Mobile Operating Rooms August 1, 2003

Mobile Operating Rooms The New Generation By Kathy Dix The first mobile operating room (MOR) was built by a French surgeon . The MOR was built on wheels and could be pressurized; it was intended to facilitate an operating environment of high air pressure. MORs have come a long way and are now located at airports, in the military, in third world countries, even on aircraft. Expanding Surgicenters Reach Rick Cochran, president and CEO of Mobile Medical International Corporation, remembers speaking with Bob Marasco, a surgery center development architect, in the early eighties. He used to laugh and say, Rick, youll never be doing surgery in the back of a truck. Id say, Now Bob, dont think of it as a truck; its going to be designed as a healthcare facility, albeit mobile. Mobiles original target market was surgery centers and surgical hospitals. I kept running into people who wanted the ability that maybe their colleagues in the larger metropolitan areas had, but they (the more rural facilities) simply didnt have the case volume to justify that, he says. Cochran decided the military might be the best means of developing his business. I went to the Army in 1987, he recalls. The Army was interested, except that they were heading down a different path with what they call deployable medical systems, [which are] currently used. Theyre ISO (international storage organization) shelters that expand out. They dont work very well. Its old technology; its not a sterile environment; its something theyre getting ready to replace. Sensing a lack of sufficient interest, Cochran shifted his attention to international and domestic applications instead. He sat down with a group of physicians who had their own surgicenters or were involved in them, and they became the core investment group. At that point, [it was] rather high risk, because we didnt know if we could do a physical prototype and if it would work and meet space limitations and provide the services you need for pre-op recovery, a bathroom, a soiled and clean room ... we eventually in 1994 formed Mobile Medical. By 1995 we had funding in place; by 1996, I actually had a prototype out, he says. The unit underwent clinical trials for approximately one year, after which it was put into service in the prison system. The concept was that instead of taking prisoners out, you would take the care to the prison, he explains. You save not only healthcare dollars, but you save guard services and transportation costs. That program has been so successful in the state of Florida that they saved enough money and actually then built modular permanent facilities. Shortly thereafter, the U.S. Army approached Cochran and asked him to develop a mobile breast care center. The breast care center had multiple exam rooms for basic clinical examinations and the option of digital mammography. The image could be sent to a remote physician or teleradiologist. If an issue was found, they could then request an ultrasound image. The center also had the potential for a core biopsy table, Cochran says. A technician or physicians assistant would be able to take a sample and have it evaluated through telepathology. The concept was to take womens health and in a matter of hours deliver a full evaluation, whereas normally it takes weeks or months in a typical process. The first unit was licensed in California as a freestanding ambulatory surgery center; it was the first in the country to receive such approval. It was then licensed for hospital renovation. But the California association that licenses one aspect of physical plants then gave Mobile a policy intent notice, an approval that took three years, to be used in any hospital in California as long as the company meets certain criteria. We are the only company in the U.S. that has a state-licensed and Medicare-certified mobile surgical unit, he adds. Mobiles MORs are being used for many procedures, including those for Medicare patients, because the ORs are located adjacent to the hospital. They can do almost anything, Cochran confirms. One unit leased for a year then had the lease extended for two more years. We become a solution; when you face a renovation, whether it be a surgical center or hospital, you dont want to lose your revenue stream or market share. This really accomplishes that. You can pull up and provide for the patients instantly. And yet it allows the contractor to go in and start their work, literally busting up the walls without having to carefully dance around current operations.

