Working Smart
Advances in OR technology—from "smart suites" to surgical robots—allow nurses to devote more attention to patients

By Cathryn Domrose
March 8, 2004

When Paula Graling, MSN, RN, a certified operating room nurse and clinical nurse specialist at Inova Fairfax Hospital in Falls Church, Va., first viewed the latest cutting-edge operating room technology at a conference in Florida 10 years ago, she felt amazed, a little overwhelmed and a tiny bit concerned.

The computers in the laparoscopic surgery suite spoke, announcing when everything was activated and ready. The lighting system dimmed or brightened the room in response to voice commands. Robots held cameras in place. Video monitors showed clear, clean pictures of the simulated model patient and procedure from all angles.

“I sat there in awe,” said Graling, national treasurer for the Association of periOperative Registered Nurses. “The first thing I thought was, ‘I’m never going to get all these things together.’ ”

In the back of her head was another, more unnerving thought: “Am I going to be replaced by this thing?”

Today, she works in a hospital with six “Smart Suites”—also called Endosuites, OR1s and Operating Rooms of the Future, depending on which company makes them—and three robots. Not only has she mastered the new technology, she loves using it. It still amazes her. But she no longer fears it could replace real nurses.

“I’m never going to be replaced,” she said. “The human component is something that can’t be replaced.”

Operating room technology for noninvasive surgery has exploded in the last five years as robots, voice-controlled systems, sophisticated imaging equipment and tracking techniques have been integrated with computer systems to create operating rooms that practically run themselves.

The new technology is expensive, ever-changing and requires more education, but generally it saves time, creates less room for error and—with the machines and monitors in the newest rooms now suspended from ceiling booms—reduces the amount of pushing and lifting nurses must do.

But the best feature of the new technology, perioperative nurses say, is that it leaves them more time to do the most important part of their job, the part no machine can replace: caring and advocating for their patients.

Laparoscopic surgery has expanded to almost every corner of the hospital. Orthopedic, endovascular, ophthalmology, plastic surgery, neurosurgery, urology and general surgeries are commonly performed using minimally invasive procedures. Surgeries that once took 12 hours now take less than three.

Leaps and bounds

As these surgeries have evolved, so has the technology used to perform them. Surgeons use 3-millimeter endoscopes and perform operations using high-resolution cameras and video monitors. Robotic arms hold cameras and light sources in place. Other robots, such as the da Vinci Surgical System, actually perform surgery, manipulated by the physician. With a patient’s permission, surgical procedures can be broadcast to classrooms in the hospital or copied onto DVDs to help educate students or other patients.

The advance in OR technology that nurses perhaps appreciate most has come in the setup and integration of the laparoscopic surgery suite. Perioperative nurses say they expect the new technology to become standard in operating rooms and intensive care units within the next few years, and eventually spread to the rest of the hospital.

Laparoscopic surgery in traditional operating rooms requires lots of machinery that must be brought in on carts or towers and plugged into wall sockets, said Robert Rege, MD, professor and chairman of the department of surgery at the University of Texas Southwestern Medical Center at Dallas. “They had nurses running all over the place from one cart to another.”

But the newest rooms have put much of the equipment onto booms that hang from the ceilings. “The first ones were quite bulky and took up a lot of space in the room,” Rege said. The latest ones have flat screens rather than bulky TV monitors and the booms tuck away. Physicians and nurses can use voice- or touch-panel-activated controls to turn on a light source or activate a camera. They can pull up X-rays and put them on a screen or send requests to the blood bank by computer. In some places, they consult with colleagues in other parts of the hospital or in offices.

“What they’ve done is to take technology that is already pretty good,” Rege said, and integrate it so it works together.

Nurses who use the integrated operating rooms say the new technology makes procedures easier and safer for patients, reducing the amount of time they are under anesthesia and the chance for error.

“The Endosuite has given us more flexibility to help patients in a minimally invasive way,” said Jill Mortenson, RN, CNOR, a general surgery and plastic reconstruction resource nurse at Abbott Northwestern Hospital in Minneapolis. “It does anybody good to see a patient heal from a major operation and be back to work in a week.”

Efficient systems

Perioperative nurses say the latest OR technology also does something most technology does not do: It saves time.

When Jane Foshay, RN, CNOR, a staff nurse in charge of orthopedics at Kalispell (Mont.) Regional Medical Center, first saw the new Endosuite at her hospital, her first thought was, “Wow, this is great!” And then, “How much work is this going to be?”

At first, she thought the system seemed slow. But after getting to know and trust it, she sees a definite advantage. Nurses no longer have to hold lights or work foot pedals, she said. They can set up an operating room in five minutes instead of 20. They don’t have to move heavy equipment in and out of rooms or risk damaging the equipment by bumping it. The neat, tidy room—with nothing on the floor, nothing to get wet, no cords to trip over or equipment to move—is a perioperative nurse’s dream.

