Design & Implementation Aspects of Operation Theatre Management Module in HMIS

Design & Implementation Aspects of Operation Theatre Management Module in HMIS

Ramneet Singh Chadha, Umesh Sharma, Vijay Uniyal Abstract- The Operation Theatre is a critical area of the hospital. Therefore, Operation Theatre Management System (OTMS) is an important component of the Hospital Information Management System (HIMS). This paper presents the design and implementation aspects of an OTMS. The innovative features like Generic Dynamic Template for capturing various types of data, Generic Consent forms, Alert Facility, Vital Monitoring and Graph Plotting facility, etc. have been integrated in this module. Design aspects related to check list facility, patient monitoring utility, video streaming, and decision support system, etc., implemented as a part of this module are also presented. Keywords: Operation Theatre Management Solution, Dynamic Template Facility, Vital Monitoring Graph plotting, Video Streaming, Telemedicine, Decision Support System, Dossier Management, Digital OT. 1. Introduction The World Bank reported that in 2002, 11% of the entire disease burdens were attributable to surgically treatable conditions. Surgical care is an integral part of health care throughout the world, with an estimated 234 million operations performed annually. Operation Theatre is one area of the hospital where clinician provides the surgical services to the patients by using its resources. The most important function of the Operation Theatre module is streamlining the flow of operations performed in the hospitals. The OTMS contains information about the availability of all the theatres, and equipment/tools. Scheduling of operations is the main function of the OTMS. It has specific transactions for Pre Anaesthesia checks (PAC), Request Raising, PAC Result Entry, Operation List Raising, maintaining records about operations and anaesthesia done by corresponding departments. Operation Theatres are high cost centres and therefore, resources are to be allocated and scheduled properly. This module handles both major and minor operations performed in IPD as well as OPD. This paper describes the design and implementation aspects of the OTMS Module developed as a part of e-Sushrut HIMS package. It is organised as follows. Section II describes the work flow of the hospital. Section III describes the design and implementation aspects. Section IV describes the dynamic template utility and Section V describes the check list facility. Patient Monitoring Utility is described in Section VI. The decision support system developed for effective inventory management in the OT is described in Section VII. 2. Workflow of the Operation Theatre Module When a Patient visits OPD and the treating consultant considers him/her for an operation, the PAC request is raised. The Anaesthesia Department performs a PAC and enters the PAC result. The OT List is raised prior to or after PAC request.

Proceedings of ASCNT 2010, CDAC, Noida, India, pp. 181 190

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When a patient is referred to Operation Theatre from the IPD, he/she is accepted in theatre and this time is considered as wheeled in Time. After the Operation is performed, patient is sent back to IPD (ward, ICU etc) and this time is considered as Wheeled out time. During the operation, pre and post-operation records are also maintained. Within the OT, the Anaesthetists maintain Anaesthesia Record. The OTMS also maintains the Minor operations performed in OPD. The Module covers functionality of Scheduling of an Operation for a particular patient, Online status of Operation Slot, Automatic search for the earliest available appointment, List of scheduled patient's for operation, Appointments based on the availability of the doctors in hospital with a facility to define number of appointment slots . It has ability to track the completion of pre-requisites for the service prior to the scheduling such as status of PAC during operation appointments for patients. It also has the provision for viewing Operations schedule for specific dates and locations, making inquiries about Operating Theatre Bookings using Location, Operation Theatre Status, Department, and Date etc. The Operation Theatre is managed with provision for overbooking as per conditions laid down by the appropriate authority . According to circumstances raised operations can be postponed or cancelled. 3. Design Aspects of OT Module Modern day Operation Theatres are powered with latest technology and equipped with high-end gadgets. OTMS not only facilitates operations using specialised equipments but also enable streaming of live videos for telemedicine and telerobotics which can be used for consultancy/cross reference, education and research purposes, . The time adherence, discipline and absence of errors are the most important considerations for designing of any OTMS. All these aspects have been given due consideration during the design. Figure 1 gives the opening screen of the Module developed. From this, doctors, and other hospital staff will be able to communicate with other specialised services. It is also possible to create dynamic templates so that the screen could be customised as per the needs.

