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The fastest growing segment of the U.S. population comprises individuals who are over age 65. Their numbers are expected to increase 53.2% by 2020 and will result in significantly increased demands for surgical services. Recent analyses have predicted increases in service demands to be as high as 14–47% in all surgical fields by 2020, according to the National Center for Biotechnology Information.
Four trends are shaping such demand for surgical services:
- Demographic shifts and changing consumer preferences are shaping care in the following ways:
- Growing rates of chronic illnesses continue to fuel (complex) inpatient growth.
- Population shifts are polarizing the general surgery business across communities and the strategies that follow suit.
- Care management efforts are bringing down unnecessary utilization through:
- Providers that are revisiting perioperative care protocols, representing a paradigm shift.
- Pain management’s focus, which is shifting from achieving zero pain to optimizing safety.
- Provider roles and clinics that are emerging to coordinate care across inpatient and outpatient sites.
- Innovations are becoming the new norm, such as:
- Applications of biologics in wound care that are gaining traction—but at a steep price.
- Robots that are becoming a cost of doing business, with key implications on surgical education.
- Surgical care that is treading into the virtual realm, though “sci-fi” applications still not adopted.
- Demand for care is shifting from inpatient to outpatient—and beyond through:
- Payers that are taking an increasingly active role in steering care to lower cost sites.
- ASCs, which are an attractive investment for hospitals, though hospital players aren’t alone.
- New treatment and medication options that may compound shift across sites and into the home.
Therefore, we need to develop strategies to meet this expanding workload, especially in operating rooms (OR). Problems in today’s OR include:
- Personnel shortages for such positions as nurses, anesthesiologists, surgeons, and technicians.
- Inefficient, ineffective, and redundant procedures for scheduling and supply management.
- Fragmented communications and isolation.
- Instrument incompatibility and connectivity problems.
A Look into the Modern OR
While operating rooms (OR) are one of the most critical areas of a hospital, historically they have had a very low degree of technological savvy. The crucial components of an OR a decade ago were surgical lights, simple operating tables, and critical surgical devices. However, there has been a significant transition thanks to technology adoption in modern hospitals. An increasing demand for operational efficiency and the need for precision and technology innovation has led to the adoption of automated and sophisticated technologies within operating rooms. Surgical robotics, high-resolution displays, advanced operating tables, and well-integrated network infrastructure now define modern hybrid operating rooms.
Yet despite the tremendous advances made in surgical techniques during the past decade, the equipment and procedures in today’s OR are inefficiently used. Reasons include a lack of compatible and interchangeable equipment and limited communications among surgeons and others on the team, especially during surgical procedures. The operating room is one of the highest cost centers of a hospital—it can often account for more than 40% of an organization's total expenses. As a result, planners are exploring ways to improve OR efficiency by reducing high, unnecessary costs.
However, building robust surgical capacity in healthcare delivery systems in resource-limited settings is complex. The system must be prepared to address a diverse group of surgical conditions. Further, patients often need to receive such surgical interventions quickly and efficiently to avert life-threatening conditions or prevent life-long disability.
Also changing is the inpatient/outpatient mix of surgical procedures, which has undergone a dramatic transformation in the past 25 years. The average hospital currently performs the majority of its surgical procedures on an outpatient basis; the rising outpatient case mix has significant ramifications for the number, location, and design of operating room suites. However, the days of the hospital as we know it may be numbered. In a shift away from their traditional inpatient facilities, healthcare providers are investing in outpatient clinics, same-day surgery centers, free-standing emergency rooms, and micro-hospitals, which offer as few as eight beds for overnight stays. They are setting up programs that monitor people 24/7 in their own homes. And they are turning to digital technology to treat and keep tabs on patients remotely from a high-tech hub. One of the key drivers of outpatient migration—and the most important trend in surgery across the past three decades—has been the shift toward minimally invasive surgical (MIS) techniques. OR design has evolved in concert with minimally invasive surgery, resulting in integrated MIS suites with streamlined equipment and image-visualization technology.
Such next-generation technologies are altering surgical paradigms, such as the introduction of robotic surgical systems, and they are producing significant market share swings in many localities. Also, imaging technologies like surgical navigation systems are projected to become more ubiquitous in operating rooms of the future. The OR is getting smarter, more effective, and a lot less risky for patients. Hospitals are investing in new devices, designs, and digital technologies that promise a new era of innovation for surgery. With some, surgeons can control robot cameras with eye movements as they move into patients’ bodies through tiny incisions. With others, doctors can create a GPS-like map projected onto a patient’s body to virtually see inside the anatomy before an operation, track their surgical tools, and help them operate more precisely. These advances are part of a growing shift away from traditional open procedures that involve big incisions, lots of blood loss, and long hospitalizations. They point toward a future where more patients can choose minimally invasive outpatient surgeries, with faster recoveries, fewer complications, and less pain and scarring.
Given the rapid pace of technological innovation in surgery, hospitals can no longer adhere to a rigid design plan for operating suites. ORs must be sized and outfitted appropriately to accommodate a wide range of current and future technologies that are able to easily adapt to shifts in treatment paradigms and service line strategy and configured to reflect an institution’s general and specialty needs. To stay viable in the market, medical device companies must fundamentally change their business models by expanding their focus from physical capital medical devices into digital solutions that surround those physical devices.
