Operating Room Research Articles

The First Surgery Experienced Through Virtual Reality: A Knee Surgery Case Report

The decision to undergo surgery and the significance of the operating theater environment are influenced by several factors, which vary from person to person. Negative perceptions of the operating room environment can influence the decision to undergo surgery and the process of treatment. Virtual reality (VR) technology offers the potential to alter individuals' environmental encounters through the provision of diverse environmental perceptions. This case study evaluates the results of a VR simulation applied during surgery to an individual with no previous surgical experience. A male patient scheduled for arthroscopic meniscus surgery was the subject of a VR simulation. The patient's perception of the simulated environment was transmitted through VR goggles from the time he entered the operating room until he left. However, the VR application was terminated during the administration of anesthesia, and no premedication was administered to the patient. The VR application included nature walks in various regions, including forests, lakeshores, and meadows, accompanied by the sound of birds. Data were collected using a visual analog scale to assess pain levels and a walking test form. The patient, a 35-year-old male, is a high school graduate and is undergoing his first surgical procedure. The patient expressed concerns and fears regarding the decision to undergo surgery. The patient's preoperative anxiety was rated at 9 out of 10 but subsequently decreased to 1 out of 10 following the surgical procedure. The patient rated his satisfaction with the surgical experience as 9 out of 10. The patient did not require sedatives or analgesics during the intraoperative period or for the first 10 hours following the operation. The patient was successfully mobilized at the 15-hour mark following surgery. The patient was highly satisfied with the application. The utilization of VR during surgical procedures has the potential to reduce the necessity for premedication and enhance postoperative compliance among patients.

Worse cholecystectomy outcomes during the COVID-19 pandemic: were staff shortages or a change in patient case-mix the culprit?

The COVID-19 pandemic has profoundly impacted the field of surgery, mostly through infectious risks, staff shortages, reduced hospital capacities, and changed patient pathways. Prompted by an increase in wound complications, we performed an in-depth analysis of an example surgical procedure. A consecutive cohort of 195 patients undergoing laparoscopic cholecystectomy was studied retrospectively. Data of patients receiving cholecystectomy before, during, and after the peak of the pandemic were compared. The potential influence of patient characteristics, pandemic phase, and staffing level (surgeons and nurse assistants) was analyzed statistically. In the primary analyses, the composite measure of a 'textbook outcome' was examined, which was defined as no relevant complication, hospital stay < 5days, and no readmission. During the COVID-19 phase, acute biliary disease was more common than in the pre-COVID-19 phase (62% vs. 30%). In 35% of cases, no qualified operating room nurse was available. Intraoperative features and postoperative complication rates were increased (bile spillage in 46%, wound complications in 24%). A 59-year-old male admitted with acute cholecystitis during COVID-19 died of wound-related septic shock. Multivariate analysis confirmed the acuity of gallbladder inflammation (odds ratio 5.3) and old age (2.6) as risk factors for a non-textbook outcome. The absence of qualified nursing staff was clearly associated with a non-textbook outcome (odds ratio 3.3). The fact that laparoscopic cholecystectomy outcomes were worse during COVID-19 can be partly attributed to a change in patient case-mix, but the shortage of qualified nursing staff in the operating room also had a strong negative influence.

Bracing urban governance against climate crises: How to integrate high reliability into strategic decision‐making?

AbstractTurning cities socio‐ecologically resilient is one of the pressing challenges in the face of ongoing climate change and accompanying extreme weather events. Despite concentrated efforts within specific urban domains, there exists a necessity for a coordinating mechanism that can concurrently monitor signals of slowly maturing long‐term crises, such as global warming and swiftly intervene to mitigate urgent threats, such as catastrophic floods. This article explores the potential of high reliability principles to inform such a governance mechanism through a novel policy operations room (POR) framework, conceptualizing urban strategic goals as critical infrastructure. We analyze the conditions for integrating elements from top‐down crisis management with bottom‐up participatory scenario exercises and policy simulations in urban governance. Based on pre‐ and post‐POR interviews and meeting transcripts in three Finnish cities we examine the regulative, normative, and cognitive aspects of integration. The analysis indicates that the implementation of a high reliability framework in urban settings can provide valuable support for addressing challenges induced by climate change.

