Home Study Program. The evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role

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1 Home Study Program MARCH 2006, VOL 83, NO 3 Home Study Program The evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role The article The evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is March 31, Complete the examination answer sheet and learner evaluation found on pages and mail with appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO or fax the information with a credit card number to (303) You also may access this Home Study via AORN Online at BEHAVIORAL OBJECTIVES After reading and studying the article on the evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role, nurses will be able to 1. discuss the evolution of robotics use in medicine, 2. describe the benefits to surgeons of robotic surgery, and 3. explain the role of a robotics nurse specialist within the context of a robotics program. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. A minimum score of 70% on the multiplechoice examination is necessary to earn 5 contact hours for this independent study. Purpose/Goal: To educate perioperative nurses about the evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role. AORN JOURNAL 629

2 MARCH 2006, VOL 83, NO 3 Home Study Program Evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role Paula, RN Use of robotics is expanding rapidly in the medical arena. Private health care facilities as well as public hospitals associated with academic centers are purchasing robotic surgical systems, and robotic systems are being used in a variety of ways across the country. In 2003, more than 250 robotic systems had been placed worldwide. 1 The number of surgeons using robotic technology also is increasing. In 2000, 1,500 robotic procedures were performed; this number increased to an estimated 20,000 procedures in A robotics program creates myriad challenges (eg, cost, training, safety) for facilities, surgeons, staff members, and patients. This article provides a ABSTRACT USE OF ROBOTICS is expanding rapidly in the medical arena. Not only are a growing number of facilities purchasing robotic systems, but the number of surgeons using them also is increasing, which creates many challenges (eg, cost, training, safety). THE EVOLUTION of robotics in surgery is presented within the context of virtual reality, telepresence, telemanipulation, and passive (ie, master-slave) robotic surgical systems. A NEW PERIOPERATIVE NURSING ROLE, the robotics nurse specialist, was developed and implemented at one facility. The need for a robotics nurse specialist and how this role can help the entire surgical team promote positive patient and facility outcomes also is discussed. AORN J 83 (March 2006) background of the evolution of robotics in surgery and describes a new perioperative nursing role the robotics nurse specialist its evolution at one facility, and how this role can help the entire surgical team promote positive patient and facility outcomes. THE EVOLUTION OF ROBOTICS USE IN MEDICINE A number of events culminated in the incorporation of robotic technology into the medical arena (Table 1). The first event was the creation and mainstreaming of computer technology. The second event was installation of robots in an American automobile manufacturing plant in Robots were used on the production line to perform repetitive motion tasks and activities that were too physically demanding on human bodies. Replacing human workers in these tasks saved the automobile manufacturer money spent on treating injuries and lost working hours. More importantly, it was the first step in introducing robotics into American culture. Although laparoscopic procedures were performed in gynecology for many years, completion of the first laparoscopic cholecystectomy in 1985 was a contributing event in the development of medical robotic technology. 4 This spurred the growth of minimally invasive surgery (MIS) into a highly practiced surgical specialty. Some of the driving factors that helped robotics enter the medical field were the frustration that surgeons performing MIS had with the lack of a three-dimensional [3-D] view, decreased dexterity, 630 AORN JOURNAL

3 MARCH 2006, VOL 83, NO 3 TABLE 1 Time Line of Robotic Development Karel Capek s play R.U.R. Rossum s Universal Robots describes robots as dumb machines for repetitive work 1942 Isaac Asimov uses the word robotics for the first time to describe the study and use of robots in his short story Runaround 1946 Computer development begins 1950s-1960s Development of industrial robots begins 1961 First industrial robot is used on an assembly line at an automobile factory in New Jersey 1985 First laparoscopic cholecystectomy surgery is performed Mid to late 1980s National Aeronautics and Space Administration working to develop virtual reality 1985 A robotic arm is created for use in urologic and neurosurgery applications Late 1980s Stanford Research Institute (SRI) begins working on robotics and telemanipulation Early 1990s US Army notices the work of SRI and becomes interested in developing telemedicine Early 1990s Independent commercial efforts in developing medical robotics for hip replacement surgery begin 1993 Project to develop an automated endoscopic system and minimally invasive surgical robotic technology begins 1994 The US Food and Drug Administration (FDA) approves an automated endoscopic system for use in human surgery 1995 Early prototype of telepresence robotic surgical system is developed Minimally invasive cardiac techniques with robotics are developed (eg, harvesting internal mammary artery, coronary artery bypass) 1997 Telepresence robotic surgical system development completed and first telepresence surgery (ie, cholecystectomy) performed 2000 The FDA approves use of the telepresence robotic surgical system for all abdominal laparoscopy procedures 2001 The FDA approves the table mounted robotic surgical system as a surgical assistant, after which the first telerobotic surgery is performed by a surgical team in New York on a patient in France 2004 The FDA approves the telepresence robotic surgical system for cardiovascular revascularization 1. ROVer Ranch, A short history of robots, National Aeronautics and Space Administration, (accessed 29 Dec 2005). 2. W Reynolds, Jr, The first laparoscopic cholecystectomy, JSLS: Journal of the Society of Laparoendoscopic Surgeons 5 (January-March 2001) R M Satava, Robotic surgery: From past to future A personal journey, Surgical Clinics of North America 83 (December 2003) R M Satava, Surgical robotics: The early chronicles: A personal historical perspective, Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 12 (February 2002) G H Ballantyne, F Moll, The davinci telerobotic surgical system: The virtual operative field and telepresence surgery, Surgical Clinics of North America 83 (December 2003) Investors relations home corporate profile, Intuitive Surgical, Inc, (accessed 29 Dec 2005). 7. T Falcone, J M Goldberg, Robotic surgery, Clinical Obstetrics and Gynecology 46 (March 2003) AORN JOURNAL 631

