Driving Surgical Quality Using Operative Video

Improving Outcomes Through Reflective Analysis

Walsh et al ² first examined this concept in an early study investigating the usefulness of operative video during radical prostatectomy. More than 60 patients undergoing surgery were recorded, their operative videos reviewed, and their postoperative sexual function documented. The authors identified 4 surgical steps captured on video that directly correlated with sexual potency. When these critical operative steps were performed suboptimally, patients were more likely to be impotent following surgery. While surgical video has traditionally been thought of as a teaching tool for trainees on the technical aspects of a given operation, this early study demonstrated the potential to correlate video capture of surgeon technique with patient outcomes.

Taking this concept further, a team led by Teodor Grantcharov has begun modelling the principles of airplane black-boxes in their operating rooms to enhance surgical outcomes. Data and information captured by industry-standard audio and data recorders (“black-boxes”) are the primary tools utilized in aviation accident investigation and prevention. Grantcharov and his team have developed an “operative black-box,” which simultaneously captures technical skills (such as surgical instrument use), nontechnical skills (such as operating team communication), and error/event rates in an attempt to identify the root causes of adverse outcomes in the operating room. ³ A group of experts in technical skills analysis, human and team performance, and surgeons then review the black-box video, audio and patient-related data to identify errors so that they may be prevented in future operations. If this tool can be simplified and matured, this is one way we may be able to reduce some of the variability seen in surgical outcomes at local and national levels.

Routine Video Documentation Use and Integration

Currently, the most commonly used documentation of what transpires in the operating room is the subjective note dictated by the surgeon at the completion of an operation (or sometimes, many days later). Unfortunately, operative notes alone often omit critical components of an operation when compared to video recording ⁴ ; routine surgical recording would add objectivity and assist quality improvement efforts. Laparoscopic footage can be easily retrieved from operating room recorders while open procedures may be captured using wearable technologies.^5,6 Recording of the full operation from beginning to end would be necessary to dissuade surgeon bias of selective inclusion, or exclusion, of particular moments from the operation. The operative video could then be stored and maintained electronically by the hospital, similar to existing patient and operating room data.

Integrating operative video into the electronic medical record would promote transparency and allow other providers to readily view key findings to facilitate better communication and patient care. ⁴ Rather than transmit patient photographs and video over nonencrypted cellular and email systems, as has become commonplace, this integration would reduce patient privacy loss. A concomitant benefit might be the Hawthorne effect: an improvement in quality due to awareness of video recording. ⁷ Furthermore, routine video use may encourage standardization of operative processes, particularly critical operative steps, which can lead to improved surgical outcomes.^8,9

However, reimbursement of the video documentation process and the resources required for maintenance of this video data is less clear. Equipping operating rooms with video recorders and assembling teams to help produce and manage the video would be costly. But, it is likely that insurers would encourage operative video and cover its capture fee if it was shown to improve patient outcomes. Therefore, additional prospective studies are needed to evidence the quality improvement in surgery through operative video, like those performed in other specialties. ⁷

Targeting Surgical Variability to Improve Quality

The importance of quality assurance programs to reduce outcome variability is well recognized. For example, widespread implementation of surgical safety checklists and hospital auditing have helped diminish this variability and improve patient care. ¹⁰ However, safety checklists primarily focus on anesthetic and nursing concerns, and do not monitor intraoperative technique or ensure that key surgical steps are performed. While surgical audits may readily capture patient and treatment-specific characteristics as well as outcomes data, they are unable to record operative events in detail. We believe that operative video documentation could further empower and disseminate these quality assurance efforts.

In a recent study by Birkmeyer et al, ¹¹ operative videos from the Michigan Bariatric Surgery Collaborative were used to examine surgical skill and their correlation with postoperative outcomes. Surgeons who performed a laparoscopic gastric bypass with superior skill—based on instrument handling, time and motion, gentleness, flow of operation, tissue exposure, and overall ability—as rated by their peers on blinded-operative video review, had significantly decreased risk-adjusted postoperative complication, reoperation, readmission and mortality rates. Perhaps just as noteworthy was the high variability seen in technical proficiency between surgeons in the lowest and highest skill quartiles, despite their having been selected from a homogenous population with similar fellowship training credentials and years in surgical practice.

Surgery is not the only profession where there are concerns that variability in quality transcend providers or regions. To better appraise law enforcement agencies nationwide, President Obama recently proposed a $75 million initiative to help purchase body-worn cameras (BWC) for local police forces. Supporters of this initiative want every officer in America to wear a BWC. The fundamental impetus for universal recording of daily police activities is similar to that of capturing every operation on camera: to increase professional accountability, minimize performance variability, promote transparency, improve quality, and ensure safety (Figure 1). As lawmakers consider making officer-worn BWCs a legal requirement, it may be equally inevitable that recording all procedures will one day be mandated across the nation to ensure universal surgical quality (as has already been introduced into the Wisconsin legislature). ¹²

OPEN IN VIEWER

Figure 1.

Schematic on the utility of video recording in the operating room.

Forward Thinking

We envision a system where every operation is recorded in its full length and then automatically uploaded, unaltered from the local server into the patient’s secure electronic medical record. There it should remain accessible by providers for a durative period, depending on existing state medical record retention regulations (eg, 6 years from discharge date in New York State). ¹³ Previous literature suggests that the critical steps for a variety of operations can be readily captured, documented and used to both demonstrate and improve quality.^9,11,14 Ideally, a shortened video exhibiting such key steps (eg, the critical view of safety in cholecystectomy) would be kept in addition to the full, unaltered version, so that providers can readily view select footage in a reasonable period of time. It is our strong opinion that using video cameras, which are already present in our operating rooms, is a necessary endeavor that will lead to increased patient safety and improved operative outcomes. Those skeptical that this process may lead to increased litigation should remember that similar apprehension was raised when physicians were first required to provide hard copies of medical records or radiographic images to their patients, but such concerns never materialized. In fact, we believe that video evidence of what actually occurred in the operating room would predominantly lend legal support to the surgeon. However, there remain substantial technical, cultural, and data storage problems associated with routine video documentation in the operating room.

As we continue to debate how we may overcome these issues, it is important to remember that previous concerns about greater transparency in medical practice, such as improving patient access to their doctors’ notes, have almost always led to increased patient satisfaction and compliance with their medical care. ¹⁵ Ensuring elevated surgical quality consistently across all providers is complex. But as evidence grows on how quality can be evaluated and enhanced through operative video, its role must be considered thoughtfully in the context of “what is best for our patients?” Using this as our guiding principle, we believe the next driver for surgical quality can be the operating room video camera.