Detecting clinical medication errors with AI enabled wearable cameras

Drug-related errors are a leading cause of preventable patient harm in the clinical setting. We present the first wearable camera system to automatically detect potential errors, prior to medication delivery. We demonstrate that using deep learning algorithms, our system can detect and classify drug labels on syringes and vials in drug preparation events recorded in real-world operating rooms. We created a first-of-its-kind large-scale video dataset from head-mounted cameras comprising 4K footage across 13 anesthesiology providers, 2 hospitals and 17 operating rooms over 55 days. The system was evaluated on 418 drug draw events in routine patient care and a controlled environment and achieved 99.6% sensitivity and 98.8% specificity at detecting vial swap errors. These results suggest that our wearable camera system has the potential to provide a secondary check when a medication is selected for a patient, and a chance to intervene before a potential medical error.

Pelvic Traumas and Hybrid Emergency Medicine System: Literature Review Based on Two Cases

Objective: Bleeding, the most common life-threatening complication of pelvic trauma occurs due to injuries of pelvic arterial and venous structures and bone fractures. The outcomes of patients can be improved by a timely performed angioembolisation (AE). Hybrid Emergency Service System (HERS) has been recently introduced a novel approach which provides trauma resuscitation room equipped with computerized tomography, fluoroscopy, and an operating room, thus effects the outcomes of trauma patients. Cases: We presented two pelvic traumas and in both cases with the most common life-threatening complication was bleeding. In both cases, whole-body computed tomography (WBCT), endovascular procedures (Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), transcatheter arterial embolization (TAE)), and injury control surgery can be simultaneously performed without the need to transport a patient to an operating room which is called HERS resuscitation. Both patients were discharged and remained free of any medical problem at long-term (12 months) follow-up. Conclusion: Considering the recently introduced HERS system in patient management and integrating it into emergency services will be extremely useful in the management of trauma and trauma-induced bleeding.

Energy Consumption Trends and Determinants in Polish Hospitals: Implications for Energy Efficiency Strategies

In the construction sector, hospitals are the buildings with the highest energy consumption. Due to the high demand for energy, hospitals’ energy efficiency is becoming very important. This study aims to examine the trends and factors that determine energy consumption in Polish hospitals from 2010 to 2019, highlighting the impact of hospital size and medical activities on energy efficiency. The analysis was carried out using data from 3061 hospital reports obtained from the e-Health Center, a state budgetary unit established by the Minister of Health. To measure and compare the efficiency of energy usage in hospitals, we developed eight energy usage efficiency indexes based on hospital size and medical activity. The size of the hospitals was described by the number of beds, operation rooms, doctors, nurses, and fixed assets value. Hospital activity was measured by the number of person-days, patients, and operations. Statistical analysis was carried out using StatSoft Statistica software version 13.3. The results show that larger hospitals are more energy efficient across various measures of energy use than smaller hospitals. The findings revealed also several important relationships between energy usage and factors connected with size and hospital activity, such as the number of beds, patients and person-days, medical staff, operations, and fixed asset values, underscoring the necessity for customizing energy efficiency strategies. This research contributes empirical insights that can guide policymakers and hospital administrators in their endeavors to improve energy efficiency and promote sustainability within healthcare facilities.

Extended Reality Applications in Otolaryngology Beyond the Operating Room: A Scoping Review.

Objective: Extended reality (XR) has increasing usage in medicine, especially surgical fields, but the scope of applications is largely limited to intraoperative navigation. The aim of this scoping review is to evaluate all the available literature on how XR technologies have been applied to otolaryngology-head and neck surgery (OHNS) beyond the operating room for applications such as patient education and interdisciplinary communication. Review Methods: Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, we systematically searched PubMed and Scopus. Studies were reviewed without temporal restriction. Inclusion criteria comprised English-language, peer-review papers or conference abstracts studying XR technologies for non-operative uses such as patient education, physician training, or interdisciplinary preoperative planning in the field of OHNS. Results: Database searching initially identified 1607 records. After filtering for duplicates, screening for relevance, and applying the inclusion criteria, 10 studies were ultimately included. This study identifies gaps in the existing literature and describes future applications and key areas of research. XR is a novel strategy for increasing patients' comprehension of their procedures and can facilitate improved communication and planning amongst a multidisciplinary surgical team during preoperative discussions. However, the existing literature is small in scale and has low statistical power for demonstrating clinical benefits. Conclusions: More robust studies are required to determine the true value of implementing XR. XR is a promising new technology with potential to advance education and patient care in OHNS. Ongoing research will continue to optimize the use of XR technology, ensuring safe and effective integration into clinical practice.