4 MARCH 2006, VOL 83, NO 3 Telemanipulation technology using robotic manipulators, telecommunications, and virtual reality concepts enables a surgeon to create a telepresence inside a patient. poor ergonomics, and inability to make microsurgery feasible. Robotic technology helps surgeons overcome the disadvantages of MIS. During the mid to late 1980s, three groups of scientists and physicians began focusing their work on developing medical robotic technology. They met via professional meetings, mutual colleagues, and networking. NATIONAL AERONAUTICS AND SPACE ADMIN- ISTRATION (NASA). Scientists at the NASA- Ames Research Center were working on the development of virtual-reality technology. The term virtual reality is defined as the use of computer modeling and simulation to enable a person to interact with an artificial three-dimensional visual or other sensory environment. Virtual-reality applications immerse the user in a computer-generated environment that simulates reality through the use of interactive devices, which send and receive information and are worn as goggles, headsets, gloves.... 5(p1) Virtual reality creates an electronic environment and uses a computer to create interaction within this environment. Scott Fisher, PhD, a computer scientist involved in early research applications for robotic technology in medicine, coined the term telepresence to describe this interactive virtual reality as,... feeling as if you had projected your presence into another imaginary place or world. 6(p1491) Telepresence was accomplished by incorporating 3-D images into virtual reality environments. A special glove is used as the interface between human and computer, and then an object-oriented computer software program interacts with the virtual-reality environment. 7 Telepresence was incorporated into telemedicine to enhance its applications beyond monitoring patients. Telemedicine can be anything from a telephone conversation between two health care professionals regarding a patient, to a consultation using satellites to communicate patient-specific health care information (eg, magnetic resonance images, ultrasound scans), 8 to a surgeon performing surgery on a patient a continent away. 9 Telemedicine was used early by NASA to monitor astronauts vital signs. STANFORD RESEARCH INSTITUTE. A second group of scientists and Joseph Rosen, MD, from the Stanford Research Institute were working on robotic technology and telemanipulation. 6,7 Dr Rosen and Dr Fisher developed an idea for using virtual reality concepts paired with robotic technology to enable surgeons to operate on patients who were not in their presence. Telemanipulation technology using robotic manipulators, telecommunications, and virtual reality concepts enables a surgeon to create a telepresence inside a patient. Robotic manipulators are mechanisms that replicate the motion of human arms in manipulating objects and tools for manufacturing, surgery, and other delicate tasks. US ARMY. The third group of physicians was in the US Army. A general surgeon, Richard M. Satava, MD, was working for the US Army at the time he met Dr Rosen and Dr Fisher. Dr Satava helped the US Army become aware of the developing idea of telepresence and robotics and its potential for allowing a physician to diagnose and treat a patient not physically in the physician s presence, which might save more lives on the battlefield. 6,7 The Army then provided funding for research and development of medical robotic technology. 6 THE CIVILIAN MARKETPLACE. Medical robotic technology entered the marketplace 632 AORN JOURNAL

5 MARCH 2006, VOL 83, NO 3 Telemanipulation involves controlling robotic manipulators from a remote site, such as a room next door or a site across the world. when Frederic H. Moll, MD, saw the commercial value of the emerging robotic technology as applied to the patient population undergoing MIS procedures. Dr Moll collaborated with Robert Younge, an electrical engineer, and John Freund, MD, to acquire the license to a telepresence robotic technology and start a company in 1985 focused on developing this technology. 6,10,11 This company used the telepresence robotic technology to develop a passive (ie, master-slave) robotic surgical system. Passive robotic systems do not generate movement themselves. Movement of the robotic manipulator (ie, arm) can be generated only through human input at a user interface (ie, master), such as a keyboard or joystick. Thus the robotic manipulator is a slave to the human via the interface. Another medical robotics company was founded in 1989 by Yulun Wang, PhD, an acquaintance of Dr Satava. 8 Dr Wang received funding from the Defense Advanced Research Project Agency and NASA for studies on robotics applied to telemedicine. 8 His company launched an automated endoscopic telescopic manipulator system in 1993 and received FDA approval for its table-mounted master-slave robotic surgical system in ,8 Obtaining licenses and patents for the two master-slave robotic surgical systems put medical robotics on course for mainstream medical robotic technology use. The two companies merged in CURRENT SYSTEMS. In the passive systems currently approved by the US Food and Drug Administration (FDA), robotic manipulators are the device s robotic arms. Telemanipulation involves controlling robotic manipulators from a remote site, such as a room next door or a site across the world. Currently, the FDA has mandated that in the United States, master-slave robotic surgical systems must be operated in the same room that the patient is in. 10 Other countries, however, are using master-slave robotic surgical systems to provide highly technical, specialized surgical care for rural areas. 9 Research demonstrated for the FDA that these surgical systems were safe for human use. 10 Now it is up to health care professionals, patients, and third-party payers to guide development and appropriate use of these systems. Medical robotic technology has the potential for rapid evolution. To keep pace with technological changes, health care team members should take an active role in educating themselves on new medical robotic technology and evaluating their own practice to ensure that they are meeting patients needs that are emerging in response to the technological changes. TRANSFORMING SURGICAL PROCEDURES Medical robotic technology is directly transforming surgical procedures (Table 2). Performing a procedure with robotic surgical technology offers a patient all the benefits of an MIS approach. Surgeons using robotic technology experience certain benefits that indirectly extend to patients. Surgeons are more comfortable when seated for a robotic procedure, and have better vision with a 3-D, magnified view. Surgeons also have improved dexterity because of increased freedom of movement with robotic instrumentation. Furthermore, robotic computers are able to eliminate the fulcrum effect and physiological tremors that surgeons may experience when performing MIS surgery. Robotic computers can scale motion size from 1 cm equaling 634 AORN JOURNAL