Fig.1: Opening Screen of the Module developed A Check List facility is provided to ensure that nothing is missed out at the start of the operation. The Patient Monitoring Utility is provided to give an overview of the intake, outtake and vitals of the patient before, during and after the operation. Telemedicine is facilitated by the Video Streaming Facility provided which streams images of the operation 182

Design & Implementation Aspects of Operation Theatre Management Module in HMIS

to doctors participating from remote locations and/or students viewing it from their classrooms. Decision Support System is provided to enable the doctors to take quick decisions, in case of emergencies. Further details of this module are given in remaining sections of this paper. 4. Dynamic Template Utility The dynamic template has evolved from the concept of Control toolbars that was available in front ends applications like Visual Basic/Power Builder. The same concept is being extended to medical fraternity through the dynamic template utility. It provides a designer area where doctors can represent the specific parameters of clinical check up for various specialities by placing various controls like Text boxes, Labels, Text Areas, Combo Boxes etc. The desired look and feel may be achieved by setting the attributes of these controls. Making fields mandatory and setting limits to values also can be accomplished by the dynamic template utility. C-DACs initial project was with a super speciality hospital (SGPGIMS)[7]. This super speciality hospital works as a referral hospital and patients are required to bring a referral slip from the referring physician. The referring physicians are requested to indicate the nature of patients' problem, the specialty at the institute they wish to refer the patient to and the nature of help required from the Institute. Being a super speciality hospital each department had its own requirements as regard to the capturing of clinical findings of the patient. We initially prepared static screens for capturing the patient details in Outpatient for different specialities, Inpatient and Operation Theatre. The next hospital we worked was a government hospital, which in addition to having a very large number of patient inflow had specific needs for the teaching wing of the hospital, which required to train the medical students on elaborate routine examinations with the exhaustive parameters for each patient. This was in contrast with the requirements of super speciality hospital, which considered only a subset of parameters and had certain additional specific parameters. Thus we encountered a major challenge of having highly dynamic requirements changing hospital wise, department wise and more specially the way doctor worked. This had a major impact on the Operation module, as the facility required effective data capturing at the stage of Outpatient and Inpatient. However the requirements were so dynamic in nature that the design of dynamic templates became a necessity. This facility provides the doctors with a tool to create their own templates of information capturing rather than being constrained by the static templates developed based on few doctors requirements. Figure 2.a gives the manual template used by one of the hospitals for capturing of information. Figure 2.b gives the corresponding template created using the Dynamic Template Facility. It may be seen that creation of any template based on manual forms is quite straightforward and does not require any modification to the developed code.

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Fig.2.a : Generation of Manual Template

Fig.2.b : Generation of Template using Dynamic Template Utility 5. Check List Facility During the Requirement Elicitation process at various hospitals it was found that numbers of patients were suffering not because of failure of Operations but due to the small mistakes happening in the Operation Theatre. An operating theatre can be an extremely challenging and stressful place where the turnover is quite fast with different people doing different things with a possible fall out of missing so many details, which may be of major significance. The best practice to use was a Surgical Safety Checklist dynamic in nature. This checklist could cater to different departments and within each department different surgeons needs, with an objective to Reduce Morbidity and Mortality.

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A checklist does three things. It ensures the things that must be done and like checking that you have got the right patient, the right site for the operation, right resources. It ensures the minimum expected steps in complex processes are carried out. And it enables the team to talk to each other so everyone knows what is to be done and if there are any deviations. This facility has a major role to play in lining up all the things before the operation is performed. A pilot study done under the sponsorship of WHO [6] wherein eight hospitals in eight cities (Toronto, Canada; New Delhi (St Stefens Hospital 733 bedded hospital with 15 operation theatre, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances participated has brought out an impact to the check list facility in actual practice. Data on clinical processes and outcomes from 3733 consecutively enrolled patients, 16 years of age or older, who were undergoing non cardiac surgery was collected and the results were compared before implementing the checklist facility and post implementation of checklist facility. The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). This proves that the use of a simple surgical checklist during major operations can lower the incidence of deaths and complications by more than one third. Fig 3a depicts the creation of a dynamic checklist in OTMS and fig 3b depicts activation of checklist at time of patient acceptance.

