a task many facilities are facing but few have successfully tackled. Here's a review of what to consider in displays, carts and computers on wheels (COWs), PACS and networking to create a filmless, image-friendly OR.

For many hospitals, the operating room (OR) is the last stand for film with OR film accounting for up to 20 to 25 percent of residual film in PACS sites. Bringing images into the OR is a multi-faceted process with several key ingredients for hospitals to evaluate and understand as they move forward in the process. This month Health Imaging & IT examines four components of image viewing in the OR: displays, carts and computers on wheels (COWs), PACS and networking. Considerations for each component often intersect and overlap, so an understanding of the big picture is equally important.


Monitors or displays are the medium on which OR images are viewed. Key considerations include size, placement and performance. Kaiser Permanente Medical Centers in Northern California rely on Planar dual display 21-inch color monitors for OR viewing. Skip Kennedy, assistant director for radiology informatics for Kaiser Permanente Northern California, discusses the essentials. "Dual displays are really critical for the OR because the standard views are AP and lateral chest, and surgeons need a large enough display to see images from a distance of 10 to 12 feet."

Another consideration is glare. Glare from OR lights can affect viewing, so brighter monitors tend to be better OR solutions. Other adjustments to minimize glare include moving the lights away from the monitor or adding a hood around the top of the display.

Fairview Health Services (Minneapolis) uses NEC 40-inch, flat-panel LCD monitors permanently mounted on the wall in its busiest ORs. Patricia Berger, IMS system director, says the larger size translates into better visualization. The 40-inch monitors also are deployed in orthopedic ORs where better visualization is a necessity. Springhill Medical Center (Mobile, Ala.) considered 40-inch, flat-screen monitors for its OR project. After a thorough analysis, the hospital wasn't able to find a strategic location on OR walls for maximum functionality and workflow and instead deployed wireless cart-mounted displays.

In lesser-used ORs and smaller hospitals, Fairview relies on 20-inch, cart-mounted displays. This option can be more cost-effective than wall-mounted displays because displays and carts can be shared among ORs, says Berger.

University of Chicago Hospital uses a mix of wall and cart-mounted displays. Every OR has dual-mounted Totuku 20-inch grayscale monitors that replicate the functionality of the film box. Cart-mounted color monitors also are available for additional views or to enable surgeons to view echo studies, cardiac ultrasound or fusion images. These displays also serve as a redundant solution if a wall-mounted display goes down. Milton Griffin, assistant director of radiology at the University of Chicago Hospital, says the layout of some ORs can make it difficult to wall-mount displays, so sometimes carts serve as a de facto solution.

Surgeons at The Ottawa Hospital (Ottawa, Canada) opted for wall-mounted displays after a one month pilot of both wall and cart-mounted displays. Michelle LeFlour, manager of the electronic health record and imaging systems, says surgeons felt carts were too cumbersome and could get in the way during surgical procedures. In addition, she says, surgeons were used to viewing images on the wall with lightboxes, so wall-mounted displays seemed to provide the most practical solution.

St. Mary's Hospital in Athens, Ga., deployed 18-inch ViewSonic monitors in its ORs. CT Supervisor and Assistant PACS Administrator Brian Duncan says one benefit of these monitors is their ability to rotate to allow portrait viewing. All OR rooms at St. Mary's use monitors on COWs with the exception of one neurosurgery room, which has a Stryker system that consists of 18-inch displays mounted on booms. This setup allows nurses to transmit images from one screen to another.

A final display consideration is consistency. When Memorial Hospital in Colorado Springs, Colo., completed a side-by-side image quality comparison of its first selection, the radiology director realized that the color was not uniform. The hospital went back to the drawing board and found 19-inch medical grade Wide monitors from Double Black Imaging fit the bill, says Sheryl Longhofer, Memorial's PACS/MagicWeb administrator.


