setting up gynecological endoscopy services
DESCRIPTION
This presentation is about setting up Gynecological endoscopy services: the components, the challenges and finally achieving and sustaining excellence.TRANSCRIPT
Setting up Gynec Endoscopy services
Thanks!
Organizing committee: AMASICON 2013 Dr. Asha Baxi Dr Sunita Chouhan
Outline: the A,B,C,D,E…
Approach Basic components Challenges Development Excellence
Contemplation: John Wild
Contemplation before surgery, by Joe Wilder
Surgeons: the modern day priests
“We are the modern day priests – we prepare, we change to our holy garments, we bring patients to another world, and we change them.”
Dr. Simpson, Your Doctors Orders.
So…
Surgeons: Modern day Priests Operating rooms: Modern day temples Patients : Our Gods Surgery: Prayer
Setting up of surgical services is thus akin to making a temple, with careful consideration, faith, hard work and tireless effort. Hoping that amidst the multitude of units, it still finds its place, providing healing and solace to people and providing a haven of safety to their troubled bodies and souls.
Gynec Endoscopic procedures
Level 1: Diagnostic laparoscopy, tubal ligations Level 2: Salpingectomy, adhesiolysis, cautery of
minor endometriosis, myolysis, ovarian drilling Level 3: oophorectomy, salpingostomy, surgery
for pedunculated fibroids, moderate endometriosis
Level 4: Hysterectomy, Myomectomy, ovarian cystectomy(>8 cm), severe endometriosis
Hysteroscopy
Diagnostic Operative: septum resection, polypectomy,
myoma resection, foreign body removal, cannulation, TCRE
Hysteroscopic procedures: office Almost all laparoscopic surgeries except TL done
in OR. Hysteroscopic procedures: Different OR setup,
skill set, instrumentation, anesthetic considerations
COMPONENTS
INFRASTRUCTURESetting up Gynecological endoscopy services
Setting up: infrastructure
STARS Start up Turnaround Accelerated growth Realignment Sustaining success
Time and Money
Operating room
Ancillary areasInstruments
Equipment
Misc: disposables, drugs
INFRASTRUCTURE
Temples
Mandala Lead from temporal world to eternal: progression
from worldly to Divine Innermost sanctum: Garbhagriha
Temple plan
Sanctum
Operating rooms
Unsterile to sterile Sterile lobby 1, sterile lobby 2 Operating room: ultrasterile area
4
Sanctum
Modular Operating Rooms
mod·u·lar (adj)
.1. Of, relating to, or based on a module or modulus.
2. Designed with standardized units or dimensions, as for easy assembly and repair or flexible arrangement and use: modular furniture; modular homes.
Components
Prefabricated GI/SS panel shell Hermetically sealing sliding doors Laminar air flow Pendants Workstations Others: scrub, surgeon control panel
Operating room
Ancillary areas
InstrumentsEquipment
Misc: disposables, drugs
INFRASTRUCTURE
One way!
One way changing room One way flow of supplies into the OR and one way
flow of soiled good outside the OR Shared corridor for patients and staff Sterile supplies delivered in OR from CSSD :separate
corridor Two designs: Double loaded corridor with
substerile rooms and perimeter corridor with clean core
Perimeter corridor with clean core
Double loaded corridor design
Recovery area
Accessible from theatre and outside 1.5 spaces per OR Space per trolley/bed 9 sq. meters O2, suction, power, lighting Communication lines Scrub, nursing station
Operating room
Ancillary areas
Instruments
Equipment
Misc: disposables, drugs
INFRASTRUCTURE
Equipment
Camera Telescope Monitor Light source Insufflator Irrigation/suction system Electrosurgical generator Recording and archiving
Camera
Single chip: all three primary colors sensed by a single chip
Three chip: three sensors for red, green and blueSD camera: A 4:3 aspect ratio, 640 by 480 horizontal and vertical lines.HD camera: The HD format provides a 16:9 aspect ratio, 1280 by 720 horizontal and vertical lines. The 1080 HD standard also offers a 16:9 aspect ratio, but 1920 by 1080 horizontal and vertical lines-seven times the SD resolution at 480 lines.
Telescope
6 to 18 rod lens system telescopes are available 0 to 120 degree telescopes are available 1.5 mm to 15 mm of telescopes are available
Light source
Halogen Xenon LED
Insufflator
Steps down the pressure Manual /electronic Heated
Others
Suction irrigation systems Electrosurgical generators Recording and archiving
Instruments
Hand instruments Specific: morcellator, endomat
What is ideal ?1
What is feasible ?2
What is viable?3
Justifying the costs
Sharing with other subspecialities Developing a high throughput unit Shared facility between different gynec
endoscopic surgeons
MANPOWERSetting up Gynecological endoscopy services
The trinity
Anesthetist: Father Surgeon: son Nurse: holy ghost!“He acts as Comforter, one who intercedes, or supports or acts as an
advocate, particularly in times of trial. He acts to convince
unredeemed persons both of the sinfulness of their actions and
thoughts, and of their moral standing as sinners before God”
Theatre: Camera person, assistant: two, scrub nurse, floor nurse
Recovery staff Support staff
PATHWAYSSetting up Gynecological endoscopy services
“The best cars with the smartest drivers cant reach anywhere if there isn’t a road”
Clinical pathway: Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions.
Integrated clinical pathway
An ICP aims to have... the right people doing the right things in the right order at the right time in the right place with the right outcome all with attention to the patient experience
Pathways
Patient admission and preoperative workup Discharge pathway Dealing with readmissions Thromboprophylaxis Infection control
CHALLENGES
Setting up Gynecological endoscopy services
Challenges
Infrastructure: maintenance and repair Manpower: training, attrition, motivation Pathways: non conformities, non compliance
“ The real challenge is to keep growing, keep moving, slowly at times, but always forward”
DEVELOPMENT
Setting up Gynecological endoscopy services
AIM
Safe Sustainable System driven Successful
Gynecological endoscopy unit
EXCELLENCE
Setting up Gynecological endoscopy services
Key performance indicators
In-patient workload Out-patient workload Cancellation rates on day of surgery Day of surgery add-on rates Start time accuracy – first case of the day Start time accuracy – subsequent cases Estimated case duration Turnover time in-patient
Turnover time out-patient Total case time in-patient Total case time out-patient Room utilization: 7:30 a.m.-3:15 p.m. Surgeon satisfaction Employee satisfaction Cost per case (labor) Cost per case (materials) Cost per case (total) Gross revenue per case
“Excellence is never an accident. It is always the result of high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives - choice, not chance, determines your destiny.”
“Magic lies in the magician, not in the wand”
The future OR
(Sandberg et al, anesthesiology,2005)
A,B,C,D,E…
Approach: akin to constructing a temple Basic components: infrastructure, manpower,
pathways Challenges Development Excellence: ongoing process
THANK YOU!