EVERYDAY

INFORMATICS

Getting Ready for Emerging

Perioperative Technologies
VANESSA ERVIN LYONS, MSN, RN, CNOR; TONI WING, BSN, RN, CNOR

T echnological advances are progressing exponen-

tially, and it is essential that perioperative nurses
stay current on these developing innovations.
This column explores the uses, benets, and challenges of
some of these innovations, such as smart glasses, three-
dimensional (3D) biological tissue printing, sensors, and
real-time diagnostics. Additional discussion considers the effect
of these advances on perioperative patients and staff members,
as well as the processes and procedures that have become
necessary to safely manage new technologies in the OR.
SMART GLASSES TECHNOLOGY
Smart glasses technologies, the most well-known example of
which is the Google GlassTM wearable computing device,
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consist of an optical head-mounted display that is designed
to appear to the user as though he or she is watching a
25-inch screen from 8 feet away.1 This technology includes
camera and video capabilities, touch and voice control
options, Wi-Fi! and Bluetooth! connectivity, a gyroscope,
a proximity sensor, and a bone conduction audio transducer.
The cost of these devices averages around $1,500 each.
On October 28, 2013, the rst live consultation during sur-
gery using wearable technology occurred between a Dutch
surgeon and an American surgeon.2 The surgery was
simultaneously broadcast to YouTubeTM using the same
wearable technology. As in this example, wearable
technology can improve communication between health care
providers by allowing for synchronous video consultations
with physicians and other experts. Surgeons in remote
locations can have immediate access to resources that were
previously unavailable in real time. Surgeons can use the
hands-free option to display patient x-rays, laboratory test
values, pathology reports, and reference materials on the
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LyonsdWing
device without having to leave the OR bed.3 The point-of-
view camera provides a rsthand view of surgical procedures
for medical students either in the OR or across the globe.4-6
Wearable technology such as smart glasses can improve
efciency and patient safety by improving information
processing and human visual capabilities. For example, a
surgeon could view radiographic images on the device
during surgery without having to turn away from the
surgical site. Finally, this technology can have a positive
inuence on patient satisfaction. Patient instructions can be
recorded for later review. It also allows the nurse or
physician to access and view patient records without having
a computer screen as a distraction from the patient.
This technology is not without its challenges. Because this
technology is not designed specically for medical use, appli-
cations must be developed to ensure compliance with the
Health Insurance Portability and Accountability Act and to
allow for modications such as the use of surgical loupes.
Room lighting conditions may make some images, such as
x-rays, difcult to see via the device. A reliable, strong Wi-Fi
connection is required for most uses, which can be a prob-
lem in some facilities. Finally, current devices have a battery
life of only about 30 minutes and require an external battery
that can extend use by two hours.7
3D PRINTING
Three-dimensional printers look similar to traditional printers,
but instead of ink they use liquid plastics or other substances
to produce physical objects. In medical applications, these
items can include anatomical models and custom-designed
implants.8 The printers can use computed tomography or
ultrasound images to produce multiple thin layers of plastic
that are stacked to form the object. This technology has
been used to produce many objects, including anatomical
models, implants, hearing aids, and articial hearts. Some
applications for the use of this technology in medicine
include surgical preplanning, training, custom-designed
implants, instrument manufacturing, and research.
For surgical preplanning, surgeons can produce realistic
models of a patients organs, such as the heart and blood
vessels, to allow them to see any defects before the actual
procedure.9 This allows the surgeon to modify the surgical
plan based on the anatomical deformities of the organ to
reduce the risks to the patient and the time in the OR, a
great benet for patients with rare or complicated conditions
or complex congenital defects. This technology is also used
in medical student training to facilitate practice before
entering the OR.10
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December 2015, Vol. 102, No. 6
Surgeons can use 3D printing to produce custom implants for
orthopedic surgery, which allows for a more anatomically
correct implant for patients.11-14 Scientists have been able to
produce tissue for transplants using animal tissue instead of
plastic materials, although this type of tissue is not approved
for clinical use. Such indications include bone, embryonic
stem cells, and skin tissue. Scientists have also been able to
print tissue cells to allow for scientic testing of cancer med-
ications and to reduce the effects of chronic conditions such as
heart disease. In addition, 3D printing has been used to
produce surgical instruments.15
The benets of 3D printing do not come without challenges.
