SETTING UP A ROBOTIC SPECIALITY- A NURSING PERSPECTIVE Peta Barnes ANUM Robotics Epworth Freemasons VPNG Presentation 2017
FOCUS ON YOUR GOAL. DON T LOOK IN ANY DIRECTION BUT AHEAD AUDIENCE KNOWLEDGE WHO? WHAT? WHY?
Definition CONTENT History & Model Development & Pros & Cons Epworth HealthCare Impact & Stats & Surgical Specialities Success Vital components- WHAT WE GOT RIGHT! Role of Robotic ANUM ROOM FOR IMPROVEMENT- WHAT REMAINS A CHALLENGE! Training Component Clinical Governance-Robot Register & Inventory Management Team Development & Challenges Robot Register & Inventory Management
Robotic Surgery using the da Vinci Robotic Surgical System is a unique minimally invasive alternative to open and laparoscopic surgery - New and Improved Laparoscopy approach DEFINITION OF ROBOTIC SURGERY
ROBOTIC DEVELOPMENT TIME LINE
KNOWN BENEFITS
Advantages Mechanical advantages over traditional laparoscopy.-enhanced visualisation- 3D & HD Stabilization of instruments within the sterile field-tremor reduction. Improved identification of tissue planes & blood vessels Better ergonomics & motion scaling. Less tissue trauma Reduced blood loss- Less transfusions rates Reduced postoperative pain Fewer postoperative complications Shorter recovery time & hospital stays (Zender and Thell 2010) Disadvantages High capital acquisition cost Instrumentation cost-current instruments are limited to a fixed number of uses, unrelated to instrument wear. Equipment maintenance, servicing and repair Large robot & console size make placement adjustments challenging Operating room time- multiple variables: Room setup time draping, docking, procedure time, room turnover time, patient selection Lack of haptics (force feedback) Mechanical Risks Problems with multi quadrant surgery(si-typical for single quadrant application- Xi multi quadrant) Training Issues-Motivation of staff that are not technically minded. Lack of outcome data Research THE NEW THE OLD
DVSR developed in 1980 by Intuitive Surgical Inc. through research by DARPA in the USA Approved for the use of Lap Surgery by the FDA in the USA in July 2000 Since 1995 Intuitive Surgical have updated the robot 3 times This gives an indication of how rapidly robotic surgery is growing QUICK HISTORY LESSON:
Standard S Robot Si Robot ALWAYS IMPROVING..
ADVANTAGES FOR OPERATING ROOM NURSES PROVIDES BETTER VISUALIZATION IN VISION CART MAKING SURGERY FOR US AS CLINICIANS EASIER AND CLEAR ALLOWS US TO HAVE MORE EXPERIENCE OF NEW TECHNOLOGIES AND ROLES MOREOVER WE CAN ESTABLISH TERRITORY AS CLINICAL EXPERTS AND EXPAND OUR ROLES AS PROFESSIONAL NURSES.
SINCE ITS INTRODUCTION IN 2001 EPWORTH HEALTHCARE UTILIZATION OF ROBOTIC SURGERY HAS EXPANDING IN ALL SURGICAL FIELDS AND SPECIALITIES Urology Gynaecology Cardiac Thoracic Colorectal Hepatobiliary
ESTABLISHED EXPERTS TEAM BUILDING ESTABLISHED EXPERTS BUILD RESOURSES AND IMPROVE EXPERTISE
Epworth HealthCare is an Australian leader in robotic surgery. Pioneered the use of da Vinci robotic system in 2003 for the first robotic-assisted radical prostatectomy in Australia at Epworth Richmond. Epworth is the busiest centre of robotic surgery in Australia. Over 4,000 surgical procedures have been performed using our robots. More than 40 Epworth-accredited surgeons are trained to operate them. The Epworth Centre for Robotic Surgery is also committed to ongoing research. Epworth s surgeons have presented multiple scientific papers and published internationally documenting the Epworth experience. The Australian Prostate Cancer Research Centre is also based at Epworth. Firsts at Epworth in Australia: First radical prostatectomy First radical cystectomy First cardiac surgery First hysterectomy First hospital in Australia to install a dual-console robot for training WHY? EPWORTH HEALTHCARE ROBOTICS
ESTABLISHED EXPERTS To date, since its commencement in mid 2011 Surgeons at Epworth Freemasons have completed 2,222 da Vinci procedures covering Gynaecology Urology Thoracic and General surgery.
