MP27: Designing team success - an engineering solution to avoid chest tube equipment chaos using best available evidence, consensus and prototyping

Background: Chest tube insertion is a time and safety critical procedure with a significant complication rate (up to 30%). Industry routinely uses Lean and ergonomic methodology to improve systems. This process improvement study used best evidence review, small group consensus, process mapping and prototyping in order to design a lean and ergonomically mindful equipment solution. Aim Statement: By simplifying and reorganising chest tube equipment, we aim to provide users with adequate equipment, reduce equipment waste, and wasted effort locating equipment. Measures & Design: The study was conducted between March 2018 and November 2018. An initial list of process steps from the best available evidence was produced. This list was then augmented by multispecialty team consensus (3 Emergency Physicians, 1 Thoracic Surgeon, 1 medical student, 2 EM nurses). Necessary equipment was identified. Next, two prototyping phases were conducted using a task trainer and a realistic interprofessional team (1 EM Physician, 1 ER Nurse, 1 Medical student) to refine the equipment list and packaging. A final equipment storage system was produced and evaluated by an interprofessional team during cadaver training using a survey and Likert scales. Evaluation/Results: There were 47 equipment items in the pre-intervention ED chest tube tray. After prototyping 21 items were removed while nine critical items were added. The nine items missing from the original design were found in four different locations in the department. Six physicians and seven RNs participated in cadaver testing and completed an evaluation survey of the new layout. Participants preferred the new storage design (Likert median 5, IQR of 1) over the current storage design (median of 1, IQR of 1). Discussion/Impact: The results suggest that the lean equipment storage is preferred by ED staff compared to the current set-up, may reduce time finding missing equipment, and will reduce waste. Future simulation work will quantitatively understand compliance with safety critical steps, user stress, wasted user time and cost.

Minimally Invasive Bilateral Anterior Cingulotomy via Open Minicraniotomy Using a Novel Multiport Cisternoscope: A Cadaveric Demonstration

BACKGROUND Bilateral anterior cingulotomy has been used to treat chronic pain, obsessive compulsive disorder, and addictions. Lesioning of the target area is typically performed using bilateral stereotactic electrode placement and target ablation, which involves transparenchymal access through both hemispheres. OBJECTIVE To evaluate an endoscopic direct-vision lesioning using a unilateral parasagittal minicraniotomy for minimally invasive bilateral anterior cingulotomy using a novel multiport endoscope through the anterior interhemispheric fissure. METHODS A novel multiport magnetic resonance imaging (MRI)-compatible neuroendoscope prototype is used to demonstrate cadaveric cingulate lesioning through a lateral imaging port while simultaneously viewing the pericallosal arteries as landmarks through a tip imaging port. The lateral port enables extended lesioning of the gyrus while rotation of the endoscope about its axis provides access to homologous areas of both hemispheres. RESULTS Cadaver testing confirmed the capability to navigate the multiport neuroendoscope between the hemispheres using concurrent imaging from the tip and lateral ports. The lateral port enabled exploration of the gyrus, visualization of lesioning, and subsequent inspection of lesions. Tip-port imaging provided navigational cues and allowed the operator to ensure that the endoscope tip did not contact tissue. The multiport design required instrument rotation in the coronal plane of only 20° to lesion both gyri, while a standard endoscope necessitated a rotation of 54°. CONCLUSION Multiport MRI-compatible endoscopy can be effectively used in cisternal endoscopy, whereby a unilateral parasagittal minicraniotomy can be used for endoscopic interhemispheric bilateral anterior cingulotomy.

New Adjustable Unloader Knee Brace and Its Effectiveness

Unloader knee braces are prescribed for patients with unicompartmental osteoarthritis of the knee. These braces aim to reduce pain in patients by applying a coronal moment to the knee to unload the symptomatic knee compartment. However, existing unloading mechanisms use straps that go directly behind the knee joint, to apply the needed moment. This can impinge on the popliteal artery and peroneal nerves thereby causing discomfort to the patient. Hence, these braces cannot be worn for prolonged periods of time. This research focused on developing a new knee brace to improve comfort while unloading the osteoarthritic knee. A new knee brace was developed that uses a four-point bending approach to unload the knee. In this brace, unloading can be adjusted, and the unloading mechanism is away from the joint. The new brace was tested on a cadaver specimen to quantify its capability to unload the knee compartment. The brace was also worn by a patient with osteoarthritis who subjectively compared it to his existing unloader brace. During cadaver testing, the new brace design could reduce the force exerted on the medial condyle by 25%. Radiographic images of the patient's knee confirmed that the brace unloaded the medial condyle successfully. The patient reported that the new brace reduced pain, was significantly comfortable to wear and could be used for a longer duration in comparison to his existing brace.

