Installation Profile: OR AV
University Hospital UAB
Jun 1, 2005 12:00 PM, By Stephen Porter
Video Enhances Hospital Efficiency
At the new, 12-story, $275 million University Hospital at the University of Alabama (UAB), there is a host of reasons for visitors to be impressed. For example, there are the 40 operating rooms, the emergency room that is as big as a football field, and the 96 private patient rooms that feature custom-built furniture and a sofa bed for visitors. There is the healing garden on the fifth floor that gives visitors a quiet place to rest, the helipad on the roof, and the 500-seat dining room with a wide range of menu options.
But of all the features that make the hospital special, one of the most important is also one of the most overlooked — the hospital's extensive use of AV technology.
The most obvious example of that technology is the bank of 42 flat-panel LCD displays that line the wall of the central nursing station, allowing constant monitoring of all 40 operating rooms. The displays make for an impressive sight, and they do attract their share of attention from casual observers. But those displays represent only the tip of the AV iceberg.
Far more impressive is the way the hospital is using video and audio to enhance surgical efficiency in the operating room, to provide communication between operating rooms, and to drive a telemedicine capability that allows doctors and students in remote locations to interact with the surgical staff during live operations.
“There may be a number of hospital facilities in the country that have one super room that is more high tech than the operating rooms we have here,” says Keith Mignault, biomedical engineer at UAB and the man who spearheaded the design of the AV system for the hospital. “But one super room doesn't buy them efficiency. It buys them a telemedicine show. It doesn't help improve the quality of the hospital care or the hospital mission. From a facility standpoint, I believe we are significantly ahead of any other hospital in our level of AV integration and the way our operating rooms function as a group.”
The two companies responsible for executing this complex AV integration project are Image Stream Medical, Littleton, Mass., and Kontek Systems, Durham, N.C. That the two companies even won the bid for the project is impressive. The competition they were up against included some of the biggest names in the field of operating room integration.
“This is a real David and Goliath story,” says Frank Konhaus, one of the two co-founders and principals of Kontek. “The major players in this market are large multinational firms. Image Stream Medical and we are dramatically smaller than the other companies who made proposals on this project.”
Not only was this by far the largest integration project Kontek had ever tackled, it was also the first one that was outside its local area.
“Mastering the logistics of staging a project out of state was one of our biggest challenges,” says Konhaus. “We had staff people who had to live in apartments away from their families for extended periods of time, and we had all kinds of equipment that we had to transport down there. We put in some grueling hours for eight months. We certainly kept the airline companies in business!”
Despite the small size of both Kontek and Image Stream Medical, the two companies won the bid because of their innovative technology and their ability to put together a customized solution for the UAB hospital.
“The bigger companies have good solutions, but they tend to be standard solutions. You have to get model A, B, or C,” explains Wes Newman, the other co-founder and principal of Kontek, who acted as project manager on the installations. “In contrast, we weren't trying to pitch them on something that was predesigned, and they saw that as an opportunity to get what they really wanted without having to make compromises.”
Another key advantage is that the competitors came at the project from the perspective of being manufacturers of medical equipment, and their solutions tended to work best with their brand of equipment. In contrast, Kontek's background is in the management of video signals, and its goal was to create a system that was as open as possible.
“We said we wanted to design the system so that they could bring any kind of equipment they wanted into the OR with the confidence that it would work,” says Newman. “The medical world uses just about every kind of video signal on the planet — RBGHV, RGBS, RGB sync on green, S-Video, and composite signals. So rather than try to create a system that would work with only one brand of equipment, we tried to make it work with anything we could imagine. Every design decision we made, from the choice of wires to the routers to the monitors, was made with the goal of making a system that was as universal as possible.”
Finally, there was the fact that none of the competitors could come close to offering a digital video recording system as sophisticated as that offered by Image Stream Medical.
The Image Stream DVR-MD is a custom-built product designed specifically for the medical environment. During an operation, a surgeon can activate the DVR using a footswitch, which then begins capturing video from any one of the many cameras used in the operating room. Once activated, the DVR records analog video in MPEG-2 format onto both a DVD and a hard disk simultaneously. It tags the video with a patient's name and tracks it by criteria such as case number and surgeon. It can export to USB devices, guarantee delivery of data to a network server, and burn DVDs in near realtime.