WHAT WAS REQUIRED TO ESTABLISH SUCCESS? Role of a Robotic Nurse Co-ordinator (ANUM) TEAM Selection: Scrub/Scout/Anaesthetic/Technician Surgeon Support Senior Management Support De Vice Technologies Representatives.
WHAT WE GOT RIGHT ANUM Role Training & Education & DRY RUNS Instrumentation Trays Fad Cards Robot Register- Inventory Management CMBS Coding Competency Tool Clinical Governance Patient Safety
DUTIES OF ROBOTIC NURSE COORDINATOR
LEADERSHIP TEAM WORK INNOVATION & DRY RUNS EDUCATION & TRAINING- (Start ups & Ongoing) SELF REFLECTION VITAL ANUM COMPONENTS:
1ST STEP EDUCATION & TRAINING DA VINCI SURGERY COMMUNITY WEBSITE Assess to online surgical website videos Up to date research Support material Online conferences Seminars mock theatre setups
2 ND STEP DEVELOPMENT OF ROBOTIC TRAINING PROGRESSION Intuitive Surgical On Line Training Modules through the DA Vinci Surgery community website are completed - Certificate Completion Printed & filed. Intensive OR training of 4-6weeks Double Scrubs minimum x 3 Double Scout minimum x 2 Anaesthetic Staff minimum x 2 Theatre Technician minimum x 4 Robotic Competency Tool Assessment to be done Feedback provided & documented Competency signed off & filed
3 RD STEP: ROBOTIC REGISTER & INVENTORY MANAGEMENT ROBOT REGISTER GYNAE ROBOT REGISTER - UROLOGY ROBOT REGISTER GENERAL/THORACIC DATE: Case No: Surgical Procedure: PATIENT IDENTIFICATION LABEL: DATE: Case No: Surgical Procedure: PATIENT IDENTIFICATION LABEL: DATE: Case No: Surgical Procedure: PATIENT IDENTIFICATION LABEL: Surgeon: Surgical Assistant: Anaesthetist: Anaesthetic Nurse: Scrub Nurse: Scout Nurse: Theatre Technician: Starting at Console: Finishing at Console: Total Console Time: THEATRE STAFF PRESENT SURGICAL CONSOLE TIMES ROBOT SCOPE NUMBERS: (please circle which tray used) Setup Commenced: Setup Finished: Total Setup Time: Robot Docking Start: Robot Docking Done: Total Docking Time: Undock Robot: Case Completion time: TIMES Coding Documentation Complete: 30 Scope: SN:SF 1704507 SN:SF 1625514 SN:SF 1639531 Tray 1: Tray 2: Tray 3: 0 Scope: SN:SF 1639502 SN:SF 0948118 SN:SF 1639503 Scope Inspection: 0 Scope: Before surgery: Scrub sign off: 0 Scope: Post surgery: Scout sign off: 30 Scope: Before surgery: Scrub sign off: 30 Scope: Post surgery: Scout sign off: ROBOTIC ENDOWRIST INSTRUMENTS- NUMBER OF USES LEFT: MARCUS TRAY1 TRAY 2 THOMAS JOBLING TRAY:1 CAREY TRAYS BLUE GREEN TRAYS YELLOW Monopolar Curved Scissors Monopolar Curved Scissors Mega Suturecut Needle Driver Mega Needle Driver Fenestrated Bi-polar 1.Convert to Open/Lap: 2.Inventory Management Completed: Prograsp Forceps Mega Needle driver Cobra Grasper PK Dissecting Forceps PK Cord TRAY: 2 GREEN SINGLE PEEL ITEMS Cobra Grasper Round Tip Scissors Tenaculum Forceps Long Tip Forceps Permanent Cautery Spatula Fenestrated Bi-polar Forceps Mega Needle Driver Mega Suturecut Needle Driver Potts Scissors Surgeon: Surgical Assistant: Anaesthetist: Anaesthetic Nurse: Scrub Nurse: Scout Nurse: Theatre Technician: Starting at Console: Finishing at Console: Total Console Time: THEATRE STAFF PRESENT SURGICAL CONSOLE TIMES Setup Commenced: Setup Finished: Total Setup Time: Robot Docking Start: Robot Docking Complete: Total Docking Time: Undock Robot: Case Completion time: TIMES Coding Documentation Completed: ROBOT SCOPE NUMBERS: (please circle which tray used) 30 Scope: SN:SF 1704507 SN:SF 1625514 SN:SF 1639531 Tray 1: Tray 2: Tray 3: 0 Scope: SN:SF 1639502 SN:SF 0948118 SN:SF 1639503 Scope Inspection: 0 Scope: Before surgery: Scrub sign off: 0 Scope: Post surgery: Scout sign off: 30 Scope: Before surgery: Scrub sign off: 30 Scope: Post surgery: Scout sign off: ROBOTIC ENDOWRIST INSTRUMENTS- NUMBER OF USES LEFT: TRAY 1 TRAY 2 TRAY 3 INSTRUMENT USED YELLOW BLUE GREEN Large Clip Applicator Monopolar Curved Scissors Prograsp Forceps Maryland Bipolar Forceps Large Needle Driver 1 Large Needle Driver 2 PK Dissecting Forceps PK Cord 1.Inventory management Completed: SINGLE