Real-time video monitoring in OR checks safety compliance
A first-of-its-kind video monitoring system used to measure hand-washing compliance at North Shore University Hospital (NSUH) in Manhasset, NY, is being expanded to include cameras in operating rooms (ORs) at a sister facility, Forest Hills (NY) Hospital.
The new pilot program strengthens patient safety by providing hospitals with real-time feedback in their ORs, and it is the first time in the United States that remote video auditing (RVA) has been used in a surgical setting, explains John F. Di Capua, MD, the Peter Walker associate professor and chairman of the Department of Anesthesiology at Hofstra North Shore-LIJ School of Medicine in Hempstead, NY. Di Capua also is chief medical officer of North American Partners in Anesthesia (NAPA) in Melville, NY.
RVA ensures that surgical teams take a "timeout" before they begin a procedure to prevent wrong-site surgeries. The cameras also are being used to alert hospital cleaning crew when a surgery is nearing completion and the preoperative area when a room is ready for the next case, which helps reduce the time it takes to prepare the OR for the next surgery. To reduce the risk of infections, the monitoring system also confirms whether ORs have been cleaned thoroughly and properly, both in between cases and overnight. (See the story on p. 90 for more on how the video monitoring works.)
The program was designed and implemented by NAPA, which is North Shore-LIJ's anesthesiology provider, in partnership with Mount Kisco, NY-based Arrowsight, a developer and third-party provider of RVA services and software.
The program was initiated in March 2013 in eight ORs at North Shore-LIJ's Forest Hills Hospital. The initial focus at Forest Hills has been on monitoring for surgical timeout compliance, and within just one week of receiving real-time performance feedback, the operating room teams achieved nearly perfect scores, says Rita Mercieca, RN, the hospital's executive director.
Given the success of the program at Forest Hills, Di Capua says the monitoring system was installed in June 2013 in more than 20 ORs at another North Shore-LIJ hospital. "We are very excited to bring this important innovation to additional surgical suites," he said. "We believe that third-party RVA can provide our hospitals with strong, sustainable tools to improve patient safety and perioperative efficiencies."
The introduction of video monitoring in ORs follows its ongoing, successful use in the medical and surgical intensive care units at NSUH. In a 2011 study published in Clinical Infectious Diseases Medical Journal, NSUH demonstrated that the use of an RVA system rapidly improved and sustained hand hygiene rates to nearly 90% in fewer than four weeks.1
Forest Hills also revised its timeout process to make it more interactive, Mercieca notes. "The anesthesiologist and the circulating nurse are asking questions rather than just going through a checklist off the top of their heads," she explains. "They ask specific questions of the surgeon and the team about the patient, making sure they have the right patient and the right procedure, and that they are prepared for anything that might occur. They make sure everyone is engaged."
The timeout should take a few minutes to complete, Mercieca says. If it takes less than a full minute, the timeout cannot be valid. Since Forest Hills began video monitoring of the time outs, the OR teams have achieved nearly 100% compliance, she says.
The video monitoring does not stop when the procedure is complete. Auditors also use the cameras to ensure that terminal cleaning is performed correctly, checking that certain tasks are included and that the cleaning takes at least one hour.
"We're at 100% compliance on the terminal cleaning as well, and that's a really big deal," Mercieca says. "We believe that will reduce surgical site infections."
The monitoring allows the collection of data on every procedure, not just sampling, and that makes the information much more compelling, Di Capua says. He points out that monitoring alone will not produce significant changes in behavior. Clinicians will be motivated to a limited degree simply by knowing that they are being watched, he says, but that effect is limited and decreases over time. The real change comes from using the monitoring to compile data about compliance and providing that data to staff and department heads.
"When you put the data out, that's when you achieve compliance. Having the cameras present without reporting the information didn't achieve much of anything," Di Capua says. "You have to report the data and let people internalize it. Once people trust the data, they will do what you ask them to do."
How remote video monitoring of OR activity works
All eight operating rooms (ORs) at Forest Hills (NY) Hospital are equipped with video cameras that enable real-time video monitoring of everything that happens before, during, and after a procedure, says Rita Mercieca, RN, the hospital's executive director.
The cameras in the ORs feed images to screens at the desk of the OR director and also at the main OR desk, where the director and others can watch for compliance. The images also can be viewed remotely by parties interested in verifying compliance or timing how long certain tasks take to complete, such as the infection control director or the quality assurance manager.
All activity in the OR is recorded and saved for 24 hours, but then the recordings are erased. In addition, the monitoring equipment is purposefully set to produce low-definition video in which the actions of the OR team can be discerned but no one's identity is clear. "We don't want to compromise a patient in any way," Mercieca says. "The auditor can see the people around the table but the patient cannot be identified at all and the OR team's faces are obscured by their masks and the low definition video."
Potential use by plaintiffs also was a factor in deciding to erase the video, she notes. The hospital wanted to emphasize to staff and physicians that the video monitoring was solely to improve quality and patient safety and not to create a video record that could be used against them in any way. Saving the video would create documentation that could be subpoenaed in a malpractice case, and even though the record might sometimes prove useful for the defense, the hospital leaders decided the best move was to erase everything, she says.
Staff and physicians initially were skeptical of being videotaped in the OR, but Mercieca says they came on board once they understood that the purpose was to improve patient safety rather than to catch them in an error and punish them.
Reference
1. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: The use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis 2011; 54:1-7.
SOURCES
• John F. Di Capua, MD, The Peter Walker Associate Professor and Chairman, Department of Anesthesiology, Hofstra-North Shore LIJ School of Medicine, Hempstead, NY. Telephone: (718) 470-7391. Email: [email protected].
• Rita Mercieca, RN, Executive Director, Forest Hills (NY) Hospital. Telephone: (718) 830-4002. Email: [email protected].