Asked how the MOR differs from normal (stationary) ORs, Cochran responds, Its better than most operating rooms. Were state of the art; in many respects, we tend to meet more codes than some of the permanent facilities. [In] older facilities, their HVAC systems are not up to code and thats why people renovate, to modernize and to update. The mobile unit is surprisingly quick to set up, requiring about an hour. Cochran says that most people picture mobile as a modular unit set up by a crane over the course of a full day. Thats not what this is about, he says. This is designed to roll up, expand out and, with or without utilities and connections, be a full service facility, says Cochran. In most cases, the hookups will be available, except maybe for disaster reaction. Thats where we see our units being beneficial. Its a dual use. It can be used every day and then in the event of disaster, simply redeploy it, he says. And in keeping with that disaster use, Mobiles MORs are designed to offer nuclear, biological and chemical protection partly inspired by the work with the military, with whom Mobile is developing the next MASH unit. Mobiles MORs are available in a large semi-truck environment and in a pair of ISO containers. Either can be flown overseas. The truck-based MOR can be driven directly to the site, expanded and put into use immediately. The military version can be fit in two 8x8x20 foot ISO containers. More recently, in both the civilian and military models, we have added another component which is probably a key piece for todays environment: an integrated self-decontaminating system. Were working in cooperation with STERIS with that, Cochran adds. Cochran says that several physician practices who cannot afford a permanent surgicenter structure can use a single MOR that spends a day or two at each offices location. Patients would come to the same waiting area (as usual), and meet the same receptionist. On this particular day, they would walk through a door into the mobile environment, he explains. Now youve just broadened the base of ambulatory surgery to users that would otherwise not be able to have such a thing. Linking MORs to Other Sites MORs can greatly increase their usefulness by connecting to stationary hospitals labs or to other physicians offices. Technology now exists that allows a surgeon using an MOR to transmit a real-time video of an operation, X-rays, patient charts, pathology reports or lab reports to other sites. Experts in one location can view blood gases or endoscopic views and advise the surgeon in the MOR. The possibilities are endless. Joe DOirio is manager of healthcare services at Tandberg, a communications company that offers solutions for audio and video data transmission. We are a telecommunications tool to allow very high quality real-time video and audio data to go back and forth between disparate locations, he says. Video conferencing, typically used in business, can be easily translated into medicine. One company working with Tandberg has a product they call the operating room of the future which [incorporates] surgical lights, beds and video monitors that hang down on booms from the ceiling and allows the surgeon to easily access TV screens and video cameras built into surgical lights. The video and audio data [can] be transmitted over a series of networks, telecommunications, ISDM, digital telephone, and IP and the Web, to classrooms, to other locations where students or physicians are learning how to do a new procedure or surgeons who are mentoring the actual surgeons in the operating room, says DOirio. As a telecommunications tool we are the interface between the video system in the OR and the outside world, he adds. There are two package models that Tandberg makes that are portable, roll-around systems very much like an endoscopy cart. When we hook up endoscopes or visualization systems, we can send ultrasound and cardiography images, [we can] hook up to echocardiograms, CT scans, X-rays. The core focus of the company is in the visualization and transporting that from Point A to Point B, he says. The carts are constructed on different CODEC technologies. One has the look of a traditional endoscopy cart. It has a spot for a PC, a monitor, on an articulating arm, a video camera, a microphone. The Intern is built on a smaller profile a videoconferencing unit on an IV pole, he says. Two simultaneous images can be transmitted a birds-eye view of the placement of the surgical staff and tray for tools, and an internal image from the endoscope, for example. Other images can include catheterization or ultrasound images. A pathologist can transmit results from a tissue sample back to the MOR. DOirio says that connectivity is not a problem, that the system can be set up so that all manner of images can be viewed. Each jack is labeled, and every signal plugs into an appropriate source.