Fig.3.a: The master screen for creation of a dynamic checklist. The user can generate the list using this facility.

Fig.3.b: gives the actual application of the checklist during the patient acceptance.

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6. Patient Monitoring Utility During the OT module implementation, the interaction with anaesthetists of various hospitals brought out the requirement of OT patient monitoring through graphs. This will bring out the state of the patient during defined periods. This was a very challenging requirement, as it required multiple parameters plotting vs. user defined increasing time intervals. It required an innovative utility, which allows a user to define the number of parameters to be plotted as well as the time slotting on which to plot these vitals. Patient Monitoring Utility is a process for monitoring the condition of the patients dynamic parameters like BP, temperature, pulse, intake, outtake, etc., during the operation. This process also generates graphs for the benefit of the doctor. These parameters are completely configurable. For example, if we have BP, temperature, pulse as the parameter for taking the reading and the doctor requires two more parameter say CO and SO2, it may be easily incorporated through master data entry. The Patient monitoring utility covers three areas of monitoring 1. Vital Monitoring: Under this category, patient condition monitoring is done like BP, Temperature, Pulse etc. 2. Intake Monitoring: Patient intake details like blood transfused, drug etc given during the operation are captured. 3. Outtake Monitoring: Patient outtake details like blood loss, drainage etc during the operation are captured. The user has the facility to add parameters and plot them simultaneously on the same graph against time. Figure 4.a gives the screen for capturing of the parameters, which is normally operated by the Anesthesist and the corresponding plotting is given in Figure 4.b. Figure 4.c again gives the capturing screen relating to intake deetails, etc. Figure 4.d gives the comprehensive summary chart of intake, outtake and vitals.

Fig.4.a: Screen for capturing of the Parameters

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Fig. 4.b: Corresponding Plotting

Fig 4.c: Capturing of Screen relating to intake details

Fig. 4.d: Comprehensive Summary Chart of Intake, Outtake and Vitals 7. Video Streaming Video services like video conferencing have taken healthcare to a whole new level. With the advent of Telemedicine, Telerobotics and Teleconsultancy the relevance of video streaming has gained significance. In the healthcare industry, video services have actually saved lives and have the potential to save many more. Operation theatre module has option for capturing video and taking still images from the video devices, of the operation of patient in the hospital. These videos and images can be stored for recording and future viewing of operation. This can also serve as a teaching aid to the medical faculty. Figure 5 gives the example of a still captured by the Video Camera.

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Fig. 5: A still captured by the Video Camera The Streaming video may be sent in compressed form over the Internet and displayed in a remote location in a real time. With streaming video or streaming media, a Web user does not have to wait to download a file to play it. Instead, the media is sent in a continuous stream of data and is played as it arrives. 8. Decision Support System Decision Support System (DSS) is a computer-based system that enables management to interrogate the computer system on an adhoc basis for various kinds of information on the organization and to predict the effect of potential decisions beforehand. As an example, consider the case of optimising the Inventory Management. For this optimization, the dossier concept was coined. Dossier is the medical inventory for an operation, which includes items like drugs, sutures, surgical, sterilized items, etc., associated with the operation. These items could then be issued and returned and can finally updated after operation. The Inventory DSS basically provides the usages of these items and acts as a feedback mechanism to optimize the quantity that needs to finetuned in each dossier. Figure 6.a gives the format of the Dossier and Figure 6.b gives the consumption pattern for a number of specific operations.

