Perioperative nurse training in cardiothoracic surgical robotics

Throughout the 1980s, technology enabled a sharp increase in the number of video-assisted endoscopies performed in multiple specialties. As the use of lasers and focused energy devices increased, more demands were placed on perioperative nurses to become technically adept.
During the past 10 years, technology has grown exponentially, and the complexity of new devices and their applications has become a challenge for surgeons and perioperative nurses. Use of computer systems is common in ORs today, and advanced minimally invasive procedures have begun to rival conventional procedures. Without a thorough understanding of how equipment functions, distinguishing between a device failure and user error can be overwhelming. The ability of nurses to master new technologies depends on personal initiative because the volume and complexity of these technologies cannot be addressed adequately at monthly inservice programs. New methods for training individuals must be explored if staff members are to become proficient and remain competent.
ROBOTICS IN THE PERIOPERATIVE SETTING
Although surgeons have improved surgical techniques in recent years, the OR itself remains underautomated. New devices and equipment have invaded the OR, but this invasion has happened in the absence of an orderly framework. The transfer of work from man to machine--a process that has revolutionized many industries--has happened slowly in the perioperative setting; however, robotic devices are beginning to enter the surgical arena, creating computer-enhanced environments. To date, more than 350 hospitals in the United States and 500 hospitals worldwide have installed robotic technology in the OR. (1)
Robotic devices available in the OR include
* computer-controlled, image-directed surgical robots;
* voice-controlled OR workstations;
* robotic visualization devices; and
* robotic surgical instruments. (2)
Administrators at Sarasota Memorial Hospital, Sarasota, Fla, have acquired the latter two technologies because
During the last decade, as managed care and cost-containment pressures have become the pivot point in managing the health care environment, patients' expectation for state-of-the-art care has remained constant. Considering this, the success of an institution often is dependent on strategies developed to balance the need for advanced technology versus the need to reduce costs. (3)In 1996, economic pressures at Sarasota Memorial forced cutbacks and required an out-of-the-box look at efficient use of resources. The goal was to consider using full-time equivalents (FTEs) more efficiently while maintaining or improving surgeon satisfaction. This motivated staff members to evaluate a robotic endoscope positioning device. The use of this device was implemented at Sarasota Memorial in 1997, and it presently is used to perform approximately 600 endoscopic procedures per year. Initially, there was skepticism about the value of this technology. The cost of employing an FTE to hold the endoscope averages $326 per 90 minutes, which is the average laparoscopic procedure length. When multiplied by 577 (ie, the actual number of procedures), the FTE cost equaled $188,102 for one year. Hospital administrators decided to lease three robotic endoscope positioning systems for $121,680 per year, resulting in a net savings of $66,422. Additionally, endoscope holder FTEs were assigned to other procedures, further improving the OR's FTE utilization. At Sarasota Memorial, the robot is as common to a general surgery laparoscopy as the insufflator or electro-surgical unit.
The success achieved with the use of robotics in general surgery encouraged administrators and cardiac surgeons to commit resources to a cardiothoracic robotic surgery project. They adopted a robotic surgical system that consists of a console, computer controllers, and three robotic arms controlled by the surgeon. One robotic arm positions an endoscope and camera assembly in response to the surgeon's simple voice commands. Working behind the ergonomic console, the surgeon uses the computer controllers to input movements that are scaled by the computer and translated onto the instruments.
CREATION OF A TRAINING PROGRAM
In June 1999, the US Food and Drug Administration selected Sarasota Memorial to participate in an expanded feasibility study. More than two years were spent developing cardiothoracic robotic surgical technology and surgeon skill by performing procedures in dry, cadaveric, and animate laboratories, both on- and off-site. Preparing the perioperative cardiothoracic surgical team also needed to be addressed.
The robotic surgical system training team consisted of three instructors who had a variety of clinical, managerial, and educational experience. The cardiothoracic surgery program at Sarasota Memorial uses six dedicated open-heart rooms, and approximately 1,600 procedures are performed at the hospital per year. More than 60% of open-heart procedures are performed between November and April. Increasing demands on staff members, including frequent overtime and increased call time, are extremely significant; therefore, selecting a group committed to learning, brainstorming, and practicing new robotic skills was paramount. Staff members understood that team training might conflict with call time or scheduled time off. Training sessions were scheduled when most team members were at work. If a session was missed, team members shared pertinent details and practiced hands-on skills during free time.