The cost of the hardware can range from $40,000 to almost
$1 million. The process of printing these models and tissue is
very time-consuming as well. For example, printing a pediatric
heart can take more than 25 hours. There are also legal and
ethical issues when discussing the possibility of mass produc-
ing tissues. Finally, patient safety concerns, such as tissue
rejection, need to be researched before this technology can be
fully implemented for use in the surgical setting.
SENSORS
Real-time sensors are being used more and more in medi-
cine.16,17 This technology offers many benets to the patient
and the health care provider. Wireless communications allow
for the transmission of information with little or no action
from the patient. For example, digestible sensors can transmit
patient information to allow for customization of care,18 and
wearable sensors can provide detailed reports on patients
vital signs, sleep patterns, and mobility. This provides a
more complete picture of the patients current health status.
It also can increase the patients participation in his or her
own health care by providing easy-to-access feedback. For
providers, the focus on outcomes rather than the number of
cases encourages the use of this technology to allow for early
intervention and possibly prevent readmissions.19
There are several different types of sensors. The standard
sensor of today is commonly used by patients. This type of
sensor requires the patient to actively transmit data to the
provider. An example would be the standard glucometer,
which requires the patient to log blood sugar values in a
journal or smartphone app and share this information with the
provider. A second type of sensor is the partially passive sensor.
These sensors automate part of the transmission process but
still require patient involvement. For example, glucometers
that allow for wireless transmission of blood sugar values still
require the patient to submit a blood sample, but the results
are automatically transmitted to the provider. The last type of
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December 2015, Vol. 102, No. 6
sensor is the passive sensor, which requires no active patient
participation. An example of this is the glucose-monitoring
patch, which constantly monitors blood glucose levels and
automatically transmits the information to the care provider.
There are many uses for sensors. In addition to blood-
sampling sensors, sensors can be implanted in tissue and
ingested for passive monitoring. Sensors can also be used to
monitor medication adherence.20,21 Improvements in textiles
allow for greater use of wearable sensors in clothing or jewelry.
Sensor monitoring can be either episodic or continuous,
depending on the individual needs of the patient. Patients who
can specically benet from the use of sensors include those
who have mental health conditions, asthma, Alzheimer dis-
ease, sleep disorders, and diabetes. For example, patients with
asthma, sleep disorders, or diabetes could improve self-
management of their conditions with the availability of real-
time data regarding oxygenation, sleep patterns, or blood
sugar levels. Challenges with the use of this technology include
concerns about patient privacy and data security along with a
lack of safety and efcacy research studies. Additionally,
reimbursement and cost issues must be resolved before this
technology can be used in mainstream medicine.
REAL-TIME DIAGNOSTICS
Another emerging technology that offers great potential for
improving patient safety and outcomes is the use of real-time
diagnostics. Two examples of this technology are uorescence
imaging and rapid evaporative ionization mass spectrometry
(REIMS). Fluorescence imaging allows for image-guided
identication of anatomical landmarks using infrared tech-
nology.22 A dye is administered intravenously and binds to
blood plasma proteins. This dye appears under the light of
an infrared camera to show the difference between cancerous
cells and healthy tissues. It also allows for easier
identication of blood ow to cancerous tumors. With this
technology, surgeons can more accurately remove cancerous
cells and reduce the damage to healthy tissue.
In addition to oncological indications, this technology can be
used to identify hidden vessels, assess blood ow to bowel
segments, and locate sentinel lymph nodes. By using smoke
from the surgeons electrocautery device, REIMS can diagnose
tissue samples with 100% accuracy.23 Diagnosis takes about
three seconds, much shorter than the current pathology
identication process, which can take up to 20 to 30
minutes. It can be used to identify cancer as well as bacteria
cells to allow for faster and more accurate diagnoses and
shorter OR times. One of the biggest challenges of these
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Emerging Perioperative Technologies
technologies is the cost, which can be several hundred
thousand dollars per unit.