6 MARCH 2006, VOL 83, NO 3 TABLE 2 Guide to Three Types of Robotic Surgical Technology System A System B System C Telepresence robotic master Table-mounted robotic Robotic arm that controls slave surgical system master-slave surgical an endoscope camera system system via verbal commands Three components Four components Three components 1. Surgeon console where the surgeon sits to operate and control instrument movement with monopolar coagulation capability instruments, telescope movement, camera focus, and size of surgical movements. 2. Surgical arm cart composed of two or three instrument arms that hold surgical instruments and one telescope/camera arm, all of which are sterilely draped and rolled up to the patient s side. 3. Vision cart composed of monitor, two camera boxes, synchronizer for camera boxes, focus control unit, and videocassette/digital video disc recorder. 1. Surgeon master/controller and monitor where the surgeon sits to operate the unit. 2. Two individual surgical arms that hold the surgical instruments are transferred from the storage holder. 3. Rolling storage holder from which the surgical arms are sterilely transferred to the OR bed side rails, and then draped. 4. Automated endoscopic arm. 1. Robotic arm is transferred from a rolling storage cart to the ORbed side rails, after which it is sterilely draped. 2. Control computer and power source. 3. Voice activated control box. 1 cm, to 3 cms equaling 1 cm, and 5 cms equaling 1 cm of movement. This allows surgeons to offer MIS approaches to patients who would not have been considered for these approaches before robotic technology was available. 1,12 For example, performing laparoscopic surgery on small children and infants is difficult because of the challenge in performing laparoscopic anastomoses of 2 mm to 15 mm. Fallopian tube reanastomosis is another example of a procedure that is very difficult to perform laparoscopically that can be performed more easily using robotics. Robotic technology also is transforming the surgical arena indirectly by changing surgical approaches, equipment, and instrumentation for nonrobotic procedures. 12 For example, robotics renewed manufacturers interest in improving traditional laparoscopic instruments. 12 To ensure that the traditional laparoscopic approach is competitive with the robotic approach, manufacturers now are investing effort and money in developing truly innovative laparoscopic instrumentation. 12 COORDINATING A ROBOTICS PROGRAM Initial up-front costs to purchase a medical robotic system can be more than $1 million per system. 2,13 In addition, training surgeons and support staff members is intensive and can be costly. 14 Some health care facilities only AORN JOURNAL 635

7 MARCH 2006, VOL 83, NO 3 Multiple services and surgeons using a single system can decrease cost efficiency and increase inventory and maintenance costs. have one service or specialty with one or two surgeons using the robotic system. Increasing the number of services or specialties and surgeons who use a system increases the confusion that can occur with communication, utilization of instruments and supplies, and scheduling of procedures. This confusion can lead to inefficient handling of the equipment, instruments, and supplies. Inefficient system use decreases cost efficiency and increases inventory and maintenance costs. Multiple users from different surgical specialties require more nursing staff members, which increases the need for coordinated, unified educational programs. For facilities whose robotic system is being used minimally, it may be possible to incorporate all functions of a robotic surgery program necessary to schedule procedures, maintain the system and instrumentation, and train staff members into the daily activities of nurse managers, charge nurses, schedulers, and other staff members who already are in place at the facility. For facilities with multiple users from many specialties, these tasks can become too numerous and time consuming to delegate to existing staff members. The University of Iowa Hospitals and Clinics (UIHC), Iowa City, received approval to purchase a robotic surgical system in April The system arrived in September Initially, five surgeons from three clinical departments began using the system in October A nurse manager coordinated the system with assistance from depart- ment schedulers and a robotics committee consisting of an anesthesia care provider, the surgeons using the robotic surgical system, a surgical services representative, and the anesthesia/or scheduling clerk. Fifteen months after initial use began, eight surgeons from five departments were using the system to perform procedures. Initially, staff members from many different departments were given coordinating responsibility for portions of the robotics program. As more surgeons from an increasing variety of surgical specialties began to use the system, this proved inefficient and cumbersome so responsibility for coordinating the robotic surgical system program was transitioned to a new robotics nurse specialist, an RN clinician. This nurse was hired to serve as a resource person for questions and to assist with problem solving. The nurse also provides patient education, staff member training and orientation, and equipment and instrument coordination and care. DEVELOPING THE ROLE OF ROBOTICS NURSE SPECIALIST The high start-up costs, time commitments, and knowledge required to efficiently handle medical robotic equipment and supplies often makes it beneficial for facilities to consider implementing the role of robotics nurse specialist, particularly if surgeons from multiple specialties will be using the robotic system. Having one person coordinate this effort allows the surgeons and staff members the time to focus on this technology and develop the level of expertise necessary to optimize use of the system. A robotics nurse specialist can build a comprehensive picture of how, why, and when a system is being used. This allows for accurate decisions to be made on how equipment, instruments, and supplies 636 AORN JOURNAL

