Journal of Clinical Monitoring and Computing (2006) 20: 165–173 DOI: 10.1007/s10877-006-9017-0
TECHNOLOGIES AND SOLUTIONS FOR DATA DISPLAY IN THE OPERATING ROOM Noemi Bitterman, D.Sc.
C
Springer 2006
N. Bitterman. Technologies and solutions for data display in the operating room J Clin Monit Comput 2006; 20: 165–173
ABSTRACT. Recent advances in technology have led to the introduction of a variety of innovative devices, each with their own platform for data display, into the operating room (OR). While these innovative applications are expanding the traditional boundaries of the surgical space and enhancing treatment capabilities, the introduction of additional screens and displays is placing an ever-increasing load on the OR team. This review describes the main data display platforms currently available in ORs: computer monitors with CRT (cathode ray tube) or LCD (liquid crystal display) screens, suspended imaging displays, wearable computers (WC), auditory displays and tactile (haptic) displays. The different display platforms are evaluated according to their compatibility with the characteristics of the working environment (OR), the monitoring task, and the users (the surgical team). No single display configuration provides an ultimate solution for presenting patient data in the OR. A multi-sensory data display including visual, acoustic and haptic manipulation is suggested as a promising configuration for data display in the OR. KEY WORDS. monitoring, wearable computers, suspended imaging, alarms, auditory display, haptic display, multimodal display
INTRODUCTION
From the Industrial Design, Faculty of Architecture and Town Planning, Technion, Israel Institute of Technology, Haifa 32000, Israel. Received 5 January 2006. Accepted for publication 20 February 2006. Address correspondence to Noemi Bitterman, D.Sc. Industrial Design, Faculty of Architecture and Town Planning, Technion, Israel Institute of Technology, Technion City, Haifa 32000, Israel. E-mail:
[email protected]
Patient monitoring is one of the central, ongoing tasks in the operating room (OR). In addition to the traditional monitors that continuously present hemodynamic, respiratory and electrophysiological signals recorded from the patient, recent advances in technology have led to the introduction of a variety of new and innovative devices into the OR. Moreover, each of these pieces of equipment features its own platform for data display, which can lead to a congestion of data screens in the OR. Consequently, the OR staff are compelled to increase the time devoted to monitor observation, and divide their attention between monitoring and the task at hand even further. This trend is expected to continue as technological developments lead to further innovations in the so called “operating room of the future” [1–5]. Four groups of innovative applications are contributing to the growing number of platforms for data display in the OR: • Surgical machine-controlled applications (e.g. robotics, minimally invasive surgery, video-endoscopic surgery, master-slave systems), with options for smart devices that transmit continuous feedback signals to the surgeon (such as: touch, blood flow, proximity, etc) [4, 6].
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• Designated diagnostic and navigation real time devices (such as: magnetic resonance imaging [MRI], computed tomography [CT], 3D ultrasound), providing intraoperative guidance along with simultaneous real time analysis of information and Virtual Reality applications [3, 4]. • Information technology (IT) applications generating a real-time connection between the OR and the hospital medical record archives (picture archiving and communication systems [PACS], videos, electronic medical records, hospital information system [HIS], and other laboratory data), supplying information about patient history prior to, and during surgery to support pre and intra-operative decisions [3]. Such innovative applications enable the fusion of preoperative images with the intra-operative visual field, making the OR a fully integrated digital environment [7]. • Telecommunication and teleconferencing systems connecting the OR in real time with other medical centers or personnel to enable sharing of information such as consultations and distance teaching, and enabling real time collaboration for remote procedures [3, 8, 9].
have followed the monitoring task of anesthesiologists in the OR and in similar demanding clinical settings such as the intensive care and trauma units [17–24]. Only a few have studied surgeons and their accessibility to on-line, real time patient data, and they were mainly related to endoscopic surgery [25, 26]. This review will present the main platforms for data displays in the OR, and discuss their main advantages and drawbacks related to their compatibility to the working environment, the tasks and the users.
PLATFORMS FOR DATA DISPLAY IN THE OR
The major technological platforms for presenting data in operating rooms are: 1. computer monitors with cathode ray tube (CRT) or liquid crystal display (LCD) screens; 2. suspended imaging displays; 3. wearable computers (WC); 4. auditory displays; and 5. tactile (haptic) displays.
