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Setting up Gynec Endoscopy services

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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Page 1: Setting up gynecological endoscopy services

Setting up Gynec Endoscopy services

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Thanks!

Organizing committee: AMASICON 2013 Dr. Asha Baxi Dr Sunita Chouhan

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Outline: the A,B,C,D,E…

Approach Basic components Challenges Development Excellence

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Contemplation: John Wild

Contemplation before surgery, by Joe Wilder

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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.

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So…

Surgeons: Modern day Priests Operating rooms: Modern day temples Patients : Our Gods Surgery: Prayer

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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.

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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

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Hysteroscopy

Diagnostic Operative: septum resection, polypectomy,

myoma resection, foreign body removal, cannulation, TCRE

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Hysteroscopic procedures: office Almost all laparoscopic surgeries except TL done

in OR. Hysteroscopic procedures: Different OR setup,

skill set, instrumentation, anesthetic considerations

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COMPONENTS

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INFRASTRUCTURESetting up Gynecological endoscopy services

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Setting up: infrastructure

STARS Start up Turnaround Accelerated growth Realignment Sustaining success

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Time and Money

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Operating room

Ancillary areasInstruments

Equipment

Misc: disposables, drugs

INFRASTRUCTURE

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Temples

Mandala Lead from temporal world to eternal: progression

from worldly to Divine Innermost sanctum: Garbhagriha

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Temple plan

Sanctum

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Operating rooms

Unsterile to sterile Sterile lobby 1, sterile lobby 2 Operating room: ultrasterile area

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4

Sanctum

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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.

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Components

Prefabricated GI/SS panel shell Hermetically sealing sliding doors Laminar air flow Pendants Workstations Others: scrub, surgeon control panel

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Operating room

Ancillary areas

InstrumentsEquipment

Misc: disposables, drugs

INFRASTRUCTURE

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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

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Perimeter corridor with clean core

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Double loaded corridor design

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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

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Operating room

Ancillary areas

Instruments

Equipment

Misc: disposables, drugs

INFRASTRUCTURE

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Equipment

Camera Telescope Monitor Light source Insufflator Irrigation/suction system Electrosurgical generator Recording and archiving

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Camera

Single chip: all three primary colors sensed by a single chip

Three chip: three sensors for red, green and blueSD 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.

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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

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Light source

Halogen Xenon LED

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Insufflator

Steps down the pressure Manual /electronic Heated

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Others

Suction irrigation systems Electrosurgical generators Recording and archiving

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Instruments

Hand instruments Specific: morcellator, endomat

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What is ideal ?1

What is feasible ?2

What is viable?3

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Justifying the costs

Sharing with other subspecialities Developing a high throughput unit Shared facility between different gynec

endoscopic surgeons

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MANPOWERSetting up Gynecological endoscopy services

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The trinity

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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”

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Theatre: Camera person, assistant: two, scrub nurse, floor nurse

Recovery staff Support staff

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PATHWAYSSetting up Gynecological endoscopy services

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“The best cars with the smartest drivers cant reach anywhere if there isn’t a road”

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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.

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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

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Pathways

Patient admission and preoperative workup Discharge pathway Dealing with readmissions Thromboprophylaxis Infection control

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CHALLENGES

Setting up Gynecological endoscopy services

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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”

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DEVELOPMENT

Setting up Gynecological endoscopy services

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AIM

Safe Sustainable System driven Successful

Gynecological endoscopy unit

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EXCELLENCE

Setting up Gynecological endoscopy services

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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

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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

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“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.”

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“Magic lies in the magician, not in the wand”

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The future OR

(Sandberg et al, anesthesiology,2005)

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A,B,C,D,E…

Approach: akin to constructing a temple Basic components: infrastructure, manpower,

pathways Challenges Development Excellence: ongoing process

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THANK YOU!