8 MARCH 2006, VOL 83, NO 3 TABLE 3 Robotics Nurse Specialist Job Roles can best be configured for optimal use. Having the robotics nurse specialist consistently present in all procedures allows accurate assessments to be made of educational and resource needs of nursing personnel and problems with the robotic equipment and instruments to be sorted out faster and with more accuracy. By reviewing daily scheduling patterns and conflicts, the robotics specialist can bring observations and concerns to the proper staff members to seek resolution. A robotics nurse specialist is the ideal person to develop a database of procedure times, type of procedures by service, and other factors. The goal of the MIS and robotic surgery program at UIHC is to use experts in clinical practice, education, and research to promote further development of MIS and robotic surgery in laparoscopic and thoracoscopic procedures to achieve the best possible patient care. The job description written for the robotics nurse specialist position designated the role to be a clinical expert and care coordinator for patients undergoing robotically assisted surgery. Duties and responsibilities were divided into five areas: clinical practice, education, administration, research, and professional (Table 3). The robotics nurse specialist coordinates scheduling, ensures instrument availability and care, assists intraoperatively with all robotic procedures, provides patient and staff member education, and assists with research efforts. Preparation for the job of robotics specialist should begin with a literature review regarding the technical, financial, and ethical aspects of medical robotics. In the future, a robotics nurse specialist will need to be a clinical expert Areas of practice Clinical Practice Education Administration Research Professional Specific roles Acts as care coordinator Provides direct patient care Provides clinical expertise Orients and trains nursing personnel Trains and mentors health care students Enlightens lay public Acts as liaison within institution Acts as liaison to manufacturer Acts as liaison outside institution with lay public and outside health care professionals Participates in data gathering Participates in data management Ensures data dissemination Maintains clinical expertise and professional skills Develops and engages in management and consultant skills in general medical robotics, not just one robotic system. The role of robotics nurse specialist is both challenging and exciting because the technology is so new and the role is open to interpretation and definition by those currently in such roles. The ability to help shape the future is a rewarding opportunity for perioperative nurses ready for a challenge. Currently, flexibility is a key component of robotic procedures because medical robotics is an evolving technology, and often, the surgeon is refining which techniques and instruments will provide the best outcome for his or her patients. Nurses must be prepared and competent to meet the changing needs of patients undergoing robotic surgery (Table 4). The robotics nurse specialist can achieve expertise by seeking opportunities to closely observe robotic procedures and consulting robotics experts, such as manufacturers representatives, visiting surgeons who are proctoring procedures, and health care providers AORN JOURNAL 637