Computer monitors The need to perform monitoring tasks simultaneously with complicated manual procedures is also typical of several non-medical work environments, such as aviation, air traffic control, space vehicle system, nuclear power operations and surface transportation [10–14]. All these work environments are characterized by an extensive need for dynamic and complex online information, a massively focused workload, high risk and time-pressured tasks, immense attention, mental stress and cognitively demanding situations [15]. The monitoring task in the OR may be considered even more challenging, being performed under higher manual and visual constraints than most of the above mentioned work environments. Ongoing monitoring of a patient’s physiological data during surgery is critical, enabling operating decisions to be taken rapidly by the surgical team, which is simultaneously performing highly skilled manual manipulations, and directing its attention between numerous visual fields [7, 10–12, 16]. There is no fixed or predetermined scenario for the task of monitoring during operations. Monitoring protocols may be changed dynamically in accordance with the physical status of the patient, reaction to the surgical procedures performed, and medication used. For surgeons, additional tasks which they need to perform concurrently with monitoring include the coordination of the activities of the OR team, teaching students and tutoring residents [7, 16]. Monitoring during surgery is performed continuously by all team members (surgeons, anesthesiologists, nurses, technicians, and perfusionists), although each according to a different pattern and frequency. Several studies
Most of the physiological information currently presented in the OR is visual and displayed on computer screens. The standard hemodynamic monitoring systems used in the OR comprise sets of monitors (usually a main monitor with several slave screens) presenting the same physiological data simultaneously to the whole team. The traditional monitors are usually suspended from the OR ceiling or placed on the walls, directed at several angles to enable observation from different locations in the OR. The large, flat-screen LCD displays currently used provide better information visibility than CRT displays, for all OR personnel. Stand-alone monitors for specific data are placed nearby and under the control of the anaesthesiologists, technicians or perfusionists. The data are presented the on the monitor screens either in a discrete manner or as an integrated display. The most common single–sensor, single indicator (SSSI) [27] layout presents on each bin information derived from a single sensor. The data are usually displayed on the screen both as analog (wave form) traces and corresponding numeric data. While the numeric data derived from digital processing of the analog signal are absolute values, the wave forms running horizontally at the same time scale represent relative information [15]. The integrated display presents several physiological parameters simultaneously. An integrated display supports a highly sensitive graphic platform that enables detecting changes from baseline conditions at a brief glance [28–30]. The most basic configurations of integrated displays are sets
Bitterman: Data Display in Operating Room
of lines (up to 8) radiating out from a central point, each line pertaining to a particular variable, forming a polygon display [28, 29]. Sophisticated versions of integrated displays are based on categories of graphic objects [27, 31, 32] and were found to improve anesthesiologists’ performance in comparison to the traditional digital/waveform discrete horizontal traces running on the monitors, by shortening the time taken to detect and correctly identify critical events [31, 32]. Various visibility problems are encountered with the remote positioning of the computer screens in ORs, such as poor visibility, low contrast, glare, fuzzy image, etc. Still, CRT monitors are cheap and robust, readily available, familiar and compatible with the mental model of the medical personnel, and therefore straightforward to manage.
Suspended imaging display Suspended imaging display is based on techniques of projecting information on any flat surface, without the need for a screen, and reproducing it as many times as needed without causing overload or congestion [33–35]. Suspended imaging is used in the aviation and transportation sectors, where information is projected in front of the driver/pilot, onto the dash board or instrument panel [14, 36, 37]. As these technologies develop, the projection sites will be changeable in accordance with the user’s position or direction of gaze [4]. Ergonomically, the ideal location for projection of the data display is on the operating table, adjacent to the surgeon/anesthesiologist’s hands, or else on the dividing partition, the sheet around the surgical site or even over the patient [35]. Yet, while Hanna et al. [25] found that task performance improved when the image was positioned at the level of the surgeon’s hand, Wentink et al. [26] did not find any advantage in placing the image close to the surgeons’ hands. Suspended imaging offer many advantages over solid monitor screens. These include eliminating sterility problems, reducing the need for repetitive eye scanning, overcoming equipment congestion, and enabling as many displays, and in whatever positions, as necessary. The current limitations of suspended imaging technology are the need for a flat surface, and maintaining a low level of ambient illumination in the OR [33]. Advanced laser technologies, which enable the projection of holographic pictures floating in space (i.e. LaserCube [38]) may overcome the flat surface constraint, and allow a true suspended image display. However, the visibility of the image will still depend upon the illumination level in the OR.