A multiport MR-compatible neuroendoscope: spanning the gap between rigid and flexible scopes

OBJECTIVE Rigid endoscopes enable minimally invasive access to the ventricular system; however, the operative field is limited to the instrument tip, necessitating rotation of the entire instrument and causing consequent tissue compression while reaching around corners. Although flexible endoscopes offer tip steerability to address this limitation, they are more difficult to control and provide fewer and smaller working channels. A middle ground between these instruments—a rigid endoscope that possesses multiple instrument ports (for example, one at the tip and one on the side)—is proposed in this article, and a prototype device is evaluated in the context of a third ventricular colloid cyst resection combined with septostomy. METHODS A prototype neuroendoscope was designed and fabricated to include 2 optical ports, one located at the instrument tip and one located laterally. Each optical port includes its own complementary metal-oxide semiconductor (CMOS) chip camera, light-emitting diode (LED) illumination, and working channels. The tip port incorporates a clear silicone optical window that provides 2 additional features. First, for enhanced safety during tool insertion, instruments can be initially seen inside the window before they extend from the scope tip. Second, the compliant tip can be pressed against tissue to enable visualization even in a blood-filled field. These capabilities were tested in fresh porcine brains. The image quality of the multiport endoscope was evaluated using test targets positioned at clinically relevant distances from each imaging port, comparing it with those of clinical rigid and flexible neuroendoscopes. Human cadaver testing was used to demonstrate third ventricular colloid cyst phantom resection through the tip port and a septostomy performed through the lateral port. To extend its utility in the treatment of periventricular tumors using MR-guided laser therapy, the device was designed to be MR compatible. Its functionality and compatibility inside a 3-T clinical scanner were also tested in a brain from a freshly euthanized female pig. RESULTS Testing in porcine brains confirmed the multiport endoscope's ability to visualize tissue in a blood-filled field and to operate inside a 3-T MRI scanner. Cadaver testing confirmed the device's utility in operating through both of its ports and performing combined third ventricular colloid cyst resection and septostomy with an endoscope rotation of less than 5°. CONCLUSIONS The proposed design provides freedom in selecting both the number and orientation of imaging and instrument ports, which can be customized for each ventricular pathological entity. The lightweight, easily manipulated device can provide added steerability while reducing the potential for the serious brain distortion that happens with rigid endoscope navigation. This capability would be particularly valuable in treating hydrocephalus, both primary and secondary (due to tumors, cysts, and so forth). Magnetic resonance compatibility can aid in endoscope-assisted ventricular aqueductal plasty and stenting, the management of multiloculated complex hydrocephalus, and postinflammatory hydrocephalus in which scarring obscures the ventricular anatomy.

Percutaneous Intracerebral Navigation by Duty-Cycled Spinning of Flexible Bevel-Tipped Needles

BACKGROUND: Intracerebral drug delivery using surgically placed microcatheters is a growing area of interest for potential treatment of a wide variety of neurological diseases, including tumors, neurodegenerative disorders, trauma, epilepsy, and stroke. Current catheter placement techniques are limited to straight trajectories. The development of an inexpensive system for flexible percutaneous intracranial navigation may be of significant clinical benefit. OBJECTIVE: Utilizing duty-cycled spinning of a flexible bevel-tipped needle, the authors devised and tested a means of achieving nonlinear trajectories for the navigation of catheters in the brain, which may be applicable to a wide variety of neurological diseases. METHODS: Exploiting the bending tendency of bevel-tipped needles due to their asymmetry, the authors devised and tested a means of generating curvilinear trajectories by spinning a needle with a variable duty cycle (ie, in on-off fashion). The technique can be performed using image guidance, and trajectories can be adjusted intraoperatively via joystick. Fifty-eight navigation trials were performed during cadaver testing to demonstrate the efficacy of the needle-steering system and to test its precision. RESULTS: The needle-steering system achieved a target acquisition error of 2 ± 1 mm, while demonstrating the ability to reach multiple targets from one burr hole using trajectories of varying curvature. CONCLUSION: The accuracy of the needle-steering system was demonstrated in a cadaveric model. Future studies will determine the safety of the device in vivo.