STERI- PEEL ITEMS Cobra Grasper Round Tip Scissors Tenaculum Forceps Long Tip Forceps Permanent Cautery Spatula Fenestrated Bi-polar Forceps Mega Needle Driver Mega Suture cut Needle Driver Cadiere Forceps PK Cord 2. Revert to Open or Lap: Potts Scissors 3. Riskman completed: Black Diamond Micro Forceps Surgeon: Surgical Assistant: Anaesthetist: Anaesthetic Nurse: Scrub Nurse: Scout Nurse: Theatre Technician: Starting at Console: Finishing at Console: Total Console Time: THEATRE STAFF PRESENT SURGICAL CONSOLE TIMES Setup Commenced: Setup Finished: Total Setup Time: Robot Docking Start: Robot Docking Complete: Total Docking Time: Undock Robot: Case Completion time: TIMES Coding Documentation Completed: ROBOT SCOPE NUMBERS: (please circle which tray used) 30 Scope: SN:SF 1704507 SN:SF 1625514 SN:SF 1639531 0 Scope: Tray 1: SN:SF 1639502 Tray 2: SN:SF 0948118 Tray 3: SN:SF 1639503 Scope Inspection: 0 Scope: Before surgery: Scrub sign off: 0 Scope: Post surgery: Scout sign off: 30 Scope: Before surgery: Scrub sign off: 30 Scope: Post surgery: Scout sign off: ROBOTIC ENDOWRIST INSTRUMENTS- NUMBER OF USES LEFT: Barnett/Wright INSTRUMENT USED THORACIC TRAY 1 Large Clip Applicator Monopolar Curved Scissors Permanent Cautery Spatula Fenestrated Bi-polar Forceps 1.Inventory management Completed: 2. Revert to Open or Lap: 3. Riskman completed: SINGLE STERI- PEEL ITEMS USED Cadiere Forceps Maryland Bipolar Forceps Prograsp Forceps
DRY RUNS ALLOCATION TIME & CO- ORDINATION
Epworth Freemasons Hospital da Vinci SI Critical Elements Identifies: 1) Location of emergency wrenches 2) Application of use of emergency wrenches 3) Method of use in emergency Verbally identifies: 1) Emergency situations of power Loss or non-recoverable fault 2) Corrective actions of stabilizing Verbalize and demonstrate steps to preparing system to power off including patient cart storage. Successfully power system off. Demonstrate Patient Robotic Register documentation for case specialty Demonstrates Case RAS Coding Documentation accurately for 4ARMS= RAS4 Demonstrates Case RAS Coding Documentation accurately for 3ARMS= RAS Date/ Initial CORE COMPETENCY CHECKLIST RN s and DIV 2`s and OR Technician Program Name: Robotics davinci SI (Core Competency Training) Staff member name: da Vinci SI Critical Elements Successfully completes the Intuitive Online Training Tool for the da Vinci SI Surgical System Demonstrates plugging in all electrical parts of robotic system correctly and connecting the three components of the robotic system appropriately Powers up system and demonstrates how to verify correct system settings Verifies that Camera and Camera Cables are Correctly attached. Can successfully complete White Balance and Calibration of both the 0 degree and 30 degree scopes. Can properly identify and demonstrate the use of the Patient Cart Arms, Port Clutch and Clutch buttons to position the cart for Draping, Docking and Loading of the instruments Demonstrates proper draping of patient cart arms and camera system Date/ Initial DEVELOPMENT OF A COMPETENCY TOOL Demonstrates and communicates OR room considerations necessary for successfully docking the system including overhead lights, patient positioning, room traffic and vision cart location Can identify, verbalize and demonstrate the importance of and the positioning for the Patient Cart Sweet Spot Demonstrates driving the patient cart for docking Can successfully dock a patient cart arm to a cannula/port Can verbalize proper pre insertion position for the Endowrist instruments. Demonstrates proper placement and removal of instruments on the robotic system including demonstration of the Guided Tool Change Can demonstrate usage of all vision cart monitor tabs. Ensure understanding of each. Can verbalize the location of robotic icons and their correct interpretation Can locate and override fault alarm. Can locate event logs Can locate da Vinci reference manual and da Vinci customer service phone numbers.
