Physicians, physician assistants, advanced practice RNs, and nurses involved in direct patient care are often curious about perioperative procedures and how they influence pre- and/or postoperative care. Although these health care providers may have experienced a clinical rotation during their training, many professionals cannot appreciate the nuances that occur within the operating room. In order for learners to understand the surgical technique, interprofessional collaboration, and patient experience in the perioperative setting, the education department at Kalispell Regional Healthcare was tasked with coordinating a live surgical broadcast (LSB) for an annual educational conference. An LSB is defined “as remote observation of a surgical procedure in real time, using video technology” (Sade, American Association for Thoracic Surgery Ethics Committee, & Society of Thoracic Surgeons Standards and Ethics Committee, 2008, p. 257).
The conference planning committee believed an LSB would engage the audience by creating a room with a view into the operative world, demonstrating surgical technique, interprofessional collaboration, and patient experience. To this end, the continuing education coordinator (CEC) was tasked with developing a plan to execute the learning methodology, integrating the goal of the activity while mitigating concerns and risks associated with live broadcasts.
First, because this was a new endeavor for the organization, the CEC investigated how other entities conducted LSBs. Through a literature search, the CEC found guidelines that would help promote the goals of live surgery, safety, and educational impact (Miyamoto et al., 2014). A review of these published guidelines provided structure to our planned program by listing requirements of live surgery, safety measures, ethical issues, and program evaluation. The guidelines helped planners ask targeted questions and ensure that the patient was the primary concern.
Second, the CEC identified stake-holders involved with coordinating a live broadcast (see Table 1 for the list of those involved). The CEC invited the surgeon and select planning members to initial meetings with hospital administration and legal/risk/compliance departments to explore the resources and risks associated with an LSB. The resources necessary for this program included personnel time and technology equipment. Risks revolved around patient safety, patient privacy, and legal culpability. The literature provided support that for cardiology procedures, “the procedural and 30-day clinical outcomes were similar to those found in daily practice” (Eliyahu et al., 2012, p. 224) Additionally, “in the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries” (Rocco et al., 2018, p. 175).
The risk/compliance team reviewed the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (U.S. Department of Health & Human Services, 2017) with the surgeon and select planning members to ensure that patient privacy was protected throughout the procedure. The legal and risk departments worked collaboratively to create a patient consent form specific to the procedure and educational initiative. They identified that three patient consents would be necessary: modified procedure consent, blood transfusion consent, and marketing consent. A fourth consent was required for staff who may be inadvertently visualized during the procedure. In addition, a preprocedure script was provided with the input of both legal and risk departments to announce that rebroadcasting using cell phones or other devices was not permitted by attendees. The surgeon agreed to be responsible for the patient consent, clinical staff consent, and conference audience script. Education department staff would be at the conference to monitor adherence.
The legal team reviewed organizational risks associated with broadcasting a live procedure. Addressing these risks included discussion of the procedure and precedent for this type of education with the surgeon and identifying the following stipulations to mitigate organizational risks:
- Verbal discussion between surgeon and patient.
- Review of process by safety officer.
- Use of deidentified language by operating room staff.
- Identifying thresholds for when and how to cut the transmission.
- Having a back-up program readily available.
Based on this information, the legal team provided support for this program. In this organization, after a form is modified, it needs to be re-approved by a forms committee, sent to the print shop for conversion to a template, and then added to the electronic medical record. As the planning progressed, stakeholders were invited to planning meetings according to their role and expertise.
Third, technology to support an LSB must be reliable and tested. The CEC investigated technology needs and explored current equipment capabilities to stream a live surgery. The CEC worked with the information technology department that provides telemedicine and questioned if the telemedicine equipment could be used to broadcast an LSB at an educational conference. Information technology stakeholders confirmed that this equipment would meet the technology needs. The telemedicine equipment used at this organization is a HIPPA–compliant class 1 medical device used for meeting the patient care needs of the rural surrounding communities. This equipment has a screen, a rotating camera, and software “to simulate the experience of face-to-face patient care” (InTouch Health, n.d.). It is a lightweight, portable, and durable device that uses an HDMI-enabled monitor using a high-performance camera with pan–tilt-zoom capability to visualize the patient and project to a screen. The device can be disinfected and used in the operating room (Perisho, personal communication, 2019).
