Live-streaming of an open-heart surgery

In order to familiarize myself a bit more with the medical domain in preparation for the DISA project, I decided to attend the lectures of the “Medical Informatics” course given at the IT department at Uppsala University. The course comprises several study visits, the first one of which consisted in attending a live-streaming of an open-heart surgical intervention at the Uppsala University Hospital.

The live-streaming, which consisted of a high-quality video feed without sound, was orchestrated and commented by a clinician. Before and throughout the three hours that lasted the streaming session (which, unfortunately, ended before the end of the actual operation), the clinician provided us with some background on the ongoing procedure and explained to us how the main machinery and tools in use during the operation worked – showing us real-life examples of what these tools look like.

Throughout the streaming session, we had access to three different cameras located at different places in the operation theatre and capturing different angles of the intervention. As such, there were three different “views” available:

  • the operation theater as a whole, where we could see who was present in the room and how the medical staff was standing around the patient;
  • the “surgeon’s view”, where we could see the (opened) chest of the patient, as if standing above the patient’s body;
  • the vital signs monitor.

The main view used during the streaming session was the second one, the “surgeon’s view”. However, we switched several times to the general, operation theatre view, though for shorter amounts of time.

The live-streamed intervention revolved around placing an artificial valve inside the patient’s heart. In order to do this, the clinicians needed to:

  • Open the patient’s chest (including the chest bone);
  • “Connecting” the patient to the heart-lung machine (described in more detail below);
  • Stop the heart;
  • Open the heart;
  • Fix (with stitches) the artificial valve inside the heart;
  • Close the heart (with stitches);
  • Restart the heart (a defibrillation was needed);
  • Make an ultrasound of the heart (in order to check that the valve was working and well-adjusted);
  • Set up draining tubes (in order to allow for the bleeding within the heart cavity taking place during the next few hours after the operation to be drained out of the body without re-opening the chest);
  • Close the patient’s chest – a last step that we were unfortunately unable to witness.

To me, one of the most fascinating aspects of the surgery was the heart-lung machine. Its first function is to cool the patient’s blood (and, ultimately, the patient’s body) in order to minimize the risk of brain damage during the operation (which can be quite long). Its second, and probably main, function is to act as a substitute to the patient’s heart and lungs so as to enable the heart to be stopped while maintaining the patient alive. The heart-lung machine is handled by a specially trained nurse (called “perfusionist” in Swedish and “perfusion technologist” in English), who disposed of a screen (in addition to the machine’s two interface screens) with a specific MetaVision layout fitted to her particular needs.

Beyond the perfusion technologist, sitting at the heart-lung machine situated at some distance from the foot of the patient’s bed, the medical team actively taking part in the operations was composed of a main surgeon, an assistant surgeon, an operating nurse (notably in charge of handing instruments to the surgeons), an assistant nurse (notably in charge of handing equipment and instruments to the operating nurse) as well as an anesthetist and an anesthetic nurse. Interestingly, the anesthetist and the anesthetic nurse, standing at the head of the patient’s bed, were separated from the surgeons by a sort of curtain placed vertically between the chest and the head of the patient.

I noted two further interesting facts from the streaming. First, all team members except for the main surgeon are replaced at some point during the operation in order to prevent the risk for distraction- and tiredness-induced errors. As such, good “transfers of duty” seem to be an essential part of such complex and long interventions. Second, the surgeons and operating nurse did not seem to use any screen as support, and it is the anesthetist who is responsible to look at the result of the ultrasound in order to assess whether the result of the operation is satisfactory.

In summary, this was a truly fascinating and instructive “class”, though I was a bit disappointed by not having any sound – I had hoped to be able to hear how the medical team communicates and to understand when and how they use the different screens and computerized tools they are surrounded with. Hopefully I will get the opportunity to attend another operation within the next few years in order to answer those questions!

A (first) closer look at the outcome of the DISA project

The main goal of the DISA project is, according to the project application, the “creation a framework for decision support when new ICT solutions are to be implemented in healthcare […]”. However, this formulation leaves room for many questions. For instance, what decision-making process should this framework support? Who is expected to be using the framework? And what is the actual expected benefit of using this framework? In order to try and answer some of those questions, Ida and I arranged a meeting with the chief digital officer at the Uppsala University Hospital.

We learnt that the University Hospital is at the beginning of a phase of significant organizational changes, including, but not limited to, the implementation of a new digital strategy. There is a clear will to ensure that all IT-projects carried out in the future will effectively contribute to increasing the quality of care at the University Hospital. This should be achieved through a centralized project management and a systematized project application process. Concretely, this means that all project applications will be screened according to a framework composed of four different dimensions:

  1.   the project’s impact on work quality;
  2.   the project’s impact on work productivity;
  3.   the degree of risk related to the project;
  4.   the amount of resources needed to carry out the project.