9 MARCH 2006, VOL 83, NO 3 TABLE 4 General Competencies for a Perioperative Robotics Nurse Specialist Demonstrates expertise in minimally invasive surgery. Demonstrates expertise in robotic surgery. Demonstrates expertise in perioperative nursing (eg, three-years perioperative experience, multiplespecialty training, CNOR preferred). Demonstrates basic knowledge of data collection, research approaches, and protocol types. Demonstrates reasonable proficiency in basic computer software applications. Serves as an excellent role model and provides leadership for staff members. Demonstrates self direction with excellent prioritization skills. Assumes responsibility for and engages in activities that develop and maintain clinical expertise and professional skills. at other facilities where a surgical robotic system is used. The robotics specialist should continually seek additional educational experiences by searching the Internet and networking with colleagues. He or she should request instructional material and learning opportunities from the manufacturer of the robotic surgical system being used. The evolving nature of this technology means that even experts must work to maintain a current level of expertise. Coordinating a robotics program requires constant prioritizing. Decisions are influenced not only by what the robotics nurse specialist sees as valuable for excellent patient care but by the needs of surgeons using the system; the perioperative nursing staff members; and the central sterilizing department, hospital marketing department, and procedure scheduling personnel. The ultimate factor in prioritizing daily activities always is patient safety and optimal surgical outcomes. CLINICAL PRACTICE A robotics nurse specialist must maintain the skills necessary to provide high quality patient care in the OR. By keeping OR skills up to date, a robotics specialist can serve as a good role model and be flexible enough to assist during staff shortages. Being able to function in both the circulating and scrub roles allows the robotics nurse specialist to more effectively assess how the robotic equipment, instruments, and supplies can best be used. It also provides a solid base from which to understand and address staff member suggestions or concerns. A robotics nurse specialist can enhance patient care outside the OR by contributing to the development and dissemination of educational materials available for patients and educational sessions available to staff members who are interacting with patients in clinic areas and on patient care units. The robotics specialist is a point of contact who can supply accurate and timely information to help educate the lay public and health care professionals regarding robotic services offered by the facility. The robotics specialist makes networking contacts within the facility to increase staff member awareness about the robotics specialist role. Establishing a good general medical robotic system background provides the robotics specialist with the knowledge to troubleshoot the system being used and not just follow a series of setup instructions. A robotic surgical system is an intricate piece of medical equipment that is treated somewhat like a medical-grade laser because of its complexity. It requires knowledgeable health care personnel to set it up, run it, and solve problems that arise. Only oriented staff members are assigned to these procedures. ROBOTIC INSTRUMENT AND SUPPLY CARTS. Assembling a cart to contain all needed robotic instruments and supplies helps maintain flexibility in the OR and enhances cost effectiveness (Figures 1 and 2). The primary supply cart is stationed outside the OR for every procedure. This 638 AORN JOURNAL

10 MARCH 2006, VOL 83, NO 3 Figure 1 The primary robotic instrument and supply cart is stationed outside the OR for every procedure. allows a procedure to start with only the essential instruments and supplies, after which extra items can be added in a timely manner if needed. Robotic instruments are different from laparoscopic instruments and require special care (Figure 3). Initially, the instruments can be sterilized individually. Robotic instruments should be irrigated on the sterile field through the manufacturer s designated ports when tissue or bodily fluids build up and before being sent for terminal cleaning and sterilization. This avoids lengthy terminal cleaning because of dried contamination buildup. At UIHC, instruments are placed in an ultrasonic cleaning machine, which uses suction to pull cleaning solution through the ports. A thorough cleaning by hand before placing the instrument in the ultrasonic machine removes gross debris on the outside of the instrument. The robotics nurse specialist gathers data regarding the frequency of use of each instrument by different surgeons during different procedures. Then, the individual instruments can be arranged in trays based on this data. The robotics nurse specialist is the logical individual to gather, assess, and implement changes in instruments and supplies based on usage data across all users of the robotic system. One tray containing six of the instruments most frequently used by all specialties and a second tray of lesser-used and back-up instruments was created at UIHC. Seldom-used instruments are sterilized separately and are accessible on the cart outside the OR for every procedure. At UIHC, introducing smaller-sized pediatric robotic instruments (ie, 5 mm versus 8 mm) increased the need for accurate organization. It became necessary to establish a replacement system so that a smaller inventory of robotic instruments could be maintained because of the high cost of maintaining a large inventory. Communication between perioperative nursing staff members, the robotics nurse specialist and central sterilizing department personnel Figure 2 The backup robotics supply cart contains a minimal number of extra robotic instruments and supplies that can be accessed in a timely manner if needed. AORN JOURNAL 639

11 MARCH 2006, VOL 83, NO 3 Figure 3 The wrists of robotic instrument have seven degrees of freedom of movement rather than the four degrees of traditional laparoscopic instruments. record this information anywhere. Perioperative personnel, therefore, are responsible for tracking the lives (ie, number of times an instrument still can be used) of each instrument. A robotics specialist can help staff members track the lives of each instrument. In addition to using the information communicated by the robotic surgical system on each instrument s remaining uses, staff members can write on the instrument with an indelible marker approved for surgical use to alert the next scrub person when the instrument needs to be discarded. Some facilities maintain a written log of use for each instrument. This log should document the name and type of instrument, serial number of the instrument, the number of uses remaining for the instrument, and the date the instrument was used last. It also would be helpful to record any complaints about the instrument or difficulty in using it. The effectiveness of the log is dependent on staff member compliance. EDUCATION Figure 4 A robotics nurse specialist can provide thorough and consistent training of staff members. is crucial to implement a minimal but adequate inventory system. MARKING REPOSABLE INSTRUMENTS VERSUS MAINTAINING A LOG. The robotic instruments used at UIHC are reposable so they only can be used a predetermined number of times. The robotic system tracks how many times a particular instrument has been used but does not 640 AORN JOURNAL Well-trained staff members are as important as the equipment and instruments needed when starting a robotic surgery program.14 A large part of the robotics nurse specialist s role is orienting new personnel, training existing personnel, and ensuring completion of competencies for all staff members; as well as assisting in setting up educational opportunities for medical residents, fellows, and staff surgeons (Figure 4). To prevent user error and rapidly recognize device failure, all health care team members must thoroughly understand robotic surgery and their role in the procedure ORIENTATION OF PERSONNEL NEW TO ROBOTIC SURGERY. A robotics nurse specialist should ensure complete and accurate orientation and training of nursing