Displays, carts and COWs often come down to a compromise among price, performance and modularity. While it sounds simple, carts need to hold displays. "Getting dual monitors mounted on a cart can be a challenge," Kennedy points out. Kaiser Permanente selected Anthro Corp.'s Point of Care carts; the vendor agreed to place yokes for the dual displays on the carts because Kaiser represented big business with an order of 300 carts.

Another consideration for wired ORs is a UPS (uninterruptible power supply). Kaiser Permanente decided to add an after-market UPS to each cart to make it easier to move carts mid-procedure and avoid laying cables during the procedure if a cart needs to be moved.

Wireless shops take a different route. Memorial Hospital mounted its six Wide monitors on Ergotron Mobile workstands and uses a 12-hour battery to ensure consistent power.

While most hospitals aim to keep costs to a minimum, multiple COWs per room can streamline workflow. Springhill Medical Center uses two cart-mounted, 17-inch monitors in each of its OR rooms. One monitor is used by the nursing staff for OR notes and clinical records, and the second is dedicated to PACS.

St. Mary's Hospital opted to configure computer carts for its OR project. Duncan says, "This way we knew we'd get exactly what we wanted."


PACS issues for image viewing in the OR include bandwidth requirements, image distribution capabilities and ease of use. Fairview's Berger points out, "Every PACS can provide good distribution within the walls of radiology. For OR viewing, the hospital needs a solution with great distribution technology across the enterprise." Fairview relies on IDX's ImageCast. Berger says the company's persistent storage technology makes all images always available, eliminating pre-fetching or pushing of images to the OR.

Ottawa Hospital's LeFlour says, "Hospitals should look at vendors that provide multiple options for viewing images-both on the web and on PACS workstation." Overall, web-based systems are easier to deploy in the OR and provide the robust access needed for OR projects. At The Ottawa Hospital, McKesson's Horizon DX View serves as the PACS solution for web-based OR viewing.

Kaiser Permanente uses Stentor's iSite PACS. Kennedy says Stentor's compression technology cuts bandwidth requirements by 75 percent, allowing the hospital to get good performance with a 100 Base-T fast Ethernet network.

PACS' performance is certainly an OR concern. Jack Dempsey, director of radiology at Springhill Medical Center, says surgeons need ease of use in PACS. But there a few features that make a big difference in the OR. For example, surgeons often need to view and navigate multiple images in multiple modalities, viewing CT studies on one monitor and MRIs on another. Another requirement for PACS is the ability to display two images of the same modality on dual displays while retaining the ability to navigate PACS. University of Chicago Hospital gained these abilities with the latest release of its Amicas Vision Series PACS software.

"A key-images function is most relevant for surgery," Dempsey opines. This allows surgeons to request key images prior to surgery to streamline the image delivery process.

A final piece of the PACS puzzle is remote capabilities. LeFlour explains, "Being able to take remote control of the PACS prevents us from having to suit up to work on the PACS in the OR."


Wireless may be ideal in the OR. After all, life expectancy of cables in the OR can average less than a month because the cords are constantly run over with heavy objects. Moreover, stretching cables across a busy OR can be a safety hazard. Longhofer of Memorial Hospital admits that cables posed a significant safety issue when the hospital went filmless in the OR. The hospital decided to place six wireless access points in each OR to eliminate the cord issues. While wireless may not be an option for image viewing in radiology, 11-megabyte wireless transmission can suffice for OR needs. Although Memorial Hospital relies on an 11-megabyte wireless network for OR image transmission, Duncan recommends a 54-megabyte wireless network. "Anything slower might slow image transmission," he says.

Not every hospital is poised for wireless in the OR. One way around the wireless issue is to wall-mount monitors, which eliminates cables on the floor. And if the hospital remains entrenched in a wired environment, a 100-megabyte network, which is becoming standard in PACS hospitals, should transmit images to the OR in near real-time. In fact, Berger points out that ImageCast doesn't require a 100-megabyte network for OR transmission.