These next-generation devices contribute to the rise of the “digital operating room,” which aims to integrate the images, information, and work flow available in the hospital and in the operating theater. Such integration can distribute and record information while adding intelligence.
There is also a need for smart operating room components that can enable surgeons to perform surgical procedures effectively and rapidly. The biggest challenge for current market participants is dealing with product differentiation. Additionally, innovations and adoptions are happening at a quicker pace than before. A simple data management tool when integrated well with the existing infrastructure provides extremely useful and intelligent data.
The notion of a digital operating room is highly variable. Whereas digital operating rooms are rapidly being incorporated in the hospitals, the clinical validation of improved quality of surgery is limited. The proven and expected usefulness of image distribution in one OR (routing and switching) or outside the OR (broadcasting), of integrating information, of image and video registration, and of intelligence, is reviewed with the perspective of quality and safety of surgery. It is expected that the digital OR will contribute to the learning and teaching and to the quality of surgery. Especially, the introduction of augmented or artificial intelligence (AI) will be a major step forward.
Transformed Surgical Spaces
In recent years, advances in surgical technique and technology have placed unprecedented space and capacity demands on today’s operating room. Consequently, hospitals are replacing antiquated surgical spaces with new operating suites at a rapid pace as outpatient surgery, minimally invasive techniques, and technological innovation drive changes in OR design.
As an increasing number of technologies occupy the OR, they compete with staff and standard fixtures for a place around the operating table. An optimal OR size of about 600 to 650 sq ft accommodates the majority of technologies with ample room for staff circulation. To anticipate potential changes in surgical offerings, outfitting OR ceiling spaces with clean tiles and extra boom mounts enables swift conversion to different specialty layouts without major renovations. Hospitals seeking greater day-to-day OR flexibility are experimenting with “universal” designs to ensure surgeon and staff comfort with any operating space. New and renovated ORs are incorporating additional wiring capacity to allow maximum flexibility in accommodating future technologies. To achieve seamless integration of OR technologies, it is critical to collaborate with vendors early in construction phases and negotiate no-cost upgrades to ward off obsolescence.
Although universal ORs may be ideal under many circumstances, not every surgical specialty fits the one-room mold. Given the significant cost of specialized suites, however, customized ORs should be considered for only those service lines and technologies likely to benefit from dedicated spaces: cardiac, neurosurgery, ortho/spine service lines, and endovascular minimally invasive and robotic surgery. While the “pod” and “racetrack” designs are favored by most hospitals and architects, the complexity of an individual hospital’s surgical processes and department may dictate an entirely different OR configuration. It is crucial to evaluate each design layout through three lenses—patient flow, staff flow, and material flow.
Most current hospitals were built from inpatient-oriented blueprints, but they are now proving insufficient for meeting today’s (and tomorrow’s) outpatient market realities. Given heightened service expectations and recovery requirements, hospitals face unprecedented pressure to reconfigure their inpatient and outpatient surgery facilities. A number of hospitals are investing in ambulatory surgery centers (ASCs) to ease capacity constraints as well as retain outpatient business. Surgeons are attracted to hospital outpatient surgery centers with the promise of efficiency improvements, while patients value ASC amenities that provide a level of comfort and service far above the traditional (inpatient) hospital experience. Many hospitals are discovering (the hard way) that the efficiency promises and substantial technology upgrades of a distant ASC location are often not enough to inflect surgeon practice patterns. Collaboration with surgeons on ASC strategy and location is essential to ensure their buy-in and prevent OR underutilization. Designating ORs specifically for outpatient services within the traditional surgical suite is an appealing option for hospitals seeking to cater to the outpatient market yet ensure convenience and efficiency for surgeons. For instance, positioning inpatient and outpatient ORs together under one roof allows hospitals to use dedicated outpatient ORs for specific types of inpatient cases as demand fluctuates.
Newly constructed facilities allocate double the amount of prep and recovery space per OR compared to today’s existing paradigm. Likewise, the majority of hospitals are adopting private rooms to flex based on demand and gain space efficiencies by combining prep and recovery spaces.
At first glance, the future prospects for the hospital industry’s surgery business look promising. Profit margins for most procedure lines remain solid, and an aging population will fuel growth in a broad array of surgical interventions. However, demographic trends are not the sole driver of surgery volumes—technological and competitive forces will also exert a significant influence on the future course of surgery. On the technology front, advances in biomedical engineering will create new surgical interventions while rendering existing surgical procedures obsolete. Technological innovations will also redefine how surgery is performed. Patient demand for less invasive procedures has already spurred the development of new techniques such as single-incision laparoscopy and natural orifice-based endoscopic surgery. In addition to minimizing the invasiveness of surgery, surgeons will demand more advanced imaging modalities to improve the precision of their operations.
Competition is likely to intensify in key service lines. In particular, as the inpatient-to-outpatient migration of surgery continues at a gradual pace in the coming years, freestanding surgery providers will target short-stay inpatient procedures in orthopedics, bariatrics, and other lucrative procedural areas. Even as hospitals prepare to defend their profitable inpatient surgery base from new competitors, the looming shortage of surgeons could pose a daunting challenge to sustaining a robust surgery business.
The field of surgery is evolving very fast, and technological advances are making it more efficient and effective and improving patient outcomes. While surgery may never be fully automated, in the future robots will be smarter and more interactive, bringing as much information to surgeons as possible during surgery. Of course, many technologies are still in development, and others have yet to be widely adopted or fully evaluated for safety and cost effectiveness.