Advanced software applications and surgeons’ ability to conduct more precise, image-enabled and image-guided procedures make access to images in the OR increasingly important. Facilities are expanding and implementing PACS and displays that allow for easier image distribution, while accommodating a variety of needs from their different surgeons.

Wide appeal

Palmetto Health, a three-hospital health system in South Carolina, implemented IMPAX PACS from Agfa HealthCare in 1999. Within a couple of years, they made PACS accessible in all operating suites. Surgeons use PACS images during all types of procedures. “Generally, they bring up the study and the most appropriate images and have them on display so that they can look and scroll through them if they need to,” says Carrie Boothby, IT manager, clinical applications. The surgeons who prefer to drive the PACS themselves during a procedure use keyboard covers and plastic bags over the mouse.

Some of the operating rooms use PACS workstations on carts on which users can view true DICOM images. Because space is often at a premium in the OR, the carts allow for more flexibility, Boothby says. They also can be rolled from room to room. Renovations currently underway at the Baptist, Columbia campus will equip every operating suite with wall-mounted PACS viewing capabilities.

Most of the ORs have dual displays, although Boothby says some orthopedists have requested 42-inch plasma screens. However, current large screens affect image quality, so Boothby says they plan to wait for more hardware manufacturer improvements.

Meanwhile, the organization is looking at templating capabilities for orthopedics as well as working on more integration between cardiology and radiology services. A big goal is improving imaging access for heart surgery because that is such a big growth area. The system has a freestanding heart hospital and is feeling a push from the cardiology environment, she says.

The renovations will equip each OR with monitors viewable from any position and more flexible controls to allow for adjustments. “Improving our accessibility improves workflow within the OR suites,” she says. The renovations also will help the facility accommodate growth. “We find that with new and improved processes, it’s good to equip the rooms with the latest and greatest technology.”

Options and flexibility

Halifax Medical Center in Daytona Beach, Fla., implemented Unity PACS from DR Systems in 2003. The operating rooms went live with PACS about 60 days later. The biggest challenge, says System Administrator Bill Kazee, is that the surgeons all look at the films differently. Neurosurgeons, for example, prefer to hang up 8 to 12 films and scan all of them. Orthopedic surgeons generally look at one sheet of film.

The solution, he says, was to provide a mix and match of options. During phase one of implementation, dual monitors were wall-mounted in the ORs to allow for as much real estate as possible. The team addressed each physician group’s needs: Neurosurgeons got a quad bank of monitors on a mobile cart while orthopedists and other surgeons got dual-monitor carts. Some surgeons like the carts because they can be rolled to either side of the operating table or wherever is easiest for the surgeon to see them. The goal was for the surgeon to never have to leave the table.

Most of the rooms have multiple 20-inch monitors which allows for more “ability to divide and conquer that exam” by providing, for example, axial images on one screen and post-processed images on another. Initially, Kazee installed wall-mounted monitors in the rooms. However, he learned that the surgeons preferred the ability to move their viewing station to various locations.

During surgery, the physician will either manipulate the station before scrubbing in or have a circulator drive the cart for him, Kazee says. If the surgeon wants to zoom in on a certain image, the circulator can drive the software. Every OR already had a circulating nurse not involved in the table field. Once a case is brought up on a monitor, they don’t need very advanced skills to alter images. The involvement of the circulator during a procedure was provided to the surgeon as a result of the workflows demanded of the surgeons at other facilities where they have to leave the sterile field to manipulate the image data. “It really made sense to us to implement the product like this, as why force the surgeon to leave the table field in a demanding procedure and spend costly time manipulating the images himself. Plus, the surgeon can preplan image views most likely to be needed during the case.”

When installing the equipment, Kazee says the team had to ensure power and networking drops in locations where the carts would be used. Some network drops were a problem but new ORs are being built now and all will be wireless.

Kazee took advantage of the  lessons learned from OR implementations at other hospitals in the area. Beyond the involvement of the circulators, he also had large multi-display station’s installed in the OR physician lounge and on each of the patient floors—something that was not made so readily available to the physicians at other institutions. That lets surgeons preplan procedures and take last-minute looks. He says the feedback has been fantastic.

Overall functionality

Wilson Memorial Hospital in Sidney, Ohio, also is in the process of renovating its operating rooms and installing image displays on booms. Wilson implemented Vision Series PACS from AMICAS a year ago, says Tony Linkmeyer, director of imaging. The facility had been an early adopter of PACS in the late 1990s, but the system needed to be replaced. The previous, thick-client PACS was very heavily server-based, which made it difficult to distribute images. “We knew we had to shift gears and move to a model that would let us distribute images more easily.” 

Linkmeyer says his surgeons wanted speed, flexibility and accessibility. “They didn’t need too many bells and whistles as much as good functionality of the system overall.” AMICAS offers a “forever priors” concept, he says. Since the physicians had asked for a guarantee of available images, the facility chose to migrate five years of the prior eight years of images into the PACS. “If support staff didn’t push images before a procedure, the doctor was screaming at me,” he says. Now, surgeons can call up priors themselves.

Wilson used to have two imaging carts with the thick-client PACS loaded on and hooked into a jack. Data and images were loaded to those review stations, which were limited to cart locations. The renovations currently underway will put all patient monitoring stations and viewing on a series of monitors suspended above the patient. That frees up floor space and provides image and data access in each room.

Although the AMICAS PACS wasn’t purchased in anticipation of these renovations, Linkmeyer says the investment will certainly pay off. For one thing, “the expectation from our referral base is images anywhere, anytime.”

“Because our CIO had the forethought to create a good backbone, we’ll be able to acquire CT images and link them with 3D mapping software,” he says. He predicts that, more and more, users will need large, digital images that can be quickly moved to the OR suite. “We’ll need the ability to get doctors access to larger images and more complex exams along with 3D mapping software for planning surgery.”

Advice from the field

Thin-client PACS, flexible mobile carts, a range of monitors and advances in software are all driving increased imaging demand in the OR. There are factors to consider to meet that demand successfully. “I think the system is only as good as its users,” says Palmetto Health’s Boothby. “Provided you have good physician buy-in, the sky’s the limit.” Good training and support is important.

Plus, she recommends accomodating for unanticipated growth in the budget to allow for new equipment every year. You’ll start out with adequate equipment but “as users grow and depend on the system, you have to be cognizant of their needs. Make sure you plan for additional equipment every year.” Once physicians get accustomed to using PACS and all of its capabilities, they don’t want to go back to film. “If you don’t have the digital equipment available, that can cause problems.”

Wilson Memorial’s Linkmeyer suggests preparing with a very strong backbone for the IT infrastructure, fast switches, plenty of capacity for web-based tools and a vendor that will accommodate distribution of images, not just image acquisition. “Everybody can take your image and hold it. A good company can move that image around and that’s become more and more important.”