RAM is actually more important than network speed, opines Longhofer. Memorial Hospital placed 1 gigabyte of RAM on its Siemens MagicWeb to enable surgeons to flip through MR and CT images in the OR; however, Longhofer confirms 256 megabytes would have worked, too.


  • Wireless mice - "In theory, these sound great," admits Berger. But Fairview tried wireless mice enclosed in sterile bags, but "it was a disaster," Berger shares. "They were lost all the time, and physicians didn't like them." The current Fairview solution is to bring images up outside of the sterile field via a traditional wired mouse.
  • "Have a functional solution for downtime during procedures," advises Griffin. University of Chicago Hospital burns CDs of all patients scheduled for surgery and deposits the CDs in a central location.
  • A high level pre-project dialogue with surgeons can go a long way in securing buy-in and a solid understanding of image viewing in the OR, says Griffin.
  • Similarly, training of both surgical and PACS staff is critical. PACS staff need to understand the OR environment to serve its needs, and OR staff need to develop a basic understanding of PACS functions to rely on digital images.


Although hospitals that have implemented filmless ORs report tremendous benefits, a few items loom on the horizon. For example, software to allow digital templating is just hitting the market. Surgeons at the University of Chicago Hospital still template from hard copy for total hip and knee replacements. The Ottawa Hospital also faces this conundrum, but is actively searching for a software solution. Vendors also are catching on to other OR image viewing needs. New solutions, including carts specifically designed for the OR, are hitting the streets.

Surgeons often want to see CT with 12 images in a single view next to large size images in the OR. Griffin admits, "We haven't overcome this challenge. We'd like to have one screen with the 12 to 16 images and the other display each image in large size."

Image navigation for scrubbed surgeons can be tricky. Most sites rely on a nurse or tech outside of the sterile field. High on the OR wish list at the University of Chicago, too, is a footswitch to enable easy image navigation.

Finally, 64-slice CT is here. If it's in your hospital's plans, check to see if the network bandwidth can deliver that amount of data to the OR. 


Digital viewing in the OR carries a number of benefits. Take for example Fairview. The health system set a goal of 85 percent filmlessness 18 months after its go-live date, but achieved 90 percent filmlessness on day one because it deployed an OR solution concurrently with PACS. At Springhill, Dempsey says the time delay of images to surgeons has improved from 15 minutes to 1.5 seconds with PACS. He continues, "This all snowballs. Patient care is better because they spend less time under anesthesia." The minutes freed up during each surgery add up during the day, allowing the hospital to maximize use of their ORs.

There are a variety of ways to bring digital images to the OR - and do it right. A bit of homework will go a long way toward ensuring success and acceptance of the project.

Making Your List, Checking it Twice

The Display Checklist

  • What size and configuration will work best in the OR?
  • Can a combination approach with multiple monitor sizes best meet surgical and site needs?
  • Check for glare and consistency on-site. How will the hospital minimize glare?

The COW Checklist

  • How will the displays be mounted?
  • How many COWs are needed to meet the hospital's budget and workflow needs?
  • Can a combination of wall and cart-mounted displays enhance the project by streamlining workflow or providing redundancy?
  • Is a UPS necessary in the wired OR?

The PACS Checklist

  • Is the PACS web-based or does it have a web component? This is essential for image viewing in the OR.
  • Demo a version of the PACS on the hospital's network to see the speed of image delivery to the OR.
  • Ease of use on the PACS solution is essential for surgeons, says Jack Dempsey, director of radiology at Springhill Medical Center (Mobile, Ala.). "They don't need sophisticated toolsets. They need ease of use and simple routing."

The Network Checklist

  • If wireless is the solution, be sure to strategically locate access points so that there is network access everywhere in the OR.
  • Whether wired or wireless is the solution, check to make sure that the network delivers images in minimal time.
  • Make sure the PACS has sufficient RAM to allow navigation through large data sets in the OR.