12 MARCH 2006, VOL 83, NO 3 Practice sessions simulating procedure setup can help facilities that only perform a small number of procedures adequately train and maintain staff member skills. staff members to robotic procedures. Achieving competency requires time and repeated participation in robotic procedures. 15 Establishing a thorough basic foundation of robotic technology can make orientation to the robotic system in the OR more meaningful for staff members. Training while setting up for a procedure is possible, but places a time constraint on staff members that often is not conducive to learning. It is best that first-time exposure of staff members to robotic procedures be conducted in a learning environment versus a real-time surgical procedure. Orientation is best accomplished oneon-one so that staff members have hands-on experience. New staff members then can be paired with more experienced staff members during an actual procedure. This approach provides an opportunity to answer questions and correct the technique of the orientee. MAINTAINING COMPETENCY IN ROBOTIC SURGERY. Competencies for robotics nursing staff members at UIHC were designed by the robotics specialist in collaboration with the perioperative educator. Initially, many UIHC staff members were sent for training by the manufacturer of one robotic system, and copies of the training certificates are maintained in their personnel files. On-site training is becoming necessary, however, because of budget and time constraints, as well as a lack of assistive staff member training opportunities. A robotics nurse specialist can provide consistency in the material taught and current expertise in developing and assessing competencies. Yearly competencies can be used to provide refresher training for staff members, as well as document critical education provided. Competencies should include safely and accurately moving, connecting, and plugging in the system; setting up the appropriate camera and instruments; performing necessary equipment checks; properly cleaning and sterilizing instruments; loading instruments on robotic arms; interpreting robotic system messages; and demonstrating understanding of emergency procedures (Table 5). PROVIDING EXPERIENTIAL OPPORTUNITIES. Currently, the small number of procedures performed at many facilities makes it difficult to provide enough experiences to adequately train and maintain OR staff members skills. To address this problem, one-on-one reorientation sessions with staff members can be implemented as time allows. Practice sessions for two staff members that simulate setting up for a procedure also are beneficial in helping staff members maintain skills. Specific needs for each staff member should be documented and identified. Staff members also should be asked to identify what they perceive their training needs to be. Having a robotics nurse specialist in all procedures places one person in a position to assess staff members learning needs and create a foundation for developing resource materials and orientation modules. ESTABLISHING REFERENCE MATERIALS. It is essential to provide good reference materials for staff members because the number of robotic procedures may not be adequate to maintain a sufficient number of staff members expertly oriented to these procedures to cover for various staffing needs (eg, vacations, illnesses). It may be necessary for robotics-trained staff members to cross train so they are comfortable working in several services or specialties. This makes it very important to have staff members trained with a good basic robotics background and good reference materials readily available for them so that they will be able AORN JOURNAL 641

13 MARCH 2006, VOL 83, NO 3 TABLE 5 Robotics Surgical System Staff Member Competency Form Purpose The purpose of the surgical robotic system competency session is to 1. validate, through a trained observer, the ability to perform/respond to required competencies; 2. demonstrate psychomotor competencies; 3. maintain currency of staff member records; 4. assure compliance with professional and accreditation standards; and 5. provide assessment of staff members for minimal level skills that ensure patient safety. Target audience Perioperative division staff members who have completed hospital orientation to robotic surgery. Directions for completion of robotic competencies Please read the instructions carefully. 1. Prepare/study the targeted competency for the surgical robotic system. 2. The skills and techniques included in this handout are mandatory. You will be required to answer questions and perform the critical elements of each skill or technique. 3. Met indicates that the staff member has successfully completed that portion of the skill. Not met indicates that the staff member must have remedial training in order to complete the skill. 4. Return completed handout to (robotics nurse specialist). Staff member name: Date: Critical elements General Met Not met Describes moving all three robotic system components in and out of storage properly and covering console and surgical arm cart. Demonstrates plugging in all electrical parts of robotic system appropriately. Demonstrates connecting three components of robotic system to each other correctly and verifies correct camera attached. Powers up system and demonstrates how to verify correct system settings. Correctly homes the robotic system. Folds robotic surgical arm cart in a manner that protects the system. Correctly powers down the system after verifying instrument use. Completes robotic surgical system competency test, scoring 85% or better. Instrumentation Met Not met Correctly inputs proper camera into system. Demonstrates proper draping of surgical arm cart and telescope/camera system. Successfully completes calibration of telescopes. Verbally identifies proper method of cleaning and irrigating robotic instruments and locates sterilization instructions in ORs and robotic book. Demonstrates proper placement and removal of instruments on robotic system. Verbalizes correct interpretation of robotic icons. Identifies location of emergency wrenches, application for use, and method of use in emergency. Verbally identifies emergency situations of power loss or nonrecoverable fault and corrective actions of stabilizing instruments, removing instruments, and pulling system back. Verbally identifies location of robotic resources and proper resource personnel from hospital and manufacturer. Staff member signature: Competency assessor signature: Reprinted with permission from University of Iowa Hospitals and Clinics, Iowa City. 642 AORN JOURNAL