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Wearable computer displays Wearable computers (WC) include various configurations of fully functional, self powered, self contained carried computers that allow their users to access information anywhere and at any time, while leaving the hands free [39–41]. The great advances in wearable computers were achieved due to development of miniaturization methods, microprocessors, small sensors and wireless technologies [6]. The Head-Up Display (HUD) or Helmet Mounted Display (HMD) are the most common versions of WC’s, and are mostly popular in the aviation sector [2, 14], having either binocular or monochromatic displays [42–44]. Aligning the WC display to the visual task, in close proximity to the eyes (i.e. helmet, glasses, binoculars, etc) enables the information display to follow the movement of the person and be perceived at the same distance as the working site, thus avoiding the need for refocusing the eyes. There are contradictory reports on the benefits of overlapping information such as presented by HUD/HMD [14, 36, 37]. Clinical experience with HUD/HMD systems is still limited, and there are some reports of inappropriate accommodation with HUD and HMD systems, misperception and faulty judgment, such as size and distance of objects in the outer field of vision, and loss of contrast sensitivity [45]. The second group of WCs includes configurations that are aligned to the manual task, being attached to the arm, waist, hand or fingers. This type of WC can be affixed to the sleeve of the operating room garment (“smart OR costume”, “computational clothing”) [46–49], or placed as a separate accessory on any part of the upper limb, embedded into a glove, ring, bracelet, wristwatch, etc. [42, 49]. The WCs have, in their current technological state, a small display area that is capable of presenting a limited amount of patient information. However, WCs can be used as a complementary display for presenting specific information of special importance to the user. This additional information can be delivered for the duration of the surgery, or alternatively, can be activated at particular stages of the operation (e.g. in an emergency situation). The main advantages of the WCs are personalization and the option of simultaneously having online management of additional information that can be programmed into the monitoring display, all accessible without impeding the user’s mobility. The drawbacks of the WC include the high cost of certain applications, the need for multiple units for each team member, and the problems of maintaining sterility in the OR. WC platforms currently in use in the OR are still clumsy, too heavy for extended use, require time for adjustment, have a limited display area, and offer low image quality [1, 48, 50, 51]. Smart shirts are in use for patient monitoring
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[42, 43, 46], yet, issues of laundering and sterility still need to be better addressed before they become a routine feature for OR personnel. The field of WCs is developing rapidly, and we can assume that improvements in size, weight and quality of display will be achieved in the near future.
display can be especially helpful for residents and novice surgeons who are still struggling with the need to perform complex manual maneuvers while simultaneously following the monitor screens [21, 57].
Auditory alarms Auditory data display The most popular and almost the only acoustic display available in any clinical setting is the pulse oximeter, supplying continuous information about heart rate and arterial hemoglobin saturation. Acoustic pulse oximeter display was proven to be very effective in the practice of anesthesia [52]. Most physiological hemodynamic parameters can be expressed by acoustic dimensions such as semantic content, tone, pitch, location and loudness. Yet several physiological parameters and most images can not be displayed vocally. Recently, a non- speech method of sonification (continuous acoustic display) was developed for clinical use. Sonification is the auditory counterpart of the integrated visual display, simultaneously presenting multiparametric acoustic status reports on the patient as background information [53]. The basic concept of integrated sonification is that only changes in the physiological parameters will attract the attention of the team, once they get used to the repetitive beeps of the auditory display. It has been shown that, with some training, clinicians could successfully detect and identify six or eight vital signs using auditory display [54, 55]. Sonification can even reduce the dependence of the staff on traditional alarms [23, 53]. Auditory icons and “earcons” are advanced auditory modalities [53]: “Earcons” are auditory displays that encode data or system states into short tunes, whereas the auditory icons are sounds that have immediate natural associations with a state or object. However, unlike sonification, auditory icons and earcons still require the listeners’ focused attention, and therefore seem to be less recommended for the surgical team. The auditory information can either be displayed continuously (or periodically) in the OR, or be presented upon demand. Verbal request, touch screen and possibly in the near future gestic manipulations [56], such as hand signals and body movements, are possible modalities for eliciting the auditory information. The use of earphones can reduce environmental noise and enable personalization of the information (including translation of the information into various languages, or special amplification for a hearing disabled team member). However, the use of earphones will detract from the atmosphere of team partnership created when the same information is shared vocally in the OR. The auditory