MANAGING NEW TECHNOLOGY IN THE
PERIOPERATIVE SUITE
Protecting patients and ensuring staff members have the ed-
ucation and training to provide safe patient care must be
priorities when new technology knocks on the OR door.
AORN states that the role of the perioperative nurse is to
verify that all members of the perioperative team have received
education and completed competency verication on new
procedures, techniques, technology, and equipment before their
use in an operative or other invasive procedure . . . . When
clinicians use equipment with which they are unfamiliar, it
may be hazardous to both patients and perioperative team
members. Misuse of complex technology can cause injury to
patients and even death.24(p1,4)
Perioperative departments must have established policies and
procedures to manage new technology entering the OR. This
ensures that the perioperative team has the knowledge, edu-
cation, and training to safely use new technology. First,
departmental policies and procedures should ensure that there
is adequate notication of the new procedure or technology to
allow appropriate education and training of the periopera-
tive team.
When a facility examines a new technology, considerations
should include the following questions:
! Is this a new procedure or technique that requires surgeon
credentialing? Will a surgeon proctor need to be present?
What type of staff education is required?
! Is this an experimental procedure or clinical trial that will
require additional patient consent and institutional review
board (IRB) approval?
! What about insurance reimbursement?
! How will patient outcomes be tracked?
! Is there a potential for physical injury not only to the patient
but also to the staff members using this new equipment?
! Is this new technology storing or transmitting protected
health information that could pose a security breach?
Next, the perioperative nurse must know what hospital re-
sources are available to assist with managing new technology.
Facilities rely on both government regulations and institu-
tional policies when investigating and adopting new technol-
ogy. Some important government regulations include
the following:
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LyonsdWing
! The Department of Health and Human Services provides
government regulations, such as the Affordable Care Act and
Health Information Technology act, and laws to protect
patients participating in medical research and trials. Through
the National Institutes of Health division, it also provides
millions of dollars in grant money to fund research projects
across the country.
! The US Food and Drug Administration (FDA) is a regula-
tory body within the Department of Health and Human
Services that establishes laws and regulations to ensure that
medications, biologicals (eg, tissue and tissue products), and
medical devices intended for human use are safe and
effective.
! State and local laws and regulations establish criteria for
patients participating in clinical trials, experiments involving
prisoners, consent age, gene research, and medical record
privacy.
! The Health Insurance Portability and Accountability Act
focuses on securing protected health information stored and
transmitted through the use of new technology.
Although clinical trials and newly developed devices are
regulated by the government, many innovative procedures and
new surgical techniques, such as a different surgical approach,
do not fall under governmental regulation. Because new pro-
cedures are not classied as research on human subjects, the
government does not monitor them. However, new pro-
cedures must be regulated and approved by the local institu-
tion and, although national organizations provide guidance
regarding credentialing standards, establishing the criteria for
granting privileges to the surgeon ultimately falls to the indi-
vidual facility. Perioperative nurses should be aware of the
institutional regulatory committees that are in place in their
settings. These resources assist with the development and
enforcement of new technology policies and procedures for the
OR.25 Some common institutional regulatory committees are
listed here.
! An IRB: The FDA requires institutions to establish IRBs
whenever they conduct research involving human subjects.
The purpose of the IRB is to approve and monitor these
research studies to protect the rights and welfare of human
participants. Another purpose of the IRB is to stop a clinical
trial if protocols are not followed or undue harm comes to
the participants.
! Hospital ethics committee: This serves as an educational
resource, can assist with the development of policies and
procedures involving bioethical issues, and assists with case
reviews.
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December 2015, Vol. 102, No. 6
! Hospital credentialing committee: This committee estab-
lishes the criteria for the skills, training, and expertise
required to perform the new procedure. This committee
denes the level of supervision required and monitors pa-
tient outcomes.
