Towards implementing laboursaving technology in surgery

Abstract

This thesis is to provide an interdisciplinary overview of the implementation of labour-saving technology in the OR, using surgical instrument counting as an illustrative case.

In Chapter 2, we present the current situation of surgical instrument counting in clinical practice. Through observations, we found that OR nurses use various strategies and counting techniques to manage disruptions and limit workload. We also found that there is limited interest in the use of supportive technology during a surgical procedure; nurses prefer this support in the preparatory and closing phases of surgery.

In Chapter 3, we dive deeper into the current use of labour-saving technology. In Part 1 we focus on weighing systems (i.e., scales). Introduced around twenty years ago, they were meant to standardise and automate surgical instrument counting. Instruments are weighed before and after a surgery, and if the weight matches, the instruments are complete. Around a quarter of Dutch hospitals still use a weighing system in their instrument lifecycle, but many mention that it is unreliable. This triggered us to investigate further. We visited several hospitals throughout the country to see how the system is used. We found that each hospital adapted their workflow in a unique way to accommodate the limitations of the weighing system, with a varying degree of success, or fidelity. It turns out that this fidelity is higher in hospitals where communication between departments and different user groups occurs more smoothly, thereby increasing trust in the system’s accuracy.

In Part 2 of this chapter we focus on a different technology, introduced around ten years ago in the Reinier de Graaf hospital in Delft: DORA (Digital Operating Room Assistant). DORA was developed to improve efficiency surrounding medical devices situated in the OR. In case of a device malfunctioning, DORA allows for an immediate error report to the technical department instead of OR staff having to call a technician. In our evaluation study, we found that while most OR users are satisfied, some issues remain that nudge people to the old way of reporting device malfunctions. Technicians are less satisfied, as the relatively short battery life of the sensor requires them to find devices in the operating rooms just to replace a battery. However, the added value of the system when these issues are resolved is clear, as developments of a new DORA system are underway.

Chapter 4 presents the uniformity and variations in surgical counting protocols among Dutch hospitals. Two-thirds of all hospitals participated in this study, showing that surgical instrument counting is an important topic in the field. Compared to a similar study performed in 2006, various improvements have been made to increase standardisation and patient safety. However, perceived high-risk situations have remained largely unchanged, such as staff changes and emergency situations. In addition, most hospitals describe a shared responsibility of the instrument count in their protocol, a policy we speculate could contribute to uncertainty and unsafe practice. We also found that a quarter of hospitals use a weighing system in their instrument workflow, with half of them noting that this system is unreliable in its purpose to count instruments.

So far, no technology has managed to fully replace the manual process of surgical instrument counting. However, with continued interest and development of technologies for this application, such as computer vision algorithms, this might still happen in the near future. In Chapter 5, we analyse jurisprudence and legal precedence to determine who is actually responsible for instrument counting. According to national guidelines, the instrumenting nurse is responsible for performing the instrument count. Looking further, however, the surgeon and the hospital are liable for damages following a retained instrument. Adding to that, new technological innovations will likely make use of artificial intelligence (AI), where the way in which an algorithm comes to an output often remains unclear. Legal experts and lawmakers have not yet worked out how this will relate to the responsibility and liability of users in the medical context.