Form a significant group of acoustic signals in the OR. Many physicians have reservations about alarms; they find them loud, irritating, startling, confusing, and subject to a high false rate, all of which can lead to the intentional disabling of the alarms by the OR team [53, 58]. Moreover, it was demonstrated that anesthesiologists are not always able to identify the origin of an alarm sound or its urgency [58, 59]. The use of verbal displays and integrated auditory information such as sonification can significantly reduce the amount of auditory alarms in the OR [53] by performing a dual function: supplying data while simultaneously acting as a meaningful alarm system. Spatial separation of the auditory signals and the use of assorted pitches or different speakers’ voices – techniques which are successfully applied in aviation – have been shown to enhance differentiation between signals [14]. The acoustic signals (in contrast to visual displays) are omnidirectional and are therefore suitable for OR personnel whose visual system is overloaded, or who are operating in stressful, yet relatively quiet environments, with visibility constraints [14, 60]. Acoustic displays are not space-restricted and hence present a great advantage in equipment-congested environments such as the OR; moreover, they can be considered the most hygienic of all display modalities.
Haptic – tactile display Haptic sensory information can either be tactile or kinesthetic, presented to the skin in the forms of force, texture, electric stimulation, vibration or thermal sensation [56, 61, 62]. Using multiple addressable tactors spread across the area of the body enables complex and coordinated information to be conveyed. Tactile display is omnidirectional, can be perceived simultaneously with visual and auditory signals, places few demands on resources of attention [56], and is expected not to interfere with the ongoing manual tasks of the OR team. Tactile displays were developed primarily as a replacement or supplementary channel for the sensory impaired (the deaf and blind). Recently, the development of tactile information displays has been accelerated by the need for
Bitterman: Data Display in Operating Room
tactile feedback in minimally invasive surgery, in simulators, and especially in the fast developing area of virtual reality (VR) environments [4, 6]. The miniaturization of haptic devices has made them easier to apply in operational settings, as has been successfully implemented for pilots in the cockpit [6, 63]. Tactile displays cannot completely replace visual or auditory displays; however, they can reduce noise pollution in the OR (or alternatively, enable functioning in noisy environments), decrease visual strain, and deliver personal, discreet and continuous information to any free moving team member. Not all parameters can be presented by tactile display, and currently the most promising clinical applications seem to be alarm signals or navigating utilities [62]. The olfactory interface is the least developed modality for presenting information [61] and at this stage it does not seem to be suitable to use taste or smell for data display in the OR.
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Based on the specific characteristics of the OR, the auditory display is compatible with most of the issues, except for background noise. The salient benefits of auditory displays are full proof of sterility, lack of illumination constraints and electromagnetic interference, overcoming congestion and overload of personnel and equipment, compatibility with changeable teams and agreement with meticulous maintenance requirements. Visual display platforms are incompatible to some extent with several OR characteristics such as illumination constraints, maintenance and sterility requirements, moisture conditions and electromagnetic disturbances. WC seems to be the less compatible with OR requirements, mostly because of sterility issues, maintenance and illumination constraints. Suspended imaging is preferable for sterility issues, crowding and congestion, and changeable missions and positions. Yet illumination conditions are the main weakness for the use of suspended imaging displays in ORs. Haptic display seems to conform with most of the OR constraints, although we lack studies on its use in clinical situations.