14 MARCH 2006, VOL 83, NO 3 Robotic set-up guides, designed to stand alone or be used with existing surgeon preference cards, provide details about room setup, equipment, instruments, and patient positioning. to apply their training when working in procedures that are not in their specialty service. DEVELOPING ROBOTIC SET-UP GUIDES. At UIHC, a robotic set-up guide is used that details which tray and specific instruments should be added to the sterile field for each particular procedure (Table 6). This configuration reduces the cost of resterilizing robotic instruments that are not used or are seldom used. It also decreases the workload on central sterilization department personnel and unnecessary wear and tear on the robotic instruments. Wrapping and sterilizing the zero-degree and 30-degree 12-mm telescopes separately also allows for greater flexibility while keeping costs down. This robotic set-up guide also can provide information on patient positioning, which is similar to positioning for laparoscopic procedures, but occasionally has significant differences. Some surgeons turn the OR bed and position the patient to meet the surgical robotic arms; others position the robotic arms in the room differently for each procedure. When positioning the OR bed and patient, the circulating nurse must account for factors such as overhead lights that could hamper placement of the robotic arms. Furthermore, some surgeons use eggcrate foam padding underneath infants and small children. These guides can be designed to stand alone or to be used to enhance existing surgeon preference cards or care plans. At UIHC, the robotic set-up guides are used to enhance existing care plans that cover needed equipment, instruments, and supplies for the procedure in addition to items needed to convert to an open procedure, if necessary. The robotic set-up guide diagrams the robotic surgical system placement in relation to all other OR equipment. Other facilities are using digital images instead of diagrams. This information also can be useful for anesthesia, perfusion, and radiology personnel. The robotic set-up guide details patient positioning, robotic instruments needed, instruments to have available but not open, sutures for the robotics portion of the procedure, and miscellaneous items of importance. These guides are kept in a robotics reference manual; which is kept with the robotic surgical system. Thus, it is readily available for review the day before, morning of, and during every procedure. The robotics specialist can place reminders strategically on equipment in the OR and also in a centrally located robotics reference manual to assist nursing staff members with procedures on handling instruments and equipment by clarifying some of the specific details of setting up a robotic system. Examples of resources are pictures of how to store the robotic equipment for maximum protection from damage, labels demonstrating where cables should be plugged into monitors and recording devices, reminders to black balance cameras before white balancing, and a set-up procedure list with pictures. Feedback received from staff members at UIHC indicates that these reminders have been helpful. The robotics nurse specialist also can make significant contributions to peer education on robotic technology by providing lectures at continuing education 644 AORN JOURNAL

15 MARCH 2006, VOL 83, NO 3 electrosurgical unit and suction Mayo stand surgeon console vision cart back table Port sites Port #1: 5-mm accessory port Port #2: 12-mm port centered above the patient s umbilicus a minimum of 18 cm from the pubus for the telescope Port #3: 5-mm accessory port, if needed, for extra retraction Port #4: 12-mm port with 5-mm reducer cap to accommodate laparoscopic stapler Port #5: 8-mm robotic port Port #6: 8-mm robotic port TABLE 6 Robotic Set-up Guide for Prostatectomy anesthesia machine overhead instrument table port #1 port #2 port #3 port #4 port #5 port #6 robotic voice-control center robotic surgical arm cart Mayo stand Mayo stand gowning table 0-degree and 30-degree endoscopes Basic robotic instrument tray Robotic accessory tray Positioning Tape mattress to frame of split-leg OR bed to prevent sliding when in Trendelenburg position. Place patient supine on OR bed. Tuck patient s arms at his or her sides. Place temperature-regulating blanket on patient s upper body. Place bed in reverse Trendelenburg; lower bed before bringing in robotic arms. After prepping and draping, move Mayo stand over patient s head to protect from camera arm. Suture 0-polyglactin with a medium-sized cuttingtaper needle for ligating the dorsal vein complex; cut 6 inches long and flatten needle; have ready for emergency use during stapling of dorsal vein complex. 3-0 polyglactin with small-medium taper needle; cut 5 inches long for oversewing bulldog clamps on pedicles. 3-0 poliglecaprone with small taper needle (ie, one each dyed and undyed), which are tied together with tissue bolster. Robotic instruments Bifurcated light-cable tray Bipolar electrocautery tray Stapler with special port Starts with 30-degree endoscope, robotic bipolar forceps, monopolar spatula electrocautery, round-tip scissors, and two large needle drivers. Notes Open the following items. Extra-long laparoscopy suction/irrigation tip Bulldog clamps and appliers Put 1,000 units (ie, 1 ml of 1:1,000) heparin in 1,000 ml bag of normal saline (NS) (ie, 1 unit heparin/1 ml NS). Have suture boots ready to place on a curved grasper or fine dissector for retraction during urethral anastomosis. Have the following available in the room. Hemostatic agent and applicator Endoscopic-laparoscopic pouch Ligature clips/appliers for nonnerve-sparing procedures. Reprinted with permission from University of Iowa Hospitals and Clinics, Iowa City. AORN JOURNAL 645