“It's really been designed as a medical management device,” explains Peter Renzi, vice president of engineering at Image Stream Medical. “It's reliable, easy to use, and offers extremely high performance.”
A total of 42 DVRs were used in the UAB installation — one in each operating room, one in a conference room, and one in the office of the chief of cardiovascular surgery. Footage captured by the DVRs is useful not only as archival material but as a training tool, which is critical given UAB's status as a teaching hospital.
“If a case suddenly goes interesting, a surgeon simply activates the DVR with the footswitch, and he instantly has some valuable material he can use in the classroom the next day,” says Newman.
In addition to a DVR, each operating room is equipped with five surgical-grade, flat-panel monitors from Morgan Hill, Calif.-based National Display Systems, three of which are suspended on booms and can be positioned as needed by a surgeon. A fourth display is mounted on the central equipment column, which is suspended from the ceiling and is used to mount various types of medical equipment. The fifth monitor is located on the wall at the charting nurse location.
The surgeons, anesthesiologist, and nurses use the displays to view video images captured by the various cameras in the room, as well as data produced by various pieces of medical equipment.
Most impressive, however, is that the displays can be used to view video images from any of the other operating rooms in the hospital.
“Every operating room has three outgoing video channels that can be viewed in any combination in any other operating room or at various monitoring locations such as the main nursing station or the hospital conference rooms,” explains Newman.
With such a capability, a surgeon operating in one room can consult on a procedure going on in another room.
“For example, you might have a senior surgeon in one room and some residents in another room working on a case,” says Newman. “With this system, he can use his bank of monitors to keep abreast of the progress on that procedure so that he knows when it's time for him to go in there and get involved. And because we have multiple streams, he can even get different views. He can access the overview camera of the room to see who's in there, he can look at the video from the endoscopic camera to see what's going on inside the patient, or he can get a view from the surgical light camera. There is a lot of power in that.”
Because the microscopes in the frozen section lab are also tied into the system, a surgeon doesn't even need to leave the OR to go to the lab to view cell samples from a biopsy. He can just call them up on one of their displays.
UAB's Mignault says that ability to share video streams is not just a convenience, but results in significant improvements in hospital efficiency and patient care. “If a surgeon needs to leave one room to consult on a procedure in another room, or if they need to run down to the lab to look through a microscope, that means the patient is left sitting on the table for an extra 15 to 20 minutes unnecessarily,” he says. “And from a patient care standpoint, the longer someone is under anesthetic, the longer the recovery times. So the reason you want shorter procedures is not only because it's more efficient for the hospital, but it results in a better patient outcome.”
Video streams can also be sent to a Polycom iPower 9000 videoconferencing system located in the hospital's central video routing hub. From there the video can be sent to the university's conference center located in a separate building several blocks away from the hospital. The room was set up by Kontek as a dual-image presentation room that features two ceiling-mounted NEC MT1065 projectors and a SmartBoard Sympodium system that allows a presenter to annotate on top of high-resolution video. A Crestron touch panel control system mounted in the lectern allows a presenter to access any video source from any room at the hospital and put that video live on the screen.
Video sent to the conference center travels over fiber-optic links that emanate from the central video hub at the hospital. Within the hospital itself, the video is sent over coaxial cable on the hospital's Ethernet LAN.
“In general, we used two formats of video wiring,” says Newman. “We used RGBHV for hi-res signals, such as those used by various computer devices and the endoscopic camera. And we used S-Video, also known as YC, for low-res signals, such as those used by the room camera, the surgical light camera, and the portable X-ray device.”
To manage the flow of video throughout the hospital, Kontek utilized Crestron control systems, Extron switchers and converters, and an enormous 128×128 AutoPatch Epica router.
The AutoPatch router, which is the biggest router Kontek has ever installed, is housed in the central video hub located on the seventh floor of the hospital. It's responsible for bringing in the three outbound video signals from each OR and feeding them out to other operating rooms, conference rooms, or any other outside destinations.
The amount of AV equipment inside the individual operating rooms was kept to a minimum. Besides the flat-panel displays, each room contains a compact, stainless-steel cabinet that houses Image Stream Medical DVR and a Sony 5-disc CD changer, which is used to play music through the room's JBL Control 26C loudspeakers. There is a single Audio-Technica minature boundary mic mounted in the ceiling to capture audio in the room. And there is a charting nurse's station, which folds up against the wall, that consists of a flat panel display with a touch panel overlay.
