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Setting up gynecological endoscopy services

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This presentation is about setting up Gynecological endoscopy services: the components, the challenges and finally achieving and sustaining excellence.

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Setting up gynecological endoscopy services

  1. 1. Setting up Gynec Endoscopy services
  2. 2. Thanks!  Organizing committee: AMASICON 2013  Dr. Asha Baxi  Dr Sunita Chouhan
  3. 3. Outline: the A,B,C,D,E…  Approach  Basic components  Challenges  Development  Excellence
  4. 4. Contemplation: John Wild Contemplation before surgery, by Joe Wilder
  5. 5. Surgeons: the modern day priests “We are the modern day priests – we prepare, we change to our holy garments, we bring patients to another world, and we change them.” Dr. Simpson, Your Doctors Orders.
  6. 6. So…  Surgeons: Modern day Priests  Operating rooms: Modern day temples  Patients : Our Gods  Surgery: Prayer
  7. 7. Setting up of surgical services is thus akin to making a temple, with careful consideration, faith, hard work and tireless effort. Hoping that amidst the multitude of units, it still finds its place, providing healing and solace to people and providing a haven of safety to their troubled bodies and souls.
  8. 8. Gynec Endoscopic procedures  Level 1: Diagnostic laparoscopy, tubal ligations  Level 2: Salpingectomy, adhesiolysis, cautery of minor endometriosis, myolysis, ovarian drilling  Level 3: oophorectomy, salpingostomy, surgery for pedunculated fibroids, moderate endometriosis  Level 4: Hysterectomy, Myomectomy, ovarian cystectomy(>8 cm), severe endometriosis
  9. 9. Hysteroscopy  Diagnostic  Operative: septum resection, polypectomy, myoma resection, foreign body removal, cannulation, TCRE
  10. 10.  Hysteroscopic procedures: office  Almost all laparoscopic surgeries except TL done in OR.  Hysteroscopic procedures: Different OR setup, skill set, instrumentation, anesthetic considerations
  11. 11. COMPONENTS
  12. 12. INFRASTRUCTURE Setting up Gynecological endoscopy services
  13. 13. Setting up: infrastructure STARS  Start up  Turnaround  Accelerated growth  Realignment  Sustaining success
  14. 14. Time and Money
  15. 15. Operating room Ancillary areas Instruments Equipment Misc: disposables, drugs INFRASTRUCTURE
  16. 16. Temples  Mandala  Lead from temporal world to eternal: progression from worldly to Divine  Innermost sanctum: Garbhagriha
  17. 17. Temple plan Sanctum
  18. 18. Operating rooms  Unsterile to sterile  Sterile lobby 1, sterile lobby 2  Operating room: ultrasterile area
  19. 19. 4 Sanctum
  20. 20. Modular Operating Rooms mod·u·lar (adj) .1. Of, relating to, or based on a module or modulus. 2. Designed with standardized units or dimensions, as for easy assembly and repair or flexible arrangement and use: modular furniture; modular homes.
  21. 21. Components  Prefabricated GI/SS panel shell  Hermetically sealing sliding doors  Laminar air flow  Pendants  Workstations  Others: scrub, surgeon control panel
  22. 22. Operating room Ancillary areas Instruments Equipment Misc: disposables, drugs INFRASTRUCTURE
  23. 23. One way!  One way changing room  One way flow of supplies into the OR and one way flow of soiled good outside the OR  Shared corridor for patients and staff  Sterile supplies delivered in OR from CSSD :separate corridor  Two designs: Double loaded corridor with substerile rooms and perimeter corridor with clean core
  24. 24. Perimeter corridor with clean core
  25. 25. Double loaded corridor design
  26. 26. Recovery area  Accessible from theatre and outside  1.5 spaces per OR  Space per trolley/bed 9 sq. meters  O2, suction, power, lighting  Communication lines  Scrub, nursing station
  27. 27. Operating room Ancillary areas Instruments Equipment Misc: disposables, drugs INFRASTRUCTURE
