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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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The Barnes Jewish Hospital, Washington University, St. Louis

Imagine this: You’re an anesthesiologist in the operating room at a busy hospital. Your patient is in mid-surgery, and you receive a call from the Anesthesia Control Tower that the patient’s blood pressure is too low, your blood transfusion replacement is inadequate, and that the patient is in danger. What do you do? How do you feel about all this?

Anesthesiologists at Barnes Jewish Hospital at Washington University in St. Louis, Missouri are studying a novel system they call the Anesthesia Control Tower (ACT). The ACT is a telemedicine-based intraoperative clinical support system. A team led by an attending anesthesiologist uses remote monitoring to provide evidence-based support to anesthesia colleagues in all the operating rooms. The ACT is similar in concept to an air traffic control tower. The clinicians in the Anesthesiology Control Tower, called ACTors, monitor operating rooms (ORs) in real time by following the electronic health records. Just as an air traffic control tower monitors aircraft and delivers information and alerts to the pilots, the ACT communicates with anesthesia providers to assist them in providing safe care.

A press article describing the ACT states: “Surgery is a big insult to the human body. A lot can go wrong. In fact, it does. An estimated 10 to 20 percent of patients who undergo major inpatient surgery experience major complications such as heart attacks, unremitting pain, infections, and blood clots in the weeks to months following their procedures; about two percent are dead within 30 days of surgery. Some of this morbidity and mortality may be preventable through early identification of risk factors and better communication to mitigate risks during the surgery. . . . Air traffic control concepts can predict high risks for healthcare complications and improve decision making.”

The Washington University ACT provides a watchful eye over 60 operating rooms at Barnes-Jewish Hospital, watching over nearly 1,000 patients per week.

A software program used in the ACT is called AlertWatch®. The ACT anesthesiologist (ACTor) watches a monitor displaying the Tower Mode census view (Figure 1 below), which shows an overview of all the patients in the ORs. Alerts or abnormal vital signs and laboratory results are represented by squares and triangles, respectively. Checkmarks indicate alerts that must be addressed by the ACT. The Tower Mode view looks like this (Figure 1):

Figure 1 Census View, Anesthesia Tower

The Tower Mode includes a display for each individual patient (Figure 2 below). The organ systems are labeled with relevant physiologic variables and values. Colors outline each organ, and include normal (green), marginal (yellow), or abnormal function (red). The left side of the display shows patient case information. Information regarding the patient’s medical problems can be accessed by selecting the organ system or laboratory study of interest. The black checkmark at the bottom of the left panel indicates that there is an active alert for the ACT clinicians to address (Figure 2 below):

Figure 2 Individual Patient Display, Anesthesia Tower

Clicking on the checkmark opens the case review dialogue, which looks like this (Figure 3):

Figure 3, Case Review Dialogue, Anesthesia Tower

The Anesthesia Control Tower is physically located within the hospital complex, but is remote from the operating rooms. Washington University has expanded the ACT to include the Recovery Control Tower, which provides similar surveillance over patients in the Post Anesthesia Care Unit (PACU).

This photograph below depicts the Anesthesia Control Tower manpower at work at Barnes Jewish Hospital at Washington University in St. Louis:

Monitoring surgeries from the Anesthesiology Control Tower (left to right): Omokhaye M. Higo, MD, vice chair for innovation, Thaddeus Budelier, MD, program manager for the Perioperative Innovation Center, and Bradley A. Fritz, MD, assistant professor of anesthesiology, Washington University Medical School.

Some anesthesiologists were initially skeptical about the ACT idea. But Washington University Anesthesia Chairman Dr. Michael Avidan stated, “Most of the skepticism has evaporated over time as clinicians have perceived that innovation and technology are not threats, but rather enhancements. The conceptualization of our Perioperative Innovation Center is more akin to ‘phone a friend’ than it is to a sinister ‘big brother.’”

Current staffing levels of anesthesia professionals in the United States are inadequate. The shortage of anesthesia professionals, particularly in rural areas, may someday be remedied by a telemedicine system which resembles the ACT. We may someday see anesthesia managed by less highly trained persons in the OR, with an ACTor backing them up by watching from on high.