This overlay and Crestron touch interface device are the primary interface for the system. Nurses and doctors use it to select the video streams they want to display on their monitors, adjust camera and light settings, manage the DVR, and control camera positions. The interface was custom designed for the hospital using the Crestron programming language.
All the other supporting AV equipment is installed in Middle Atlantic equipment racks that are housed in closets just outside each operating room. The key components in these racks include Extron 16×16 S-Video and RGBHV matrix switchers, Extron interfaces and converters, and a Crestron remote control system and volume control matrix router.
Although the AV installations for most of the operating rooms are identical, there are a few rooms that have a few extra pieces of equipment. Most notable are the 15 rooms that have been outfitted with the RGB Spectrum QuadView windowing device, which makes it possible to put up to four overlapping windows of any size on a monitor screen simultaneously.
The QuadView accepts high-resolution RGB, HDTV, S-Video, component, and composite video. Each input can be sized and positioned anywhere on the screen, as well as panned and zoomed to emphasize areas of particular interest.
“The QuadView has lots of interesting applications in the OR,” says Newman. “For example, an anesthesiologist is often located behind a curtain so they can't always see what a surgeon is doing. With the QuadView, they can use one window to show a full room view, another window to monitor the patient's vital signs, and a third window showing a view from the endoscopic camera so that he can see when the surgeon is about to cut a vessel or do something else that might affect the patient's vital signs.”
The QuadView displays have proven to be so popular with the medical staff, adds Newman, that they're now talking about putting them into all the operating rooms.
Of the 15 rooms that have the QuadViews, eight have been designated as telemedicine rooms, and thus have been equipped with a few more extra features. These features include two outbound high-resolution RGBHV trunk lines that go to the central hub, making it possible to send true hi-res images to outside conference rooms.
The telemedicine rooms are also equipped with a Comtek IFB transmitter base station and personal receiver. These are used to support an Audio-Technica wireless lavalier microphone and earpiece, which a surgeon can wear when conducting a telemedicine session. A Polycom Vortex echo-canceling system is used to prevent audio feedback problems during those sessions.
Before long, the hospital will be adding one more feature to its list of AV capabilities: the ability to stream its video live over the Web so that doctors can access the video from any computer. The technology for doing that has already been put into place. The system is built around an Image Stream Medical LiveStream server that sits in the central hub and communicates with the Crestron controllers in each operating room. Using a web interface developed by Image Stream Medical, doctors can access the web server and request any video feed they want from any OR. Once the request is made, the AutoPatch router sends the appropriate video to one of the 32 streaming servers in the hub, which converts the video into an MPEG-4 data stream and sends it out over the Web.
“The only thing we need to do before we deploy streaming video is develop a security system that will protect the streams from being viewed by unauthorized people,” says UAB's Mignault. “It's very important to us to protect patient privacy. We don't want to just throw streams out on the Web without being able to control access to those streams. So we're in the process of developing a system that will ensure proper protection of the streams.”
In the meantime, says Mignault, the hospital staff is enjoying all the other benefits that the AV system is providing them. “Everybody just loves it, from the surgeons to the biomedical engineering staff,” he says. “And now that they've had a chance to use it for awhile, people are coming up with all kinds of new ideas they want to add to the system. It's kind of like a boys-with-toys thing.”
Already Image Stream Medical is working on an enhancement that will make it possible for the DVRs in each operating room to record two streams at once. And Kontek says it's going to have to add a jack in each room so doctors can plug in their iPods.
“That was one of the more interesting requests,” laughs Newman. “It never dawned on us that surgeons would be packing iPods. But they are. iPods weren't really popular when we designed the system, so we put CD players in there, but no iPod jacks. So now that's on our wish list.”
“When we put this project out to bid, Kontek and Image Stream Medical were the only ones who said they could do everything we wanted,” says Mignault. “And they actually did it. They were right on the money. They weren't late on anything. We wanted a system that was cutting-edge and flexible enough to handle future growth and enhancements. And that's what they gave us.”
For More Information
Image Stream Medical
Middle Atlantic Products
National Display Systems
Stephen Porter is a freelance writer who has been covering video, graphics, and digital content creation technologies and applications for more than 18 years. He can be reached at firstname.lastname@example.org.
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