Unsettling Emotions: Explaining the vision Being Inclusive Honest Communication Unfamiliar Roles: Clear definitions Working with peoples strengths Different Environments: Liaising with different specialities Encouraging creativity & solutions EDUCATION CHALLENGES AND ACTION TAKEN:
Clinical Nursing Audits Regular 1 on1 Staff Reviews Documentation Compliance Robotic Register Documentation Inventory Management Compliance Robotic Scope Damage Audit Case Code Compliance Set Up Time Audits Procedure Time Records CLINICAL GOVERNANCE-
Lack of STANDARDS & GUIDELINES: Research & building networks- Robotic Workshop Interstate. Competencies and Guidelines devised. Time Restraints Teaching to Team and Individuals : Increase Staffing levels where possible. Encourage a supportive environment. Co-ordinating an unfamiliar list: Standardise practises re surgical sterile setups and surgical processes. Multi skilled team to confidently assist one another. CHALLENGES: Multidisciplinary team training for resuscitation: Ensure Patient quality care Empower nurses to feel confident and prepared during robotic surgery
MORE CHALLENGES Limited Robotic Research Early starts Late finishes Trouble shooting equipment Theatre room modifications Limited knowledge and skills Individual learning needs Liaising with different specialities Learning new processes Limited sharing of knowledge Economic competition in the Private Health Care System Developing a network of knowledge.
A FEW LESSONS LEARNT? Being a good role model as the ANUM is vital within your team. Fully understanding your role will ensure clear direction. Safe and efficient leadership is important. Be resilient your team will need you through the good times and the bad. Be supportive of new ideas- if you do not try you will never know. Keep challenging yourself and your team Be patient Implementing new technology and techniques takes time and patience.
REFERENCES: 1. Ali Abdel Reheem. (2017). Robotic nurse duties in the urology operative room:11 years experience. Asian Journal of Urology. 4 (4), 116-123. 2. Francis P. (2006). Evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role. AORN Journal. 83 (3), 629-650. 3. Haggag A. Robotic surgery: when technology meets surgical precision. Internet J Health. 2006:5(1). http:/www.ispub.com/ostia/index.php?xmlfilepath=journals/ijh/vol5nl/davinci.xml. (Accessed 08 July 2017) 4. Herron D M & Marohn M. (2008). A consensus document on robotic surgery. Surg Endosc. 22 (22), 313-325. 5. Intuiitive Surgical Inc. 2013 History of Da Vinci (Online) Available at: http://www.intuitivesurgical.com/company/history/ Assessed (03 July 2017) 6. Schrender H, Wolswikji R, Zweemer R, Schijven M, Verheijen R. Training and learning robotic surgery time for more structured approach: a systematic review. BJOG 2012:119:137-149. 7. Taylor.D.(March 2016). A Refection on the experiences of implementing gynaecology robotic surgery. Clinical Feature.26 (Issue 3),36-41. 8. Zender,J Thell,C. (July 2010). Developing a successful robotic program in a rural hospital. AORN Journal. 92 (No 1), 72-83.
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