From Knowledge Transfer to Capability Development: The Future of PBL + CBL Teaching Method in Operating Room Nursing Education

Concomitant with the advancement of contemporary medical technology, the significance of perioperative nursing has been increasingly accentuated, necessitating elevated standards for the pedagogy of perioperative nursing. Presently, the PBL (problem-based learning) pedagogical approach, when integrated with CBL (case-based learning), has garnered considerable interest. An extensive literature review has been conducted to analyze the application of the PBL-CBL fusion in the education of perioperative nursing. Findings indicate that this integrative teaching methodology not only enhances students’ theoretical knowledge, practical competencies, and collaborative skills but also contributes to the elevation of teaching quality. In conclusion, the PBL-CBL teaching approach holds immense potential for broader application in perioperative nursing education. Nevertheless, it is imperative to continually refine this combined pedagogical strategy to further enhance the caliber of perioperative nursing instruction and to cultivate a greater number of exceptional nursing professionals in the operating room setting.

Assessing use of the WHO surgical safety checklist for pediatric surgery in Senegal: A nationwide survey

Introduction The World Health Organization (WHO) introduced the surgical safety checklist (SSC) to reduce postoperative morbidity and mortality; however, its use in low- and middle-income countries is still low. Methods We conducted a survey from January 2 to 22, 2024, in public hospitals’ pediatric surgery departments and units in Senegal to assess the use of the WHO SSC or an adapted version. Results The participation rate was 100% (23 hospitals), with 11 second-level hospitals (47.8%) and 10 (43.5%) having at least two pediatric surgeons. All hospitals had an anesthetist nurse, and 18 hospitals (78.3%) had at least two scrub nurses. For the surgical workload, 14 hospitals (60.9%) had five to 10 surgical interventions weekly. Eleven hospitals (47.8%) had training on use of the SSC, and 8 of the 23 hospitals (34.8%) used the SSC. The WHO SSC nonutilization was mainly due to a lack of training in nine hospitals (60%) and SSC unavailability in five hospitals (33.3%). Members of 22 hospitals (95.6%) were available for training on use of the SSC. Conclusion The WHO SSC is poorly used in pediatric operating rooms of public hospitals in Senegal. The main reasons for nonutilization are remediable.

Clinical implementation of the Validated Intraoperative Bleeding Scale: Perioperative patient management and effective team communication from the nurses' perspective.

Major bleeding represents a critical scenario that can quickly evolve into life threatening, thereby compromising patient safety. A Validated Intraoperative Bleeding Scale called VIBe Scale was introduced and studied as part of a quality improvement initiative. This study evaluated the clinical implementation of the VIBe Scale in perioperative patient management and team communication from the nurses' perspectives. A descriptive study was undertaken, incorporating introductory lecture, simulation of major bleeding event and post-lecture questionnaire with 33 operating room nurses. Despite many participants not previously having experience of the VIBe Scale in practice, over two-thirds reported the scale could improve situational awareness. Furthermore, nearly two-thirds reported they could see the utility of the VIBe Scale as a tool to improve communication. Our study shows that the VIBe Scale is an easily understood concept, has the potential to increase situational awareness and can support team communication around intraoperative bleeding events.

Quantifying Medical Waste at a Veterans Affairs Operating Room.

Introduction: Medical waste is an environmental, financial, and administrative burden to the health care system. Attempts to decrease waste should begin by quantifying the amount of waste at an individual facility. This study attempts to quantify the amount of medical waste associated with operative cases at an urban Veterans Affairs Medical Center (VAMC). Methods: The study was a prospective of analysis of surplus equipment and supplies accumulated by a single surgical team over a 6-week period from a VAMC operating room. The equipment and supplies were counted and weighed. The cost of the most common items was calculated using standard procurement values. Results: Overall, there were 81 pieces of surplus equipment and 1122 pieces of surplus medical supplies. The most common piece of equipment was a towel clip, and the most common medical supply was a blue towel. The total weight of the equipment was 72.2 kg. The five most common items were blue towels, suture, gloves, gowns, and gauze pads. Based on standard pricing, the individual price for each of the five above items was $1.32, $1.84, $4.05, $5.74, and $0.13, respectively. Over the 6-week period, the total cost of the five most common items was $1,764.56. Finally, the total weight of the surplus items was 72.2 kg. Conclusions: Operative waste includes equipment and supplies that increase time, effort, and costs. Quantifying the waste allows each facility the opportunity to introduce potential strategies to reduce extraneous medical equipment and supplies.

