OR evolution at MUSC: How the health system brought 24/7 robotics to emergency surgery

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Surgical robotics platforms are increasingly being integrated into operating rooms at health systems across the country. 

"The future of robotic technology is to improve patient outcomes and decrease the total cost of care," said David Zaas, MD, CEO of Medical University of South Carolina, Charleston Division, and Chief Clinical Officer for MUSC Health. However, adopting and broadly using surgical robotics requires training and overcoming cultural challenges. 

Becker's Hospital Review recently spoke to Dr. Zaas, along with Bruce Crookes, MD, chief of the division of general surgery at MUSC, and Betts Bishop, BSN, RN, MUSC's robotics coordinator, about MUSC's experience building support for and implementing a robotic surgery program at MUSC. 

MUSC's rationale for investing in robotics is driven by its values

The decision to invest in robotics, Dr. Zaas explained, was driven primarily by MUSC's values that include patient care, innovation and education. "One of our core values is innovation," said Dr. Zaas. "Being on the forefront of robotics ensures that MUSC provides the highest quality and value of care for our patients and families." It also provides MUSC's surgeons with access to the latest technology as part of fulfilling MUSC's goal of being innovative. Adoption of robotics is also important for MUSC's learners, by ensuring that trainees have access to the most current robotic technology.

In addition, Dr. Zaas said MUSC wanted to integrate robotic-assisted surgery not just in the tertiary academic medical center, but also in community hospitals. This widespread adoption helps support the health system's physician recruitment goals and helps ensure the same level of quality care is offered throughout MUSC.

By moving forward with surgical robotics, Dr. Zaas stressed that MUSC was not looking for a vendor, but wanted to "create a partnership with aligned incentives for not only growth of the [robotics] program, but for quality, innovation and shared risk." MUSC felt that Intuitive provided that level of partnership. Dr. Zaas said, "What really appealed to us is the idea of collaboration, partnership and shared risk, all focused around the patient."

Early skepticism, Intuitive 360 and the expansion of MUSC's robotics program 

Initially, robotic-assisted surgery platforms were only used at MUSC's main hospital in gynecology and urology and eventually grew in cardiothoracic and general surgery after the da Vinci Xi was introduced. But Dr. Crookes felt it was important for MUSC to use robotics for emergency surgery and trauma at multiple MUSC campuses, in multiple ORs, 24/7. 

While Dr. Crookes was a passionate champion for surgical robotics in trauma and emergency surgery, he was also a realist. He knew that with new technologies and processes, "There are always bumps in the road." Entire teams need to be trained and become comfortable with a new technology, and there are often cultural barriers, explained Dr. Crookes. "There was an alternative to this [robotics] technology; we could do all of the stuff through a laparoscope, albeit less efficiently. So, there was always an easy fallback. That can make moving forward difficult." 

Dr. Crookes also recognized, "There can be some resistance from physicians or nurses," which increases the difficulty of embracing a new technology, even an important, innovative technology with clear benefits, like surgical robotics.

Prior to the Intuitive 360 conference, held virtually in October 2020, Dr. Crookes' group had started doing cases using da Vinci, building up case volume and thinking about a business plan to expand the surgical robotics program. 

Still, Dr. Crookes remained somewhat skeptical about expanding MUSC's robotics program and about the Intuitive 360 event. "I came in as a skeptic," he said. "I was the first to admit that this is fancy, it's cool, it's fun. But is it cost effective? Is it doable?" He wondered if he was setting himself up for failure.

But Intuitive 360 proved to be extremely valuable. Dr. Crookes heard from others who had dealt with the challenges he was facing. He heard how they figured it out and what their experience was like once they got their robotic surgery program up and running. "One really important thing," recounted Dr. Crookes, "was hearing about the learning curve." Through peer-to-peer conversations during Intuitive 360's breakout sessions — which Dr. Crookes termed "probably the most valuable thing at 360" — he heard key takeaways from other surgeons indicating that it can take a few dozen cases to feel truly comfortable with the platform. He also heard valuable tips about engaging the team and about the different kinds of leadership skills needed to run a 24/7 robotics program. 

