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New Frontiers in Robotic Surgery

Nurses help programs reach the next level of patient safety, patient care and surgical technique

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For many people, the term "robot" conjures up images of clunky, metal approximations of human-like forms - C-3PO from Star Wars or Rosie from The Jetsons might come to mind. But for today's healthcare clinicians, the term "robot" has a much different meaning. Sophisticated, precise robotic technology is being incorporated into medicine in amazing ways. Although a far cry from the beeping, talking, house-cleaning versions movies and cartoons instilled in our collective memory, medical robots, too, have the capacity to stroke the imagination and portend future advancements.

Rise of Robotic Surgery

As more healthcare facilities - from large university medical systems to small community hospitals - create robotic surgery (also called robotic-assisted surgery) programs, it is clear there are both major benefits and major challenges to undertaking such an endeavor. The benefits are easily delineable by nurses involved in robotics programs: less-invasive surgery, shorter hospital stays, less need for pain medication, faster healing and decreased risk of postoperative complications.

These benefits are made possible by toothpick-thin instruments that operate through multiple 3 mm to 5 mm incisions (smaller than those required for laparoscopic procedures). Surgeons control robotic tools from a console, which provides 3-D imaging of internal structures - better visualization than surgeons are able to get with open procedures. Blood loss is about one-tenth of that in traditional procedures due to significantly less internal trauma.

The impetus to provide robotic surgery combines all of these benefits into a simple mantra: providing the best care for patients, said Pearl Cunningham, MBA, BSN, RN, CNOR, nursing director of the operating room at Brigham and Women's Hospital in Boston. "We look for the best way to provide the best care for our patients," she said. "[That includes] being on the leading edge of integrating medicine and technology."

At CentraState Medical Center in Freehold Township, NJ, which performed its first robotic surgery procedure in April 2010, staff saw the writing on the wall. "We realized robotic surgery is becoming the new standard of care," said Deanna Sitren, BSN, RN, CCRN, OR nurse manager.

Challenges Loom Large

While the driving force behind implementing a surgical robot is usually good, not all facilities are adequately prepared to take this step. "The worst thing a facility can do is say, 'Let's get a robot,' but have no idea what is required. The program will suffer or the robot will simply be underused," said Lynda Jayjohn, BSN, RN, CNOR, nurse manager of perioperative services and nurse manager of robotics at Ohio State University Medical Center (OSUMC) in Columbus, the first facility in North America to perform robotic surgery. Instead, a clear picture of what is involved in a robotic surgery program is needed - and nurses are at the forefront of this effort in hospitals around the country.

OSUMC, which will perform approximately 1,300 cases in fiscal year 2009-10, was a global leader in robotic surgery. "When we started to ramp up our program in 2005, from about 20 cases a year to 500 cases a year, there were not a lot of people for me to talk to," said Jayjohn.

Facilities just starting out now, however, can benefit from the experience of others. "Visit a facility like mine and get didactic information through a robotic program management site visit," Jayjohn recommended. Once facilities start to get an idea of what is involved, they can start to comprehend the challenges they will need to address before the robot arrives.

Patient positioning, surgical scheduling, sterilization of the robotic instrumentation, even simple logistical concerns such as having enough voltage in the OR to support the additional equipment, can be challenging and time-consuming, said Cunningham. However, the task is not insurmountable. A copious amount of research, planning and staff training is required.

If possible, hire or appoint a robotics coordinator, said Donna Seifert, MBA, RN, clinical director of perioperative services at USC University Hospital, Los Angeles. The robotics coordinator, often a nurse manager, can coordinate the planning and staff training necessary for good outcomes.

Sitren recommends robotics coordinators work closely with the facility's surgeons who have robotic surgery experience. These surgeons can provide invaluable input as to what is needed to maintain a robotic surgery program.

Staff Training

Educating staff members is an integral part of creating a successful robotic surgery program.

"As a nurse manager, you have to coach the nursing and medical staff through a somewhat challenging learning curve," said Claire Fitzgerald-O'Shea, MSN, RN, nursing director of the OR at Brigham and Women's. This will likely require multiple site visits, mock procedures, inservices with the robot vendor and creation of self-study materials, Sitren said. At OSUMC, there are five robots: four are consistently in use for surgery and one is reserved solely for training and mock procedures.

But training should not stop at clinical competency with the robot, said Jayjohn. "Staff members need to know how to troubleshoot common problems with the robot. What happens if a light bulb goes out in the middle of a procedure? It's not fair to the patient on the table, who may have traveled a great distance and spent a lot of time and money choosing your robotic surgery program, to have to convert to an open procedure because of a technical problem with the robot."

Finally, remember that enough staff members must be trained to provide backup at all times. "During the initial ramp-up of the program, cases can run later than expected. If cases run late, staff on multiple shifts must be trained and ready to take over," Cunningham said. But training every staff member in robotics may not be the answer either; limiting the number of staff trained in robotic surgery can ensure all maintain the necessary level of competency for excellent care, she added.

An Ongoing Process

Creating a robotic surgery program is an ongoing process, not one that is achieved when the first case is completed or a certain number of robots are up and running. Make sure your organization is committed to supporting and developing the program over the long-term, Fitzgerald-O'Shea said.

Continue to do research, even after that first case, Sitren said, so you are aware of the diversity of the robot. The facility may be able to incorporate new types of surgery and more complex cases over time. "After they've been doing cases for a while, send staff back for training on more complex cases," Jayjohn said.

In addition to expanding the scope of the robotic program, "everyone must constantly reassess the program that is in place to identify areas for improvement," Cunningham said. At Brigham and Women's Hospital, a committed group of nurses identifies staff concerns and system issues within the robotic program on a continual basis.

Finally, do not lose sight of the "bottom line," Jayjohn said. Incorporating robotic surgery is exciting, but ultimately only worth the investment in time and money if it ends up making patient care better.

Diana Friedman is regional editor at ADVANCE.


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Another point to consider: will the robot be stored in an OR designated only for robotic surgery, or will the robot, console and monitor need to be transported to a storage area after each case. The equipment is not that easy to move.

Dorothy  Madritch ,  RN, CNOR,  Duke RaleighJune 12, 2010
Apex , NC




     

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