In the past, said Christine Pizzulli, RN, assistant director for clinical operations for the main operating room at the UCLA Medical Center, nurses had to run in and out of operating rooms to get supplies, go to the blood bank, take out specimens.

“The biggest thing for the nurses is that they don’t like to leave the room,” she said. “They really feel that’s important.” With the new systems, nurses can place their orders by computer. Supplies are brought in on carts and nurses have more time to assess and open supplies as needed.

The efficiency of the new technology leaves nurses more time to spend with their patients and coordinate the surgical team. Mortenson estimates she spends at least 10 extra minutes talking to her patients before surgery about what will happen during and after the procedure—time she otherwise would have spent helping set up the room. Forshay, a scrub nurse, said she feels less stress when she knows her circulator won’t be leaving the room to get supplies or equipment.

During surgery, nurses have more time to mentor colleagues, complete documentation, watch the positioning of the patient, assist with anesthesia, keep track of instruments, maintain sterility and watch the procedure on their own monitors.

“I feel more fully integrated with what’s going on,” said Aletta Harres, RN, specialty coordinator for pediatric/adult, general, laparoscopy and robotics at Presbyterian/St. Luke’s Medical Center in Denver.

Just as physicians are drawn to hospitals with the latest technology, nurses also seem attracted to the new operating rooms, and some hospital managers see the technology as a recruitment tool.

“People really like it,” said Deb Cooksey, RN, patient care manager for general operating rooms and minor surgery at the University of Maryland Medical Center in Baltimore, which recently opened a new surgical facility. “It’s really exciting to see the amount of pride because of the technology that’s been made available to them.”

The new technology has offered some challenges for perioperative nurses. Although it was not difficult to learn, it took time for nurses and support staff to become comfortable with it and to trust it, Forshay said. She recalled one instance when a nurse didn’t turn on the system properly and the computer wouldn’t respond to the doctor’s voice, causing a 20-minute delay of a procedure.

Some nurses never get comfortable with the new technology. Mortenson said her department has lost a “fair number” of nurses who transferred from other areas of the hospital and became overwhelmed by the technology. “They give up and go back to floor nursing. They just can’t do it.”

She remembers feeling the same way 20 years ago, when she started working in the operating room. She was afraid of not passing the instruments fast enough and told the doctor, “I can’t do this.” Now, she said, nurses are afraid of pushing the wrong button or not knowing how to troubleshoot a machine that doesn’t work. “There is so much for them to learn,” Mortenson said.

Keeping up

Nurses, who may see as many as 10 new things a day in the operating room, should speak up if they are not comfortable using any of the new technology, said Dawn Tenney, MSN, RN, associate chief nurse of perioperative nursing services at Massachusetts General Hospital in Boston.

This can be difficult for a nurse, especially if a physician comes in excited about a new device he or she has spent a week learning about, she said. In her hospital, if the nurse can understand how a new device works and feel comfortable with it, it can be used. If not, the physician must find a nurse who is comfortable with it or else not use it.

“Whether it was 20 or 30 years ago or with all the technology in the room today, the nurse’s role is to be the safety officer,” Tenney said.

Constantly changing technology also must be constantly upgraded, which costs a lot, nurses said. Integrated operating rooms that were state of the art five years ago now seem behind the times. Tammy Woolley, MS, RN, CNOR, associate chief nursing officer at Presbyterian/St. Luke’s, estimates her older rooms will cost about $100,000 to update. Installing a new integrated operating room cost about $250,000 two years ago.

“You’ll think you have the latest and greatest thing and someone will say, ‘That’s old. This is new,’ ” Woolley said.

Not all technology is always worth the cost, nurses said. Tenney said surgeons at Mass General haven’t really taken to the surgical robots, finding them too bulky and slow. Rege said he hasn’t been able to justify the cost of buying a robot for the surgeons at his facilities, though he expects robotics to make great strides in the next five to 15 years.

Tenney expects the next revolution in OR technology to come with advances in radio frequency tracking. Her hospital is using a location device to track patients’ progress through the hospital. Eventually, she said, the tracking device and the patient’s medical history will be incorporated onto an identity bracelet that operating room computers can pick up and transmit to the surgical team.

Her hospital also is trying out a new surgical table that minimizes manual patient transfers. The patient gets into a stretcherlike holder and is wheeled into the operating room. The surgical team hooks in hosing, the wheels and trolley pull away and the device becomes an operating table.

In addition to their excitement over the new technology and the possibility of even more exciting things to come, perioperative nurses say they do not fear losing their personal touch any more than they fear machines will replace them.

“Technology will never replace the nurse’s thought process in making sure the patient is being cared for correctly,” Harres said.

Mortenson said she occasionally sees a nurse who seems more interested in the machines than in the patient, but most have gone to nursing school because they want to care for people. “They can be techno-geeks,” she said, “but they still have that personal touch. You can train anybody to run a machine. But to put the people part with it is the trick. We tell them it’s always the patient first.

“Get that down and then we can work with everything else.”

Contact Cathryn Domrose at kaguilar@well.net.