! New technology committee: This group has become an
important addition to assisting hospitals with new technol-
ogy management. Just as the credentialing committee fo-
cuses on the provider skills and training to ensure safety, this
committee evaluates the procedure and device for safety and
efcacy. This multidisciplinary team reviews not only the
professional medical associations guidelines but also the
patient populations served and nancial effect, helping in-
stitutions decide what new technology is best for their
hospital and community.
! Perioperative governance committee: Surgeons and staff
members on this committee can serve as patient safety
champions monitoring the implementation of new tech-
nology in the OR.
! OR products and practices committee: This group evaluates
the cost of the new equipment and supplies, negotiates
contracts, and manages product trials.
The availability of these groups varies with the size of the
organization, but knowing what hospital regulatory commit-
tees are available will not only assist with establishing safe
policies and procedures but also with identifying sponsors and
champions to support these initiatives.
Finally, policies and procedures for implementing new tech-
nology need to be developed at the departmental level. Policies
addressing staff education and training on the use of new
technology are essential. In fact, the ECRI Institute identied
insufcient training as one of the top health technology haz-
ards.26 With the varying degrees of complexity, each new
technology must be evaluated to see what skills are required
for safe use. The involvement of the surgical team with the
equipment use needs to be evaluated, such as assembly and
setup, calibration, or operation. The level of education
required for competency must be determined, such as
hands-on training, competency verication, or simply
knowledge and instruction.
Depending on the complexity of the new technology, these
needs could vary greatly. For example, the surgical team has
little to no involvement with the use of wearable technology
(used by the surgeon), so knowledge of the benets of smart
glasses and the steps that are in place to protect the patients
privacy are sufcient education. Robotics equipment, how-
ever, is very complex; requires a great deal of staff member
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December 2015, Vol. 102, No. 6
involvement; and requires extensive training and hands-on
experience, competency demonstration, and continued com-
petency validation to ensure safe patient care.
Policies and procedures must also address what assistive re-
sources are necessary, such as an equipment checklist to ensure
the correct setup and calibration. One study evaluated 28
studies on surgical errors and suggested that one in ve surgical
errors was related to equipment or technology errors.27 The
ndings indicated that 37.3% of those errors were attributed
to equipment availability, 43.4% to conguration and
settings, and 33.5% to direct malfunctioning. The use of a
specic equipment checklist reduced equipment errors by as
much as 40% to 60%. As a result, the investigators
recommended including an equipment check in the
World Health Organizations Surgical Safety Checklist.
Determining the need and detail of an equipment checklist
should be based on the complexity and staff member
involvement in setup, calibration, and operation. Assistive
resources should also include access to troubleshooting tips
and resource guides to assist staff members with quick
resolution of issues that may arise intraoperatively.
CONCLUSION
The new equipment and technology entering the perioperative
suite is more and more intricate and advanced. Surgeons and
vendors can often apply pressure to use this technology before
the perioperative team members feel competent. Hospital
regulatory committees and clinical leaders must be responsible
for assisting with the development and enforcement of policies
and procedures. Being a part of these technological advance-
ments that improve patient outcomes is very exciting, but
having policies and procedures in place to regulate the
entrance of new technology into the OR ensures that the
perioperative team is trained to deliver expert patient care
while empowering staff members to speak up when necessary
to ensure the safety of both patient and staff. !
Editors notes: Google Glass and YouTube are trademarks of
Google, Inc, Mountain View, CA. Wi-Fi is a registered trade-
mark of the Wi-Fi Alliance, Austin, TX. Bluetooth is a registered
trademark of Bluetooth SIG, Inc, Kirkland, WA.
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Emerging Perioperative Technologies
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Vanessa Ervin Lyons, MSN, RN, CNOR, is the peri-
operative staff development and technology coordinator
at Murray-Calloway County Hospital, Murray, KY.
Ms Lyons has no declared afliation that could be
perceived as posing a potential conict of interest
in the publication of this article.
Toni Wing, BSN, RN, CNOR, is a consultant at Coratek
Perioperative Consulting, LLC, Curtice, OH. Ms Wing has
no declared afliation that could be perceived as posing
a potential conict of interest in the publication of this
article.

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