Medical images moving electronically from ER to OR, ICU to clinical departments and physician offices to surgical suites throughout the healthcare enterprise via PACS provide opportunities for glory or disaster.
If you select appropriate solutions, you’ll have happy and productive clinicians reviewing images close to the point of care. Choose wrongly and you have a snarled mess that slows workflow and diminishes productivity. The potential for disaster is real, but manufacturers of furniture and mounting devices stand at the ready with a selection of fixed and portable solutions to provide the most effective solutions for image review.
The stakes are high in the OR
Nogah Haramati, MD, chief of Radiology and professor of Clinical Radiology and Surgery at the Jack D. Weiler Hospital of the Albert Einstein College of Medicine of Yeshiva University (A Division of Montefiore Medical Center) in the Bronx, N.Y., describes the unique ergonomic solutions that they have designed in conjunction with AFC Industries for their operating rooms.
The complexities of viewing images in an OR cannot be overstated. Each case or individual surgeon can require a specific configuration. Surgical procedures require different positioning for each patient. The surgeon may stand on either side of the table, the anesthesiologist needs to be at the patient’s head, but that could be in several directions within the room. The other pieces of equipment are jammed into an OR where “real estate” is precious. Given this scenario, Haramati explains that the traditional approach of mounting images in one spot on the wall may not prove effective. To meet the complex needs, they designed three different approaches which they may employ in tandem with other solutions.
The first involves ceiling-mounted articulating arms with LCD screens on each end. Some of their rooms have as many as eight of these arms, which is why they call it “the octopus.”
The second approach is to piggyback viewing monitors onto a previously installed pillar used to provide oxygen, carbon dioxide, nitrogen, and vacuum lines necessary for surgical procedures. “That way we can put on each monitor whatever the surgeon wants for that case, including patient biometric data such as pulse oximetry, optical data such as a video camera, as well as x-ray data, arthroscopy data or whatever the clinician wants.” In some instances, the monitors are tiled into four or more sections.
Haramati cautions that when institutions employ wireless systems in the OR, they must test other pieces of equipment because, for example, the cautery knives may interfere with wireless devices.
The third approach in the OR involves using mobile carts with monitors that can be moved into place within view of the surgeon. The other benefit to this approach is that if a monitor malfunctions, it can easily be replaced, taking care of the issue far from the high stress surgical suite.
The other critical issue in the OR is the stringent requirement for infection control. Haramati encases their monitors in glass non-reflective coverings that can be bleached at the end of each procedure. He recommends making sure that the glass is as close as possible to the monitor screen so that neither dust particles nor optical distortion affects image quality. He stresses that they do not use a “one size fits all” approach, but purchase their monitors with the glass housing in place. One further consideration is that monitors must be cooled, so they have fins on the housing in a baffle array to prevent moisture from getting in while providing cooling functionality.
In a wireless environment, such as throughout the UCLA Medical Center in Los Angeles, PACS Applications Manager Rick McGill, BS, RT(MR)(R), says that because they have a voice recognition system and their radiologists can generate a full report within a two-hour window, they are able to use full-functioning PCs with a monitor, CPU and power supply on a cart on all the floors and nursing units. Anthro Corp. manufactures about half of the carts they use in the hospital. “Many times the resolution of the monitors we put up on the floors is equivalent to or better than the native resolution of typical CT or MR or ultrasound monitors that come with that equipment.”
By using a cart-based approach, they are able to maximize their utilization of resources to take viewing monitors to the patient’s bedside and then returning the cart to the usual spot where it resides near the power outlet. “The other beauty of this system is that although most PACS monitors are only grayscale monitors, the monitors we’re putting on these carts are regular color monitors.” This means that nurses can use these systems for charting or accessing the radiology information systems (RIS), images can be viewed in color where applicable, and the multi-functionality design of these systems renders them workhorses.
The carts offer height adjustability to meet the needs of a variety of users. McGill says that one of their physicians who used to play professional basketball is over seven-feet tall, while one of their nurses is four foot eleven on a good day. Having a highly adjustable cart capable of moving up and down easily is quite important. “These carts were made for full functionality of RIS, HIS and PACS. The CPU is very small and is placed at the base of the unit, so this makes a stable solution.”
Plan, plan, plan
Terry Napper, MBA, RT(R), director of radiology at Parkland Health & Hospital System in Dallas, explains that outside their radiology department, they have PACS deployed in virtually every area of this 1,000-bed hospital, using a combination of fixed monitor installations and movable carts. Using EnovateIT consultants to assist in the design and installation process proved a beneficial approach to their unique issues.
EnovateIT staff performed initial needs assessment considering space, workflow, productivity and ergonomic principles and then advised on options to meet their specific challenges.
For example, the nursing stations on each of the care units are busy centers where a number of staff requires desk space to complete their tasks. EnovateIT designed what Napper calls their “Magic Web Kiosk tables” that are stationary viewing stations very close to the nursing stations, but removed from the hub of activity. This allows nursing staff to continue with their functions while physicians review images. In addition, there are viewing monitors mounted on movable carts in strategic areas.
The operating suites, which number 16 in all, are set up around the needs of the specialties utilizing them, such as orthopedics or neurosurgery. They have 42-inch wall-mounted monitors, complete with hard drives and peripheral equipment in addition to cart-based systems that can be moved in when necessary. As a Level 1 trauma center, any given patient could require more than one sub-specialty surgical team performing procedures simultaneously in the OR.
Staff at the USC University Hospital and Norris Cancer Hospital in Los Angeles is in the thick of PACS deployment with an anticipated completion date near the end of the year. Initial planning involved installation of a robust network, with a 10 Gig backbone and 1 Gig connections to desktops, modalities, and printers, says Javier Morlett, USC’s manager of information systems for those hospitals. Besides designing the viewing areas in their new tower hospital building with 11 new operating rooms as well as 14 existing operating rooms, they needed to retrofit several areas in their existing buildings and decide which monitor configurations they should employ.
“We chose Ergotron because of the array of different configurations they offer,” explains Morlett. They have selected Styleview dual display carts that offer a built-in battery and PC-based configuration to provide maximum flexibility to their image viewing needs.
As with all institutions that must consider the usual space limitations, ergonomic and licensing issues, California hospitals are regulated by the Office of Statewide Health Planning and Development (OSHPD) since the Hospital Seismic Safety Act was passed in 1971. All construction must meet stringent requirements for safety in the event of an earthquake. Ergotron has developed pre-approved mounting methods in wall design.
Throughout the hospital, they standardized to 17- and 19-inch monitor sizes with high-speed computers to handle the large image data sets. They’ll have close to 33 PACS workstations for all three buildings when the PACS and network are complete.
A decision about what furniture, carts or wall mounts to use for viewing monitors outside the radiology department requires careful consideration and planning. Less rigorous attention to these details may cause headaches of previously unknown proportions.