As MUSC's da Vinci Nurse Coordinator, Ms. Bishop approached Intuitive 360 with a different perspective. She focused on learning how the nurse coordinator can make the surgical robotics program effective, especially as MUSC anticipated using robotics at multiple MUSC campuses and ORs. She noted that several breakout sessions resonated with her, with a strong focus on education and training. Perhaps most importantly, Ms. Bishop came away from Intuitive 360 realizing, "I'm not in this alone. I realized there are a lot of resources within Intuitive to help you. There is a very big support group."

The support MUSC has received from Intuitive extends far beyond Intuitive 360

Coming out of Intuitive 360, Dr. Crookes' goals included getting the rest of MUSC's emergency surgery and trauma staff trained and integrating the surgical residents into the program.

With the support of MUSC's Intuitive representative, one-on-one training sessions with Dr. Crookes and other surgeons and physician assistants were held. Night staff at all MUSC locations were provided extensive training during slow OR periods and MUSC’s Intuitive representative was available 24/7 to assist and train with live cases. 

MUSC's Intuitive rep — who had been through the startup and training process many times — decreased the anxiety of MUSC's staff and helped the team avoid mistakes. Dr. Crookes summarized, "Our rep eased the transition and made me feel a lot more comfortable. There is a steep learning curve and I don't think we could have gotten this up and running without the support that Intuitive and our rep provided . . . he's probably been the most invaluable part of the whole process." 

Ms. Bishop concurred. She noted that Intuitive reviewed MUSC's processes and shared insights on how to improve them, which was extremely helpful. 

Expanding robotic access required extensive education, training and a focus on culture 

Through Dr. Crookes' persistent focus on robotics, he gained support from MUSC's administration, got all members of the operations team trained and over time built organizational support as team members became comfortable with the platform and saw the technology's benefits. Building this support "took some convincing," said Dr. Crookes. This involved committing, "We're going to do this," and not allowing backtracking.

It was critical to convince everyone, "We're in this together." It was important to convey that other organizations have done this successfully, and that there would be initial challenges, but these challenges can be overcome if the team works together. "Working together was the most important thing," Dr. Crookes said. 

After initial adoption, and after team members became comfortable with the robots, it made sense to expand the use of surgical robotics from 12 to 24 hours each day. As Dr. Crookes explained, "Only 12 hours a day for this capital investment didn't make any sense. Every patient deserves the best possible treatment regardless of when they come into our hospital so we had to open it up to nighttime use, and we started doing that."

A real-world case study shows the improved outcomes that robotics can provide

Weeks after attending Intuitive 360 and making it a point to train the staff for 24/7 access, a patient presented at an MUSC emergency room with an abdominal stab wound that merited an exploratory laparotomy to repair a traumatic hernia, explore the abdomen to rule out other injuries, and reduce some incarcerated omentum. Traditionally, this would have been done through a 15-cm laparotomy incision, requiring a two- to three-day hospital stay.

However, using the da Vinci platform, Dr. Crookes did the entire operation robotically, making three 8-mm incisions — and then discharged the patient home. With the support of the OR team, Dr. Crookes was able to offer a robotic-assisted procedure to this patient regardless of the time of day. 

“Traditionally, I would have done this through a 15 cm laparotomy incision, with a two-to-three-day hospital stay afterwards. The night Main OR team pulled together, and we were able to do his entire operation robotically using da Vinci - three 8 mm incisions, and a discharge to home from the PACU.” said Dr. Crookes, “This was innovation and teamwork at its best!” 

Conclusion

In recapping MUSC's experience launching its robotics program for trauma and emergency surgery, Dr. Crookes said there were some growing pains getting the program integrated across multiple sites with 24/7 access. The process involved winning over skeptics and building a groundswell of support through championing, training, gaining experience and seeing the benefits. "It's a capital investment," said Dr. Crookes, "but it's also a people investment." Already, MUSC's investments are paying dividends. In a relatively short period, MUSC has expanded its robotics platform and it is growing rapidly. 

Without the resources from Intuitive, MUSC's ramp up of its surgical robotics program would have been slower and more difficult. Reflecting on his experience with Intuitive and 360, Dr. Crookes commented, "At the end of the day, the time you spend setting this up is cut down pretty dramatically . . . You will realize that the return on the time investment [of 360] is worth it. You will meet a bunch of people who have done this, they've set things up, they've seen the mistakes, they know where the bumps in the road are and they can ease you into the process." Dr. Crookes and Ms. Bishop see Intuitive 360 as an important way to accelerate a health system's robotics journey. 

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