  28. 28. Equipment  Camera  Telescope  Monitor  Light source  Insufflator  Irrigation/suction system  Electrosurgical generator  Recording and archiving
  29. 29. Camera  Single chip: all three primary colors sensed by a single chip  Three chip: three sensors for red, green and blue SD camera: A 4:3 aspect ratio, 640 by 480 horizontal and vertical lines. HD camera: The HD format provides a 16:9 aspect ratio, 1280 by 720 horizontal and vertical lines. The 1080 HD standard also offers a 16:9 aspect ratio, but 1920 by 1080 horizontal and vertical lines-seven times the SD resolution at 480 lines.
  30. 30. Telescope  6 to 18 rod lens system telescopes are available  0 to 120 degree telescopes are available  1.5 mm to 15 mm of telescopes are available
  31. 31. Light source  Halogen  Xenon  LED
  32. 32. Insufflator  Steps down the pressure  Manual /electronic  Heated
  33. 33. Others  Suction irrigation systems  Electrosurgical generators  Recording and archiving
  34. 34. Instruments  Hand instruments  Specific: morcellator, endomat
  35. 35. What is ideal ?1 What is feasible ?2 What is viable?3
  36. 36. Justifying the costs  Sharing with other subspecialities  Developing a high throughput unit  Shared facility between different gynec endoscopic surgeons
  37. 37. MANPOWER Setting up Gynecological endoscopy services
  38. 38. The trinity
  39. 39.  Anesthetist: Father  Surgeon: son  Nurse: holy ghost! “He acts as Comforter, one who intercedes, or supports or acts as an advocate, particularly in times of trial. He acts to convince unredeemed persons both of the sinfulness of their actions and thoughts, and of their moral standing as sinners before God”
  40. 40.  Theatre: Camera person, assistant: two, scrub nurse, floor nurse  Recovery staff  Support staff
  41. 41. PATHWAYS Setting up Gynecological endoscopy services
  42. 42. “The best cars with the smartest drivers cant reach anywhere if there isn’t a road”
  43. 43. Clinical pathway: Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions.
  44. 44. Integrated clinical pathway An ICP aims to have...  the right people  doing the right things  in the right order  at the right time  in the right place  with the right outcome  all with attention to the patient experience
  45. 45. Pathways  Patient admission and preoperative workup  Discharge pathway  Dealing with readmissions  Thromboprophylaxis  Infection control
  46. 46. CHALLENGES Setting up Gynecological endoscopy services
  47. 47. Challenges  Infrastructure: maintenance and repair  Manpower: training, attrition, motivation  Pathways: non conformities, non compliance “ The real challenge is to keep growing, keep moving, slowly at times, but always forward”
  48. 48. DEVELOPMENT Setting up Gynecological endoscopy services
  49. 49. AIM  Safe  Sustainable  System driven  Successful Gynecological endoscopy unit
  50. 50. EXCELLENCE Setting up Gynecological endoscopy services
  51. 51. Key performance indicators  In-patient workload  Out-patient workload  Cancellation rates on day of surgery  Day of surgery add-on rates  Start time accuracy – first case of the day  Start time accuracy – subsequent cases  Estimated case duration  Turnover time in-patient
  52. 52.  Turnover time out-patient  Total case time in-patient  Total case time out-patient  Room utilization: 7:30 a.m.-3:15 p.m.  Surgeon satisfaction  Employee satisfaction  Cost per case (labor)  Cost per case (materials)  Cost per case (total)  Gross revenue per case
  53. 53. “Excellence is never an accident. It is always the result of high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives - choice, not chance, determines your destiny.”
  54. 54. “Magic lies in the magician, not in the wand”
  55. 55. The future OR (Sandberg et al, anesthesiology,2005)
  56. 56. A,B,C,D,E…  Approach: akin to constructing a temple  Basic components: infrastructure, manpower, pathways  Challenges  Development  Excellence: ongoing process
  57. 57. THANK YOU!

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