'The opportunities are limitless': How OR 'black boxes' are changing the way hospitals operate

Operating room "black boxes" are growing in popularity as a way to improve patient safety and operational efficiency — and it likely will not be long before they spread to other departments.

Currently, 24 hospitals in the U.S., Canada and Western Europe are using the technology. "Black boxes" — named after the recording devices on airplanes — were developed by Surgical Safety Technologies in Toronto. They gather video, audio, patient vital signs and data from surgical devices during procedures.

"The opportunities are somewhat limitless," Christopher Mantyh, MD, professor of surgery and chief quality officer for the department of surgery at Durham, N.C.-base Duke University Hospitals, said. "This is the way you improve your quality and operation. We want to look at videos where everything goes really well so we can emulate that in other rooms."

Becker's connected with surgeons from Mayo Clinic and Duke University Hospitals to talk about how the technology has created opportunities in their operating rooms.

Improving OR efficiency

Duke University Hospitals has used the technology for two years in two of its ORs. The black box system is always on — even when no one is in the room — which helped Duke improve patient care, turnover time and rearrange operating rooms for efficiency.

"When we look at the black box, we figure out exactly the right position to put everything: Where should the nurses and surgeons stand? Where do we put the trays? Where do the robot arms go?" Dr. Mantyh said. "We take an ergonomic look at everything, even the mopping, and make the room more efficient. It's the same for our laparoscope equipment, which hangs on booms. We can look at the videos and say, 'Maybe we should have the boom on the left side instead of the right.' Or, 'the anesthesia machine might be getting in the way.'"

Rochester, Minn.-based Mayo Clinic has seen similar improvements in its operating rooms since installing the technology in September 2021. The black boxes in three of its ORs helped leadership identify key pieces of equipment that were taking too long to reach at critical moments. The fix: Move it closer and make it more accessible. 

Making the OR more efficient with its equipment is only the start of improvements. 

"There have been a lot of positive changes around teamwork and team function and how we respond to things," Sean Cleary, MD, a surgical oncologist at Mayo Clinic, said. "When we have something happen in the operating room and the team's able to respond to a change in plan and done so smoothly and efficiently, we can now characterize that."

The future of black boxes

Duke is already planning to roll out black boxes into more rooms, and Dr. Mantyh has his eyes on getting the technology into other departments.

"One area that is very chaotic is our trauma bays," Dr. Mantyh said. "I remember as a resident way back when the trauma bay was the most chaotic area in the hospital. Obviously, time is of the essence. Patients can have a lot of things going on. But if you actually do it well, it is an amazingly efficient and potentially lifesaving area. So we're thinking about putting [a black box] in there."

Duke is also prioritizing its robotic rooms and looking to expand into other areas, including thoracic surgery, gynecology and urology, he said, adding, "I think people are clamoring to see how we can do it better. I do think [the black boxes] are here to stay."

Dr. Cleary agreed: "This is a disruptive technology, and I use disruptive in a good sense."

The positive and the punitive

Both Duke and Mayo Clinic have had to overcome concerns from staff members who worried the technology would be used to punish clinicians. However, Dr. Cleary and Dr. Mantyh said the technology has allowed for more positive reinforcement than punitive action.

In part, this is due to the data being disidentified and anonymized. After 30 days, the footage is deleted to protect the privacy and confidentiality of patients and healthcare providers, Surgical Safety Technologies founder Teodor Grantcharov, MD, PhD, told The Wall Street Journal.

"It's not about Jane or Joe's individual performance," Dr. Cleary said. "The whole spirit behind this system is to make things in the operating room work better. It's made to make things safer."

Morbidity and mortality reviews are one area that has seen improvements in punitive versus positive reinforcement. 

"Traditionally, it was a bunch of surgeons and nurses in a room together retrospectively recollecting what happened, and to say it was subjective would be very kind," Dr. Cleary said. "What this has done is allowed us to bring some objective data into that discussion. We can say, 'When we did this it wasn't really effective, but when you did this, this is what happened.' The natural tendency of a M and M, in a historical sense, has been to focus on when things go wrong. But this system actually allows us to focus not just on critical events that didn't go according to plan, but to look at when things went right with exemplary function, performance or teamwork and use that as an example for how we should function all the time."

However, there are still concerns about the video potentially being used in legal action against healthcare workers. 

"People always want to know about privacy," Dr. Mantyh said. "Everything from HIPAA stuff on the patient side to what will be discoverable from the surgeon side and the healthcare provider side."

So far there have been no cases in which black box video has been used in legal action. And, Dr. Cleary noted, "The fear of that kind of stuff can't stop us from getting better. That's allowing the legal system to paralyze the medical system and to enact it to virtual inactivity. [If that happens], we've made things worse."

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