EVALUATION OF POSTOPERATİVE MORBİDİTY FOLLOWİNG OPERATIONS OF IMPACTED MANDIBULAR THIRD MOLARS WITH BONE RETENTION

This study is aimed to see how gender and whether tooth is placed on the right or left affected the length of the operation, edema, trismus, and discomfort after surgical extraction of an impacted mandibular third molar. This prospective study was conducted in the Inonu University. The study included 104 mandibular wisdom tooth with bone retention. There were 55 females and 49 males among the 104 patients, with 53 left and 51 right impacted mandibular third molar. The operations were performed by the same surgeon in the same operating room. The time between the incision and the suture was determined and recorded as the operation time for each procedure. Before surgery, on the 2nd postoperative day, and on the 7th postoperative day, the patients were compared in terms of facial swelling impacted mandibular third molar, discomfort, and trismus. IBM SPSS V23 was used to evaluate the data. The left impacted mandibular third molar extraction takes longer than the right impacted mandibular third molar extraction. Tooth 38, which have a longer operation time, are more prone to swelling, discomfort, and trismus. When tooths are extracted, right-handed surgeons cause less postoperative morbidity 48. We recommend that both right-handed, left-handed surgeons operate in clinics that conduct impacted tooth extractions.

The Value of Refined Nursing Management for Surgical Efficiency, Postoperative Recovery, and Stress Response in Laparoscopic General Surgery.

The study aimed to explore the impact of refined nursing management in the operating room on surgical efficiency, postoperative recovery, and stress responses in patients undergoing laparoscopic general surgery. A retrospective analysis was conducted on 100 patients who underwent laparoscopic surgery at Zhongnan Hospital of Wuhan University between March 2023 and March 2024. The control group comprised 48 cases receiving conventional operating room nursing, while the observation group comprised 52 cases receiving refined nursing management in the operating room in addition to the conventional care. Comparisons were conducted between the two groups regarding surgical efficiency, postoperative recovery, postoperative stress indicators, psychological status before and after nursing, overall treatment comfort, perioperative complications, and nursing satisfaction. The observation group showed statistically significant improvements in surgical efficiency, postoperative recovery, and stress indicators compared to the control group. After the intervention, the Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores of both groups significantly decreased compared to pre-nursing levels (p < 0.05), while such decrease was notably higher in the observation group (p < 0.05). Patients in the observation group reported significantly higher post-nursing comfort levels (p < 0.05) and exhibited significantly fewer perioperative complications (p < 0.05) compared to the control group. Furthermore, the nurses indicated significantly higher satisfaction with patient care in the observation group (p < 0.05). Implementing refined nursing in the operating room for laparoscopic general surgery can facilitate the recovery of gastrointestinal function, reduce postoperative recovery time, prevent complications, improve patients' psychological state, and enhance their quality of life.

Effectiveness of video-based teaching in surgery residents: A randomized control trial.

To determine the effectiveness of video-based teaching in surgery residents by comparing it to the routine operating room traditional teaching. The randomized control trial was done at four institutions from September 2022 to March 2023. Interventional group underwent video-based instruction of basic surgical skills whereas the control group was taught through traditional operating room teaching. Pre and post-test mean scores were analyzed on SPSS version 20 through paired t-test. Learning gain was calculated. Supervisors' perceptions were recorded on survey form regarding direct observations and recorded video evaluations of resident skills on post-test. Out of sixty (n=60), fifty-five newly inducted surgical residents completed the study including both females (n=13) and male residents (n=42). Video intervention Group (27.93±3.72) and control group (23.07±4.62) both showed improvements in their post-test scores as compared to pretest scores of 13.68±3.25 and 13.52±3.60 respectively. Mean score difference improvement was more in video intervention group (13.9±3.8) in comparison to control group (9.5±4.3) provided both groups exhibits improvements in all seven domains of the global rating system (reflected by the p <0.0001). However, learning gain of 65% was observed in intervention group as compared to learning gain (41%) of control group. Evaluators(n=5) observed that recorded video evaluations helped to provide integrated feedback, despite being time (40%) and resource intensive (60%). Video-based teaching has higher learning gain irrespective of the fact that both groups exhibit statistically significant results in all seven domains of the global rating system. Recorded video evaluation was found feasible and reliable tool for formative assessment.

