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Special thesundaytimes February 12, 2012

SGH – Innovating Care in the World of Surgery

At the cutting edge

Lynn Seah

IN ONE of the hybrid operating theatres (OTs) at Singapore Gener-

al Hospital (SGH), the surgical team performing brain surgery can carry

out brain scans on the patient without leaving the theatre.The Magnetic Resonance Imaging (MRI)

machine, not a standard feature in OTs, comes in handy in cases such as the removal of a can-

cerous tumour. “In brain surgery, neurosurgeons tend to re-

move tumours bit by bit so they don’t do damage to the normal brain. But if they do it bit by bit, they don’t know how much they’ve got as they only have a very limited view of where they are operating. With the MRI on board, it’s very clear how much they’ve done or haven’t done,” says Professor London Lucian Ooi (right), chairman of the division of surgery at SGH, who used this to illustrate the ca-pabilities of SGH’s new-breed OTs and how they have benefited patients and doctors.

Hybrid theatres are those that com-bine operating and X-ray facilities. The new-breed OTs also include integrated theatres that link up the equipment in the theatre not just to each other but to external databases containing resources like X-rays and lab reports.

Among the 25 operating suites at SGH’s Major Operating Theatre complex at Block 3 are some of the world’s most advanced theatres.

Some of them are equipped with high-defi-nition scopes, which give surgeons crystal-clear views of previously hard-to-see areas in the body like the pelvis, enabling them to operate with greater confidence. Coupled with the use of robots to manoeuvre instruments in these narrow areas, even greater operating precision can be achieved.

These high-end OTs enable some operations to be carried out more efficiently and safely. “Some-times they make things that were not possible be-

fore possible now,” adds Prof Ooi.For example, in the case of a blockage in the

aorta, the largest vessel carrying blood away from the heart, open surgery used to be the only solu-tion. But patients in some instances may be too ill to undergo such an operation.

Now, with a hybrid OT installed with a system called Ziego iAngio, it is possible to manoeuvre a stent graft through a blood vessel to where the blockage is, without cutting open the chest.

In an integrated OT, information on the pa-tient can be pulled from multiple sources and dis-played on a wall of monitors for all to see. This enables the surgical team to be on the same page and respond more quickly.

Previously, the anaes-thetist used to see the pa-tient only on the day of the operation. If he then discov-ered any health issues that might jeopardise the patient when he was under anaesthesia, the operation would have to be postponed or cancelled altogether.

“The prime focus is how we can provide the best care for our patients, having seen what is avail-able elsewhere in the world,” says Prof Ooi.

Beyond the operationThe commitment of the surgical team to patient care goes beyond the operation it-self. Says Prof Ooi: “Surgery is probably the most critical event someone goes through in the hospital. The care involved is tremen-dous from start to end, not just in the operat-ing room, but the entire process from admis-sion to discharge from hospital.”

The hospital evaluated its processes and put in place a same-day admissions procedure that allows patients to be admitted on the day of their operations instead of having to come in a day before and waste time waiting. For same-day ad-missions, patients come at the appointed time and register at a counter that is just one floor below the Major Operating Theatre complex. An operating the-atre nurse then walks them up to the complex where they are prepared for surgery immediately.

To reduce the anxiety of family members while the pa-tient is in the operating complex, monitors in the wards display a partial identity card number of each patient in the complex, along with information on where the patient is at that time – waiting to go into the OT, in the theatre, or in the recovery room following the operation.

As SGH celebrates its 190th anniversary, Prof Ooi sums up the changes in surgery that the hospital has witnessed: “On their own, some of these changes may not seem important, but coming together the whole system works because every part has been addressed.”

SGH doctors make use of the latest technologies to perform surgical operations that offer patients better outcomes

Learning from the bestTo stay at the forefront of technology, SGH reg-ularly sends teams out to different parts of the world to learn and bring back new ideas, such as newly available equipment that the hospital could consider acquiring or more efficient proce-dures used in other hospitals.

One such idea implemented is the pre-operative evaluation clinic, which a team learnt about in the United States. This clinic allows the anaesthetist to evaluate the patient before the operation.

PHOTO: CHONG JUN LIANG

Levelling upLights in the operating theatre are now gentler on the eyes than in to the past. Hospital staff talk to patients as they are wheeled in, explaining what they are doing and reassuring them. The air-conditioning is no longer so cold, as the temperature in each theatre can now be controlled independently and need not be turned down so low unless the operation requires it.

Operating theatres these days are also much more sophisticated. Apart from the operating table and lights in the centre of the room, a basic set-up comprises the anaesthetist’s equipment for monitoring breathing and heartbeat at the patient’s head, and the surgeon’s tools. The anaesthetist’s equipment is now less chunky than in the past, and the surgeon’s tools could range from simple instruments to a heart-lung machine for open-heart surgery and robots for keyhole operations.

Some of the advanced theatres even contain X-ray facilities or have equipment that is networked so the surgical team can search for and call up information like past X-rays and lab test results if necessary.