Its very much like hooking up an endoscopy cart to a monitor, he says. Both products hold UL (Underwriters Labs) and CSA (Canadian Stamp of Authority) approval listings specifically for medical environments. Tandberg is the only manufacturer who produces telecommunications devices listed under the statute. What the UL says is that youre not bringing a toaster into the OR and using it to sterilize instruments. The intent is that products are designed and engineered for their intended purpose. Many smaller, rural healthcare facilities cannot afford to keep specialists on hand, so MORs present a unique opportunity to provide equal healthcare regardless of the geography. Videoconferencing is a powerful tool to do that, says DOirio. It bridges differences with no disparity. DOirio relates a story of a specialist in neonatology located in Honolulu, Hawaii at Kapiolani Fetal Diagnostic Center. The native Hawaiian population has a high percentage of birth defects, so early intervention is essential. A specialist in Oahu was flying to the outlying islands on a weekly basis to hold ultrasound clinics. But weather or mechanical problems would prevent specialists from getting [to the other islands]; so they use telecommunications. The ultrasound is still at the clinic, which uses Tandberg technology to shuttle that ultrasound to the neonatologist at Kapiolani to check the health of the baby in utero. Soon after Sept. 11, when all flights in the U.S. were grounded, a pregnant woman was in an accident and her car rolled over. The baby wasnt kicking, [so she] went to a clinic, hooked up using telecommunications. The doctor saw the heart beating and the baby was sleeping ... [Its an] extremely effective way to deliver that specialty service at a moments notice, DOirio says. How Mobile ORs Compare Steven M. Rudy, MD, is the executive vice president and chief medical officer at Tractus Medical, Inc., a company that provides MORs for many diverse venues. Rudy, a urologist and surgeon by trade, has been in practice since 1975. He has a longstanding relationship with surgery centers. I founded, built and operated an outpatient surgery center in 1984, Rudy explains. Ive been actively involved in this business in terms of outpatient surgery or non-hospital surgery for 20 years now. The analogy that I would give you is as ambulatory surgery was to hospital surgery in the eighties and nineties, we think that transportable surgical suites are to outpatient surgery. Mobile ORs are generally equivalent to fixed ORs, Rudy says. The capacity and the ability to perform all types of surgery here is pretty much the same as it is in any operating room. I think there are a few limitations and they probably revolve around cardiac surgery or major transplant surgery. Its a size constraint by and large [those techniques] require larger ORs because they have more people and more equipment. However, in extreme circumstances, mobile ORs could be used for such procedures, says Ron Wise, senior vice president of corporate communications and marketing at Tractus. Dr. Leonard Makowka, our co-CEO and chair who is a eminent transplant surgeon said there was no question in his mind that he could perform a liver transplant in this type of facility if it was necessary, but thats not its designated usage. In a crisis situation, it could function that way if needed. It is built to accommodate the requirements for ORs, Rudy interjects. I think that from a physicians perspective they should feel very secure using this operating theater like they would any other. Neither Rudy nor Wise can list any other significant disadvantages to the MOR; on the contrary, Wise jokes, as a California resident, he can appreciate the mobility of the unit more than most. If I were having surgery performed on me and there was a serious earthquake, I would definitely rather be in this facility than inside the hospital for several reasons, including the fact that [the MOR] has its own generators, it has its own power supply and water supply that it can utilize instantly, and its not going to shake apart. Rudy touts the occasional superiority of MORs. These ORs are the same and in some regards even better then their existing facilities. If you look around you will find that many hospitals are aging, with ORs that are ten, fifteen years old ... back East, its not unusual to find ORs that are 50, 60 or 70 years old. Wise presents the advantage of transportability specifically for a mini-chain or joint venture of several small hospitals or physician practices, which could share one MOR. In remote areas, there may be populations that are medically underserved, he explains. A facility like this could be brought in on a regular basis to those areas and the community could be provided with a state-of-the-art surgical setting to have whatever is necessary performed. The other advantage is the length of time required in establishing a fixed outpatient center.

Its not unusual for a fixed site to take anywhere from 12 to 18 months or longer to create, Rudy agrees. These facilities can be up and running in less than six months, if you started from scratch to create one and build one. Theyre a very complicated physical plant. It isnt just a trailer that somebody decided needed to have its sides pushed out. There are miles of wiring within the structure, Wise says. In a sense, its overbuilt. It was a strategic decision to make sure that it was rock-solid dependable. We believe that it could probably be built between four and six months ... which for a hospital provides the advantage of having an ongoing revenue stream a year earlier than they might normally expect. And the revenues realized from it during that time could pay for a large portion of the unit [its a] difference between bringing a surgical suite online on the first of January as opposed to Dec. 31, when the fixed site might be finally finished (if theyre fortunate). Youre talking about a whole year of revenue being generated. Its the old story about time to market, adds Rudy. If you can get something to market sooner, you can use it sooner. It can either save you money or make you money. When you look at the range of possibilities for these kinds of facilities, you realize it is an idea whose time has come, Wise continues. Certainly there is a lot of government/homeland security potential, emergency potential. This is something on everybodys mind what do you do in a real emergency situation, if the worst-case scenario actually occurs? You could lose a lot of your hospital capabilities. That could be the result of a natural disaster or an act of terrorism. No one wants that to happen, but if it did, these facilities can actually be transported by air. They can be placed on a large military cargo plane and delivered in a matter of hours, and they can be deployed very quickly, because it has onboard power and water supply ... It can be a freestanding facility that is as comfortable in the middle of the desert or the rainforest as it is in an urban setting. The redundant electrical systems, water systems and air handling systems are superior in manufacture. The reason behind the superior quality is simple, Rudy explains. One of the things Ive learned in terms of the outpatient surgery business is that when you do something that is in the eyes of a lot of people considered nontraditional, you cant merely offer the same standard that people expect from the traditional stuff. You have to hold yourself to a higher standard, because only in that way will you get the people to believe in the concept that youre involved in. And when they see that the quality and the standards and the patient safety meet or exceed everything that is out there today, then they develop a comfort level and are willing to use the facilities. BIBLIOGRAPHY: http://www.surgistrategies.com/articles/2003/08/mobile-operating-rooms.aspx

ARTICLES ABOUT MOBILE OPERATING ROOMS

SUBMITTED BY: BETHLEHEM M. VARGA BSN4-K