COMPATIBILITY OF DATA DISPLAY CONFIGURATIONS TO THE WORK ENVIRONMENT (OR)
The selection of data display platforms in the OR should take into account the specific conditions and restrictions typical for the OR, including: • Sterility, with strict separation between sterile and nonsterile zones [64]; • Varying levels of illumination resulting from several light sources (diffused light, focused light, head mounted lamps etc) [24, 64] with different levels of intensity and brightness, potentially causing shadows, glare and a continuous need for eye accommodation; • Background noise including alarms, vacuum pumps, equipment operation, paging and others [24, 65]; • Crowding of personnel (mainly in the restricted space around the OR table) [3, 66]; • High load, high paced, stressful environment [24]; • Preserving an environment free of electromagnetic disturbances; • A multipurpose-multitask environment containing a diverse inventory and changeable arrangement of equipment and monitoring devices (including possible unpredictable changes during operations); • Changeable teams, varied personnel combinations moving between different types of operations, having different needs and preferences for equipment; • Specific maintenance constraints related to low temperature, moisture and vapors, including high specifications for robust, reliable, safe devices.
COMPATIBILITY OF DATA DISPLAY CONFIGURATIONS TO THE OR TEAM
Selection of data displays in the OR should take into account the special needs and requirements of the surgeon and anesthesiologist. While the main task of the surgeon is to perform operations, the anesthesiologist’s task is to control and maintain the hemodynamic stability and anesthetic state of the patient [13, 16]. The main differences between surgeons and anesthesiologists in relation to their data monitoring tasks include:
Location The surgeon is positioned, throughout the entire surgical procedure, in close proximity to (within reach of) the patient and the operating table, functioning only in the sterile area. The location of the surgeon may be changed according to the operation site, and occasionally changed around the table during the operation. The anesthesiologist’s main territory is in the non-sterile area, usually next to the patient’s head, over the partition; the territory of the anesthesiologist is more extensive because of the need to observe in all directions, calling for “eyes in the back of the head” [45]. However, after the pre-anesthesia and stabilization of the patient, the anesthesiologist regularly moves in and out of the OR.
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Posture The surgeon is usually static, bending immobile over the patient, eyes in a top down position concentrated in a restricted working area. Pain and muscle strain of the back, shoulders and neck are frequent complaints of surgeons [11, 67]. The anesthesiologist changes position between standing, sitting, and moving, and has a wide angle field of vision.
ditory display offers special benefits for the anesthesiologist, enabling him to move freely in the OR and overcome the boring periods during the surgery. Haptic display seems to be well-suited to the characteristics of the OR and the surgical team, although we lack studies on its use in clinical situations in order to further support this assumption.
Manual activity
SUMMARY
The surgeon is engaged most of the time in intense manual activity. The anesthesiologist is active mostly during the pre-anesthesia and induction phases, and may be idle and even bored throughout the surgical phase [17, 24]
Six different platforms for data display were presented, with their advantages and limitations, according to their compatibility to the OR environment and the surgical team. A general quantitative analysis of the different configurations is not feasible; large differences exist between various types of operations and the relative importance of the different parameters on each of the surgical procedures; thus the impact of each parameter of compatibility is not equivalent to the others. For some of the data display platforms, their technology is still in the innovation stage and therefore, they are not developed to the optimal compatibility for the user. We assume that in the near future, many of these technologies will be further improved and their compatibility with the OR environment and the team requirements will increase [26, 68]. The price and quality of display are therefore not discussed at all. Although scientific visualization techniques may not yet be exhausted, some researchers believe that we are approaching the limits of the user’s ability to interpret and comprehend visual information. Surgical teams have reservations about auditory displays, probably resulting from their negative experience with auditory alarms. Yet auditory technology is constantly improving and voice activated systems are becoming more common in medical and nonmedical environments. Significant advances in this technology and its application in the OR have been achieved thanks in part to the great progress that has been made in the fields of virtual reality, robotics and master slave systems. Dividing the attention between two (or even more) modalities, such as the auditory and visual systems (crossmodal time sharing), compared to reliance on a single modality, is highly recommended in the literature [14]. Auditory input remains in the short-term memory for 3–6 sec longer than visual information; therefore it is more readily recalled when there is a change in attention level [14]. Reaction time for auditory information has been shown to be shorter than that of visual input [14], as demonstrated in the response time of anesthesiologists performing a monitoring task [55]. The auditory display cannot entirely replace the visual display since not all parameters can be represented vocally,
Task dedication Surgeons are usually dedicated users, often specializing in specific types of operations, and working regularly with the same team of assistants and nurses. Anesthesiologists are frequently casual team members, assigned at random to different types of operations with alternating surgeons.