PHOTOS: RAY KHOO, SGH

SGH — InnovatInG Care In tHe World of SurGerythesundaytimes February 12, 2012

Special20

Project editor Leong Phei Phei l contributors Lynn Seah, Koh Joh Ting, Geraldine Ling l Art And design Kimmie Tan, Vikki Ann Chan l PhotogrAPher Chong Jun Liang

editor Lee Kim Chew l creAtive director Jacqueline Wu Boey l chief sub-editor Uma Venkatraman l Admin mAnAger Zain Afridi

Advertising sAles Lam Wy-ning (9368-5685), Alfred Lee (9673-3578) For reproduction of articles or reprints of photographs, call SPH's Information Resource Centre: 6319-5508 or 6319-5726. E-mail feedback to spu@sph.com.sg

Special

More often than not, those wheeled into the operating theatre (ot) may see the nurses only briefly, if at all, as they could be under general anaesthesia.

yet these nurses play an indispensa-ble role during surgery. they check and re-check that the right patient has been sent for the right procedure. they ensure that tissue samples extracted are cor-rectly labelled. they also make certain that items like sponges and needles used during the operation are all accounted for, before giving the go-ahead for the patient to be stitched up.

“nurses in the ot are professionals with the necessary knowledge and skills to look after the safety and interest of pa-tients throughout the peri-operative proc-ess, from a to Z,” says Ms Gin Cheng yam (below), deputy director of the nursing division at Singapore General Hospital (SGH), who is responsible for the admin-istration of the hospital’s Major operating theatre (Mot) complex.

the peri-operative process covers the en-tire period the patient is in the ot. at SGH, this journey begins when he enters the Mot com-plex, a restricted area that is open only to staff and patients. this is to

preserve an optimal environment for the safety of patients, as every extra person will add to the bacteria count in the air.

Behind the wallsWithin this restricted zone are 25 oper-ating suites, and related facilities like re-covery rooms, blood fridge and specimen despatch room.

nurses working there include anaes-thetic nurses, who prepare the patient for surgery, scrub and circulating nurses, who get the equipment and instruments ready for the operation and assist sur-geons during surgery, and recovery room nurses, who monitor the patient’s vital signs at the post-anaesthesia care unit.

all operating suites at the Mot are de-signed with the “contain and confine” principle. each has its own induction room (where the patient is prepared for surgery), scrub room (where surgeons and nurses scrub in), preparation room (where equipment and instruments required are prepared), operating room, and disposal room (where soiled materials are disposed of). all tasks and materials used in an op-eration are thus confined to one operat-ing suite, for the safety of all in the Mot.

nurses play a vital supporting rolelynn seah goes behind the scenes to highlight the work of nurses in the operating theatres

Much thought has gone into the de-sign of facilities in the Mot, with nurses contributing to the inputs.

“Planning an ot is complex and in-volves the nursing administration team together with individual specific surgical teams as well as the facilities develop-ment experts within the hospital to work with the architects and contractors so that ot work processes are carefully con-sidered in the ot design,” says Ms Gin, who has been a nurse for 45 years, with 35 of those years spent in the ot in SGH.

She says the new recovery and post-anaesthesia care area has been construct-ed with individual exhaust valves, and partitions instead of curtains, to meet infection control standards.

another improvement has been the change from halogen ot lights to light-emitting diode (led) ones which are not just brighter but also energy saving. the new lights incorporate high-definition video cameras, so that views of the opera-tion can be captured and projected on a monitor for all in the surgical team to see.

ots with X-ray facilities have been fit-ted with grey doors to distinguish them. the doors can also be locked down when X-rays are activated so that no one from outside can accidentally enter the ot suite and be exposed.

Smooth operatorsapart from infrastructure improvements, attention has also been paid to processes for the smooth running of the Mot.

Staff-recall processes are in place for scenarios like when an organ becomes available for transplant, national dis-asters or mass casualties. “We are op-erationally ready to respond, whatever

the activation level. We are trained; we conduct drills and exercises, so everyone knows what to do, and there is no pan-ic,” says Ms Gin.

Information technology is leveraged for greater efficiency. an operating theatre management system, developed in-house, captures operation schedules and reports, personnel involved, and patient informa-tion. Monitors at the Mot display area provide real-time information on what operations are being done in which thea-tres, colour-coded by discipline, so person-nel involved can verify, at a glance, where they need to go. In the area of training, an Mot e-learning system enhances the teaching of new nurses in the ot.

Lifelong learnersall new ot nurses undergo an ot ori-entation and induction programme that lasts three weeks for registered nurses, and two weeks for enrolled nurses.

this is followed by short attachments to various sections within the Mot com-plex such as the anaesthetic nursing unit and the theatre sterile supplies unit, be-fore they are assigned to specific disci-plines for on-the-job training. ot nurses also undergo competency assessments every two years, and are sent on courses for further professional development.

learning is continuous for ot nurses, with the stream of new technologies and improvements that have been in-corporated into the ots at SGH over the years. the importance of the role nurses play in the surgical team is recognised, and ot nurses are sent for training at the same time as doctors whenever new ot services and surgical procedures are introduced.

Nurses are the unsung heroes who ensure patients’ safety and recovery in SGH.

PHoTo: ALViN ToH

Dr June Goh, a consultant at the department of anaesthesiology, plays a part in the smooth running of the operating theatres. PHoToS: CHoNG JUN LiANG, SGH