16 MARCH 2006, VOL 83, NO 3 A robotics nurse specialist can help clinical outcomes and resource management personnel identify areas of patient care that are being performed at high levels and those that need improvement. seminars. The robotics specialist can provide demonstrations and practice sessions to assist in educating medical students, law students, and surgical residents and fellows on the benefits and risks of a robotic surgical system. A robotics specialists can facilitate sessions with fellows, staff surgeons, and visiting surgeons demonstrating setup and basic use of a robotic surgical system, in addition to practice sessions for suturing and dissection. This person can maintain a library of robotics literature, procedure videotapes, facility-specific procedure information, and references that can be used by surgeons for lectures and educational purposes and by nursing personnel for education and training purposes. ADMINISTRATIVE A robotics nurse specialist can provide a facility with patient lists or identification codes. Clinical outcomes and resource management personnel can use these to assess areas of patient care being performed at a high level and areas that need improvement. CLINICAL LIAISON. It is advisable to designate a specific person to act as the clinical liaison who is the designated point of contact at each facility for the manufacturer regarding the robotic system. The robotics nurse specialist is the ideal person to assume this responsibility, especially if a service agreement has been purchased. The service agreement is a contract between manufacturer and facility that covers replacing defective or malfunctioning parts, providing preventative maintenance of system, and providing software updates for safety and reliability. The role of liaison is one that a robotics nurse specialist easily can fulfill because he or she interacts with surgeons, nurses, anesthesia care providers, central sterilizing department staff members, patients, patients family members, hospital marketing staff members, the lay public, the manufacturer, and other health care facilities. The robotics specialist must keep in mind at all times that he or she represents the best interests of both patients and the facility. The robotics specialist also must understand the needs of the manufacturer and act as mediator to facilitate positive outcomes when conflict arises. As liaison between the owning facility and the manufacturing company, the robotics specialist can ensure that communication between the manufacturer and facility is accurate and timely. The robotics specialist can provide consistency in communication, maintenance, and problem solving with the manufacturer. By practicing good, thorough communication, the robotics specialist can help prevent the splintering of information between clinical, business, public relations, and education departments. A robotic specialist also can be a resource and liaison for public relations and marketing personnel at the facility. Coordinating equipment for photography sessions, providing accurate details regarding procedures and users of the surgical system, and assisting with or speaking at educational seminars are all activities a robotic specialist can do to work as a partner with public relations and marketing personnel. AVOIDING SCHEDULING CONFLICTS. A robotics nurse specialist can use his or her overall understanding of how the system is being used to help troubleshoot and prevent scheduling conflicts and identify scheduling changes that will ensure the most effect use of the system. As the number of surgeons who are using a particular system at a facility increases, it becomes necessary to have an efficient 646 AORN JOURNAL

17 MARCH 2006, VOL 83, NO 3 system in place so use of OR time can be maximized. The facility s robotic surgical system should be used as much as possible, but unless a facility owns more than one system, it can be a challenge to coordinate available OR time with requested OR time. To help maximize use, the robotics specialist ensures that a facility can take advantage of time when surgeons are unavailable (eg, vacation) or their assigned OR time is fully scheduled with nonrobotic procedures. Effective communication also can enable a facility to overcome the fact that not every OR will be physically conducive to optimal use of a robotic surgery system. These systems take up much more space than typical pieces of OR equipment and are used most effectively in an OR endoscopy suite. RESEARCH The area of surgical robotics medical research has scarcely been touched. Research must be performed to determine the ability of robotics to positively affect patient surgical outcomes for various procedures and the cost effectiveness of using robotics instead of traditional approaches. A meaningful database needs to be established and examined that includes blood loss, complication rates, length of hospital or intensive care stays, operating times, postoperative pain, and time to return of activities of daily living. Procedure specific outcomes (eg, continence rates after prostatectomy) also should be studied. A robotics nurse specialist can gather data on surgical times, instruments used, problems that were corrected, practices that worked well, and patient and procedure lists. This information can be shared with surgeons, the clinical outcomes and public relations departments, and hospital administrative personnel to help promote and improve the surgical robotics program. As this basic research on patient specific outcomes is being performed, robotic technology s continuing evolution will necessitate additional research. In addition to research on patient-specific outcomes, research on new robotic surgical technology and improvements on existing robotic surgical technology will be needed. PROFESSIONAL Being an expert in a specialty field such as robotics requires an individual to take advantage of any opportunities to increase his or her clinical expertise and to develop leadership, team building, and facilitating skills. Nurses currently trained in robotic surgery have prime opportunities to step into leadership roles at their facilities. Some may choose the formal role of leader, and others will lead by example. Development of a national network of robotics nurse experts to share ideas and define nursing roles in highly technical ORs should be considered. Nurses currently in robotics nurse specialist roles should begin networking locally with one another in order to start establishing a national network. FUTURE PLANS The role of the robotics nurse specialist must evolve with the status of the program within which he or she works. It is important that the robotics specialist maintains a high level of expertise as the Nurses trained in robotic surgery have prime opportunities to step into leadership roles at their facilities. Some may choose the formal role of leader, and others will lead by example. AORN JOURNAL 649