The aim of this framework is to enable decision-makers at the department of digital development to select and prioritize IT-projects in an effective and efficient manner. The idea is also to push project applicants to motivate their project not based on technology (as in “I need an iPad”), but rather in terms of what needs to changed / improved in the affected work process (as in “I need to be able to see this data and discuss them with the patient while standing next to the patient’s bed”).

In light of this, we can re-interpret the end goal of the DISA project more as the identification and, probably, prioritization, of key factors related to the assessment of a project’s impact on nurses’ work environment than as the creation, from scratch, of a brand new decision-support framework. On the contrary, it seems at this point that finding a way to integrate the perspective of nurses’ work environment into the project assessment framework presented above is the more useful alternative. The need to visualize the different factors involved and their “weight” in the project’s assessment outcome was also underlined during the meeting.

We will of course need to dig a bit deeper into the problematic before knowing for certain what the outcome of the DISA project should look like. Considering that it is a 3-year project including three different specializations and many different studies, we are still at the very beginning of the process. Nonetheless, those first insights should be helpful in strategically planning our first steps within the project.

the Seminar Series at the BioMedIT arena at the Department

The HTO research group are a part of the BioMedIT arena at the department of Information Technology. The arena offers free lunch seminars for anyone interested in BioMedIT and related topics. We strongly recommend anyone to go who is interested!!

Information about the lunch seminars can be found here:

http://www.it.uu.se/research/arenas/biomedIT

There is also a YouTube Channel where all the talks can be found. You find it here:

The team behind a new large study on electronic health records in Sweden

In my last blog post on my personal blog I wrote about the application for ethical review, concerning a new large interview/survey/observation study with doctors and nurses at Akademiska Sjukhuset in Uppsala. The study, which will… [Read entire post]

 

Walkthrough of MetaVision and Orbit with two nurses from the Uppsala University Hospital

Paper-based forms for the daily documentation of a patient in the intensive care unit

With the DISA kick-off approaching, we have been working hard on acquiring the background knowledge necessary to getting the project started on the right track. In this context, Gerolf, Ida and I were given this week an exciting insight into the functionality and layout of two computerized systems that have recently been or will shortly be introduced at the Uppsala University Hospital, namely MetaVision and Orbit. MetaVision is a clinical information system intended to support patient monitoring in the intensive care unit and during operations. Its implementation started about one year and half ago and is now almost completed. Orbit, on the other hand, is an operation planning system whose implementation process will start at the end of the month at the Uppsala University Children’s Hospital.

Two nurses who have been actively involved in the implementation of, respectively, MetaVision and Orbit, kindly accepted to walk us through the main components of each system. In so doing, they also provided us with essential contextual information which enabled us to develop a more complete understanding of the current and upcoming situation at the University Hospital.

As I had never seen what a patient’s bedside looked like in the intensive care, I was impressed to see the number of devices connected to the patient. However, I was even more taken aback by the multitude of paper sheets that had to be filled in by nurses for each patient every day prior to the implementation of MetaVision. As the system now automatically gathers data from the different devices connected to the patient, the need for manual documentation is estimated to have been reduced of approximately 80%. The remaining 20% encompasses such information as the meals and drinks given to the patient, the activities related to personal hygiene provided by the nurses (hair washing, teeth brushing etc.), the patient’s position (back, right / left side) or the evaluation of the pupils.

In regard with operation planning, it is now handled by means of different physical folders containing waiting lists. Orbit is expected to replace those folders as well as to support the documentation of operations, where it would partly overlap with MetaVision’s functionality. However, as no integration of the two systems is possible at this point, the implementation of Orbit will require for nurses to enter twice certain pieces of information in order for patient data to be complete in both MetaVision and Orbit. This situation can be explained by the different origins behind the implementation of the two systems: MetaVision’s acquisition and implementation process was launched by the Uppsala University Hospital before the Uppsala County Council decided to have Orbit implemented as a measure to guarantee a safer operations planning.

The HTO research group: Our Mission

Our research group study the relationships and dynamics of Health, Technology, and Organisation (HTO) with the goal of creating knowledge that support sustainable development and utilization of ICT. Areas of interest include eHealth and the proliferation of such services. The concept of a digital work environment and its application to promote healthy work. Methods and techniques to support the deployment of a redesigned organisation of work including new ICT. The compatibility of user centred design and usability work with Agile methodologies and novel software development practices.  Inclusive design and design for all, as well as gender and ICT. We subscribe to an Action Research approach to study design and strive for swift and wide dissemination of our research through an array of outlets ranging from high impact journals and conferences to open platforms and social media applications.