Where sim meets surgery
Frequent moviegoers have no doubt seen scenes in which a harried pilot or astronaut brings his craft in for a bumpy landing and then—surprise, surprise—emerges from an elevated metal box, wiping his fevered brow, having just taken on a flight simulator. At William Beaumont Hospital in Royal Oak, Michigan—one of the premier surgical teaching hospitals in the United States, and second among all U.S. hospitals in surgical volume, according to 2004 American Hospital Association data—surgical teams undergo similar “full immersion” training at the facility's new Surgical Learning Center. They must manage moaning, groaning “patients” during precipitous blood pressure drops, sudden flat-lining emergencies, power outages, fire alarms, and other stressful challenges before finally emerging from the Learning Center, ready (or not) to review it all in instant replay.
The Surgical Learning Center features movable tables, virtual wrap-around monitoring technology, all-purpose environmental controls, telecommunications capabilities, a special ceiling for modular flexibility, and the latest in patient simulation. It was, by necessity, an exemplar of high-tech collaboration among designers, engineers, and physicians.
Recently, three key principals involved in the development of the Beaumont Surgical Learning Center discussed this pioneering project with HEALTHCARE DESIGN Editor-in-Chief Richard L. Peck: Rick Hall, AIA, principal, Health Care & Life Enhancement Studio, Harley Ellis Devereaux; Archie Lytle, technology director, the Barton Malow Technology Group; and Charles J. Shanley, MD, chairman, department of surgery, William Beaumont Hospital.
Peck: What was the genesis of this high-tech surgical learning center?
Rick Hall, AIA, Principal, Health Care & Life Enhancement Studio, Harley Ellis Devereaux: With 16 new operating rooms opening in 2004, at 650 square feet each, Beaumont knew that its surgical training program had to expand. The original thinking was to locate the learning center in the basement. However, after visiting similar training centers in Canada and Pennsylvania and after philanthropist Eugene Applebaum came through with a generous donation, we thought some vacant space on the third floor would be the ideal location. It was more centrally located for wayfinding and less utilitarian and more presentable than the basement space. We teamed with The Barton Malow Technology Group to expedite installation of the technology to open the learning center as soon as possible.
Charles J. Shanley, MD, Chairman, Department of Surgery, William Beaumont Hospital: When the Institute of Medicine published “To Err is Human” in 1999, the nation became focused on preventing medical errors. This report suggested that medical staff training using simulation should be encouraged and greatly expanded. It was at about this time that we were planning educational space in the South Tower addition and requested a simulation facility. The goal was to incorporate full-immersion simulation, which resembles the cockpit simulators used to train 747 pilots and their teams. We received a very enthusiastic response and proceeded to visit the major facilities in North America.
We next began a series of meetings with the architects to plan this facility. Locating the Learning Center on the third floor was brilliant. The space was next to our instrument processing facility, so instrument storage is not an issue. Perhaps more importantly, it was located in the heart of this brand-new, 21st-century hospital, sending a clear message that our culture embraces patient safety. In the design and development phases, there were many meetings among educational, nursing and surgical leadership. Beaumont already had a robust educational infrastructure for the staff, residents, nursing, and allied health personnel. This facility completed the picture by providing the bricks and mortar to support our educational enterprise.
Peck: Would you discuss some of the engineering that went into this—for example, the ceiling?
Hall: It's an open ceiling utilizing a unistrut design that is used typically for installing overhead equipment on a modular basis. It had to be painted jet black to set off the training area beneath in a dramatic way—a sort of “stage set” for surgical training.
Archie Lytle, Technology Director, the Barton Malow Technology Group: The flexibility that we had with cabling was unusual—for example, we have pull-down racks in the operating space where we can add equipment cabling as needed. The simulator technology is full-immersion, in that the “patient” has real-life functional features, such as blood pressure, respiration, CO2 blood gasses and other readings, along with heart sounds, bowel sounds, coughing, vomiting, moaning…an incredibly complex but realistic unit. Controls are set up so that we can create disaster scenarios to test the surgical staff's response—power outages, generator failures, equipment failures, fires, ground faults, and so forth. Everything that happens in terms of actions and reactions during these events, as well as regular surgeries, is recorded, digitized, and stored on hard drive and reviewable anywhere in the hospital. Also, with videoconferencing technology we can broadcast clinical values and patient behaviors to observers anywhere in the world.
Peck: To achieve this kind of technologic complexity, what sort of collaboration was needed?
Lytle: As an example, I've had a 15-year history with the Harley Ellis Devereaux electrical engineer on the project. Often during the project he'd offer ideas on IT, AV, and technology, while I would offer ideas on lighting or electrical design. I also felt very much a part of the architectural team. Yes, people sometimes fight and disagree during projects like this, but they always came together on solutions that were best for the hospital.
Hall: We had a lot of early-morning meetings, especially with the physicians, and we had weekly user meetings to make sure that all the needed technology was integrated into the design. We ordered a lot of equipment even before drawings were completed.
Lytle: Obviously we wanted to use the exact same equipment used in the operating room in the mock operating room, and then, as an overlay on that, all the monitoring technology and various controls. Even though we did our best to keep the instructional space as simple as possible, this was one of the most technologically complex projects I've ever done. We tested everything—mechanical, electrical, lighting controls, booms, cardiac monitoring, you name it—often testing it to breakage. We pushed technology to the limits and we found a few flaws, which we communicated to the vendors.
Peck: What did you learn from this project in terms of providing flexibility to accommodate future technology?
Hall: Basically we learned to provide sufficient heating and cooling, electrical services, cable trays, and wiring on the assumption that, in five years, a whole new set of equipment might be needed.
Lytle: We're moving more and more electronics into the operating room—scopes, cameras, other video technologies, computing, robotics, and more. We need a lot more infrastructure for video, data, and voice systems, and we have to think about designing it modularly. There's thinking right now that we should locate much of this technology outside of the OR to allow for better control and occupy less of the expensive surgical space
Hall: I think we're still going to need a lot of acreage in the OR in the future, but with modern communications technology, the communications issues can be accommodated without impacting the OR itself.
Lytle: Technology is networked and digital. Analog technology, such as cameras, typically had distance limitations, but networked digital technology does not. The surgical instruments are computer controlled. This will mean that much of the processing technology can be anywhere in the hospital, or in the world. In the near future, the surgeon may not even be in the same country as the patient. HD
Archie Lytle is Technology Director at the Barton Malow Technology Group.
Charles J. Shanley, MD, is Chairman, Department of Surgery, at William Beaumont Hospital in Royal Oak, Michigan.