Anesthesiologists who supervise Certified Registered Nurse Anesthetists (CRNAs) or Anesthesia Assistants (AAs) in an anesthesia care team model often have to provide care for multiple patients simultaneously. These attending anesthesiologists cannot physically be present in multiple operating rooms at all times. These anesthesiologists may be aided by Anesthesia Control Tower technology, which continually assesses patients for signs of deterioration and alerts the attending anesthesiologist when an adverse event is brewing.

If the Anesthesia Control Tower is to become a standard in hospital care, we need to know if the ACT changes medical outcomes. Washington University is conducting a study randomizing thousands of adult surgical patients in their operating rooms to an intervention group (ACT) or to a control group without ACT. An estimated 10,000 patients will be enrolled per year, and over four years approximately 40,000 total patients will be enrolled. Data from this study are as yet unavailable.

The goals of this clinical trial are 1) to develop machine-learning algorithms for forecasting perioperative adverse events; 2) to develop a clinical decision support system that suggests interventions based on the algorithms, and 3) to change the paradigm of perioperative care.

Will physicians and patients see the ACT model in the near future? Significant issues regarding the adoption of Anesthesia Control Tower technology include:

Documenting that ACT provides an improvement. A critical barrier for anesthesiologists, hospitals, and policy makers nationwide will be documenting that the ACT demonstrates an improvement in costs, patient outcomes, or patient experience. None of these things are apparent at this time.
Paying for the ACT equipment and the ACTor on duty will be an issue. Additional hardware and software would be required at each hospital. An in-person anesthesiologist is already being paid to do each case, and the ACTor is another level of anesthesia staffing someone is going to have to pay for.
Anesthesiologist opposition. A challenging barriers will be how anesthesiologists perceive systems like the ACT. Anesthesiologists are trained to be vigilant and manage their patients themselves. Having the ACT peering into the operating room, perhaps with a video camera watching the operating room, will likely be unpopular with the anesthesiologists being observed. There may also be concern that data from the ACT could be used against physicians in the event of a malpractice lawsuit. When the topic of the Anesthesia Control Tower was breached, one of my physician anesthesiologist colleagues remarked, “If that system becomes standard, I’m quitting.”
Lack of need for an ACT in ambulatory settings. According to a 2017 study by the Centers for Medicare and Medicaid Services, the majority of surgical procedures in the United States, fully 70 percent, occur in ambulatory surgery centers or offices outside of hospitals. These outpatient procedures are predominantly smaller surgeries conducted on healthier patients. These smaller ambulatory facilities would have no use for the ACT, both because patients are healthier and because the surgical procedures incur less risk and fewer complications. The costs of an ACT in these smaller settings would be unlikely bring any benefit.
Flawed analogy. Air traffic controllers exist to coordinate takeoffs and landings, so planes do not collide with each other in the air or on the runways. In anesthesiology, operating room patients will not collide with each other and do not have traffic issues with each other. Instead, the Anesthesia Control Tower will scrutinize each patient’s data for abnormalities that will predict a pending complication.
The ACT and the algorithms developed through the ACT will likely be a transitional technology. Having one anesthesiologist (the ACTor) overseeing multiple operating rooms will likely be a steppingstone to Artificial Intelligence technology in which a computer oversees the data from each operating room, with the aim to detect and prevent adverse outcomes from developing. The arrival of ChatGPT foreshadows the AI technology about to bloom in healthcare. In the future the anesthesia provider in each operating room will likely be backed up by AI technology enforcing algorithms, rather than being backed up by a human in a control tower. I described this healthcare evolution in my 2019 book Doctor Vita, in which Artificial Intelligence in the form of inexpensive, internet-connected computers took over a California medical center and changed the face of medicine forever.

Improving vigilance and improving outcomes is the ultimate goal of ACT technology. Further data on the Anesthesia Control Tower will be forthcoming. We’ll await the prospective controlled studies, and then we’ll all learn whether or not this technology is an advance to help patients and physicians.