Accessories/equipment The surgeon is loaded with equipment such as binoculars, forehead lamp, small head video camera, etc, which contribute to a feeling of heaviness and bulkiness, while the anesthesiologist is relatively unencumbered.
Visual strain The surgeon’s full concentration is in the working area, performing under heavy visual strain, often compounded by the use of magnifying binoculars. Surgeons must frequently shift their gaze from the operating table to the monitors, forcing their eyes to accommodate to glare, changes in illumination levels, and the need to refocus for each visual field. The anesthesiologist, although working in various visual fields, does not use magnification and is under reduced visual strain. Based on the specific tasks of the surgical team, the auditory display appears to be compatible with most of the needs of the surgeon. The salient benefits of auditory displays are preserving a team feeling in the OR, enabling both static and changeable positioning of the surgeon, decreasing risk of pain and muscle strain, reducing visual strain, lessening the burden of carried equipment, and decreasing the need for frequent monitor scanning of patient data. Au-
Bitterman: Data Display in Operating Room
and background noise in the OR can disrupt information transmission. Thus, special consideration should be given to developing auditory displays that do not distract, eliminate false information, or engender habituation. Haptic (tactile) displays are currently underutilized and are still not sufficiently developed for practical application [61] such as platforms of data display in the clinical environment, and especially in the OR. Tactile displays could be highly compatible with OR characteristics, overcoming both visual and auditory constraints. The olfactory modality is an even less developed modality [56, 61], and in its current level of development, does not seem to be compatible with the clinical setting. A suggestion was made to use smell for urgent information and life threatening situations, requiring a fast decision rate [61]. Ultimately, no single sensory display can provide the perfect single platform for presenting patient data in the OR, even if the technology it is based upon is improved.
Multimodal/multi-sensory display Recently, interest has been growing in the multimodal/ multi-sensory display [56, 61, 69]. Multi-sensory displays include visual, acoustic and haptic manipulation [34] (and could possibly include some olfactory presentation in the future [61]. Significant developments in multi-sensory displays have been achieved in the domain of virtual reality environments, where they provide the user with a complete feeling of immersion [56]. Combining modalities will result in mutual compensation for the limitations associated with each channel [70]. The use of multimodal displays will probably not only enhance our information processing capacity, but may possibly improve the quality of information presentation, and support coordinative functions such as attention and interruption management [61]. The use of multimodal displays will also enable personalization for different users, diverse operations and changeable OR configurations. Multi-sensory displays can provide maximal variability and flexibility in order to decrease the stress of managing the monitoring task, in parallel with the highly demanding surgical task. Sarter [61] suggested using a “modality coordinator” that will monitor the environmental conditions such as noise and visibility, and change automatically in accordance with the modality of information presented. The use of multimodal information in the OR will enable information to be delivered on various concurrent processes/events, and alternatively on various aspects of the same event or process. Effective timesharing should be applied when several tasks need to be performed concurrently, which could lead to confusion and distraction among the sensory signal channels.
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CONCLUSIONS
The selection of appropriate data display platforms in the OR should be guided by their compatibility with the needs of the specific surgical team and the OR characteristics. The selection of data display platforms should not be determined by passing trends and technological fashions, nor by a search for innovation and hi-tech appliances. Moreover, data display platforms should not be transferred directly from one medical domain to another (i.e. applying ICU technology to the OR) or even extrapolated from different surgical fields (such as between surgical endoscopy, cardiac surgery, neurosurgery etc), without first testing their compatibility in a simulated OR. Based on the variability and versatility of OR environments and users, well controlled, simulated experiments should be conducted with the different experimental monitoring systems in the assorted surgical procedures with the diverse users. Each data display platform should be checked in a simulated OR that is similarly configured, equipped and staffed, using repetitive analysis techniques. The parameters for assessing compatibility in the simulated OR should include objective, quantitative measures such as reaction time for scanning task, errors, work load, perception rating, and vigilance [12, 21, 22, 60, 71]. Preferences and satisfaction of the users should be quantified, although they are not necessary fully correlated with performance [72]. A comprehensive overall data display selection, (rather than an isolated data display platform), based on a multi-sensory approach, will allow better monitoring performance in the OR.
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