In addition to the broadcasting device, there are other technology concerns that required review. Additional equipment required and reviewed included a hot spot, three-way HDMI splitter with three screens for optimal visualization, InTouch software on a laptop to run the program, a Blue-tooth® speaker, and a driver for the camera to control visualization from a remote location.
Following weeks of planning, the team was ready to practice. The first practice session was conducted on a manikin, allowing the surgeon to determine camera placement, scope of field, and surgical timing. A key point for the team to learn was to communicate clear roles for those in the operating room and keywords to direct the driver of the camera to move the camera to the correct location.
The second practice session involved a live patient and traveling to the conference facility. This session confirmed that the technology worked at a remote site and could be easily projected so that all conference attendees had excellent visualization. A key point for the team was tracking the time from connecting to the operating room to the completion of the procedure. Because the procedure times can vary, the planning members worked collaboratively to identify how to maximize the education by starting the live surgical broadcast after the patient had been intubated and the femoral sheath inserted. A moderator instructed the audience on the preprocedure care.
The third practice session involved a live patient, two operating surgeons, and two physicians on the planning committee viewing the program from the audience perspective. Feedback from the surgeons included increasing the zoom on the surgical field. Feedback from the planning committee physicians included a desire to have simultaneous screens with a Power-Point® presentation. The education department clarified that an additional PowerPoint presentation would be made available to the learners prior to the conference and that the camera could be adjusted to travel between the surgical field, the surgeon, the fluoroscopy images, and a PowerPoint presentation. However, due to the limitations of the technology, it was determined that having an additional PowerPoint presentation at the conference on a separate screen detracted from the educational value because not all attendees would be able to see the single screen well.
Multiple practice sessions with debriefing time provided confidence that the LSB would provide robust learning for the conference attendees. The CEC documented each planning meeting and practice session to assure that all planners would have resources to review lessons learned and time lines recorded to follow during the scheduled event. The planning process involved identifying the stakeholders, reviewing the literature, practicing with technology, and keeping the patients' needs at the forefront. With excellent planning, the education department looked forward to providing a room with a view.
On September 27, 2019, the team executed a live surgical broadcast of a transcatheter aortic valve replacement. The program carefully followed the scheduled time line and preprocedure steps to ensure the most predictable outcome. Due to several practice trials, there were no unexpected surprises— with the exception of losing Internet connection for a period of 30 seconds three times during the program due to an unforeseen regional outage. This problem was quickly remedied and highlighted the importance of having a knowledgeable provider in the conference room to facilitate continuity of education while the internet connection was reestablished. The onsite provider was also able to engage the audience with questions and answers. With any educational program, contingency plans should be available. However, in live surgical broadcasts, contingency plans are a necessity.
Significant resources were required to implement a new and creative strategy for providing continuing education. Careful and meticulous planning and risk mitigation resulted in successful program implementation.
- Eliyahu, S., Roguin, A., Kerner, A., Boulos, M., Lorber, A., Halabi, M. & Beyar, R. (2012). Patient safety and outcomes from live case demonstrations of interventional cardiology procedures. JACC, 5(2), 215–224.
- InTouch Health. (n.d.). Telehealth solutions. Retrieved from https://intouchhealth.com/medical-devices/
- Miyamoto, Y., Ueda, Y., Sakata, R., Miyata, T., Adachi, H., Eishi, K. & Yamaguchi, I. (2014). Guidelines for live presentation of cardiovascular surgery (revised). Retrieved from https://plaza.umin.ac.jp/∼jscvs/guidelines-for-live-presentations/
- Rocco, B., Grasso, A.A.C., De Lorenzis, E., Davis, J.W., Abbou, C., Breda, A. & Pansadoro, V. (2018). Live surgery: Highly educational or harmful?World Journal of Urology, 36(2), 171–175.
- Sade, R.M.American Association for Thoracic Surgery Ethics Committee, & Society of Thoracic Surgeons Standards and Ethics Committee. (2008). Broadcast of surgical procedures as a teaching instrument in cardiothoracic surgery. Journal of Thoracic and Cardiovascular Surgery, 136, 273–277.
- U.S. Department of Health & Human Services. (2017). HIPAA for professionals. Retrieved from https://www.hhs.gov/hipaa/for-professionals/index.html
|Planning committee members, including representatives of the target audience|
|Education department (e.g., continuing education providers)|
|Information technology department|