Fig 6.a: Dossier Master 188

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Fig 6.b: Consumption Pattern for operation This helps the hospital management, surgeon and patients. The hospital Management by studying the pattern of item consumption during similar operations can fine tune the optimized number of items required per operation. This enables them to maintain inventory by taking appropriate actions and projecting the stock requirements in advance. The surgeons get the entire items ready as part of preparation of the operation. This is specifically advantageous to hospitals in which patient has to get the items for operation as it enables the patient to have a complete understanding of the items required and thee budgeted cost for the same well in advance. This also facilitates the Hospital Management in clearly defining the costing of various operation packages. 9. Conclusion OTMS is one of the most important components of the e-Sushrut HIMS solution developed by C-DAC. It has got a number of innovative features like Dynamic Template Utility, Checklist Facility, Vital Graphics Facility and Decision Support Systems facility. This package has been in use in a number of hospitals and is well accepted among the medical fraternity. One of the important aspects of the design is that, it is evolved, over a period of time, as per the different requirements of the hospitals. Thus, it is able to meet most of the commonly needed requirements of the Government & Super speciality Hospitals in the country. Acknowledgment I would like to thank C-DAC Management for providing me the opportunity to work in Healthcare Sector and the HMIS team for their support. I would like to make a special mention of inputs from Dr. Mahendra Bhandari, former Director SGPGIMS, Dr. Vijay Rai, CMO & Nodal Officer (IT) Dept. of Health & Family Welfare, Dr. P.K Malik CMO (NFSG) Nodal Officer Computerization, GTB Hospital, Dr Shanti Singh, Nodal Officer RIMS, Dr S.K Mishra, HOD Head Endocrine Surgery, SGPGI, Lucknow, Dr. Tempe GB Pant hospital for providing inspiration and valuable inputs.

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References |1| |2| |3| |4| |5| |6| |7|

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Springer Berlin / Heidelberg, International Journal of Computer Assisted Radiology and Surgery Volume 1, Number 3 / November, 2006 C-DAC System Requirement Study document for Delhi Government. [Internal Document] C-DAC System Requirement Study document for MGIMS, Sewagram. [Internal Document] C-DAC System Requirement Study document for RIMS, Imphal Prof S.K Mishra, Symposium on Indian Medical Standards in Indian Context. World Health Organization (WHO), Study 2008 C-DAC System Requirement Study document for Sanjay Gandhi Institute of Medical Sciences http://www.answers.com/topic/java-media-framework

About Authors Mr. Ramneet Singh Chadha is currently working as Project Manager, in Health Informatics Group. He has more than 12 Years of domain expertise in Health care Domain and has been closely involved in Design, Development and Implementation of e-Sushrut HMIS Software, since his joining C-DAC in 1997. An Engineering Graduate and College topper in Computers Systems from Nagpur University, Mr. Ramneet has done his Masters in Management (IT) and M.S (Software Systems) from BITS Pilani. He has been associated with various Public Sector & Super Specialty Hospitals like SGPGI, GTBH, RIMS, Imphal, MGIMS Nagpur, GNCTD, PGIMER Chandigarh and SMS Jaipur. He has keen interest in Interoperability of Hospitals for setting up NHIN using HL7 Standards; Cloud Computing and Telemedicine and other research areas in healthcare domain. Mr. Umesh Sharma is working as Project Engineer at C-DAC, Noida. He is working as Team Lead for PGIMER, GNCTD and SMS projects in Health Informatics Group. He has customized and implemented HMIS in Indira Gandhi Medical College, Shimla. His interest areas include System Study and Analysis, Research in Healthcare Solutions. Mr. Vijay Uniyal is working in C-DAC for more than three years. He has done Masters in Business Administration in Information Technology. He has also done Bsc and DOECC B Level course. Currently he is working as dedicated team member in Health Informatics Group for Operation Theater and Investigation Module. He is working on J2EE technologies and has sound knowledge of Oracle.

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