Training and education of operating room nurses in robot-assisted surgery: a systematic review.

With the introduction of robot-assisted surgery, the role and responsibility of the operating room nurses have been expanded. The surgical team for robotic-assisted surgery depends on the ability of the operating room nurses to operate and handle the robotic system before, during, and after procedures. However, operating room nurses must acquire the necessary competencies for robotic-assisted surgery. We performed a systematic review using the databases MEDLINE and EMBASE to review the evidence on educating and training operating room nurses in robot-assisted surgery. Studies describing operating room nurses' training and team-training with operating room nurses for robot-assisted surgery were included. The Medical Education Research Study Quality Instrument (MERSQI) and the Newcastle-Ottawa Scale-Education (NOS-E) were used to evaluate the quality of the included studies. We identified 3351 potential studies and included 16 in the final synthesis. Nine studies focused on team-training in robot-assisted surgery: four focused solely on training for operating room nurses, and only three on operating room nurses as first assistants in robot-assisted surgery. Most studies examined team-training in RAS, including OR nurses, focused on emergency situations and conversion to an open procedure. Only a few studies addressed other competencies relevant to OR nurses in RAS. No randomized controlled trials were identified. Only a few studies used pre- and post-testing, and only one examined clinical outcomes. The quality assessment of the included studies was moderate to low, with a median MERSQI score of 10.3 and a median NOS-E score of 2. There is sparse research on the education of operating room nurses in robot-assisted surgery, and the literature emphasizes the training of surgeons. More research is needed to develop evidence-based training for operating room nurses in robot-assisted surgery.

Single-Stage Image-Guided Percutaneous Ablation with Thoracoscopic Resection for Multiple Pulmonary Lesions in a Hybrid Operating Room: A Retrospective Study.

Different approaches are required in treating patients with multiple pulmonary lesions. A multistage procedure may increase the risk of complications and patient discomfort. This study reports an initial experience with single-stage management of multiple lung lesions using percutaneous ablation with thoracoscopic resection in a hybrid operating room (HOR). We retrospectively evaluated patients who underwent combined ablation and resection in an HOR between May 2022 and July 2024. All patients received a single anesthesia via endotracheal tube intubation. The clinical data, operative findings, and pathological characteristics of the lung nodules were recorded. A total of 22 patients were enrolled in this study. Twenty patients underwent unilateral procedures, while the other two patients underwent bilateral procedures. Ablations were performed before lung resection in 21 patients; only 1 patient underwent surgery first. The median global operating room time was 227.0 min. The median total radiation dose (dose area product) was 14,076 μGym2. The median hospital postoperative length of stay was 2 days. The single-stage procedure of percutaneous ablation with thoracoscopic resection under general anesthesia in an HOR is feasible and safe. This procedure is an alternative method for managing multiple pulmonary lesions.

Transcutaneous carbon dioxide monitoring in children undergoing rigid bronchoscopy: a prospective blinded observational study.

Anesthetic management during rigid bronchoscopy in children can be challenging, and continuous end-tidal carbon dioxide (EtCO2) monitoring is often unachievable. Transcutaneous carbon dioxide (TcCO2) monitoring is strongly correlated with the partial pressure of carbon dioxide (PaCO2) and EtCO2. We aimed to investigate the incidence of hypercapnia in children undergoing rigid bronchoscopy. We enrolled patients aged < 18yr scheduled for rigid bronchoscopy in a prospective observational study. We recorded TcCO2 values from anesthesia induction to the postanesthesia care unit (PACU) stay. We ended monitoring when TcCO2 reached values ≤ 50mm Hg. The operating room (OR) team was blinded to the TcCO2. The outcome of primary interest was the incidence of hypercapnia (TcCO2 > 50mm Hg) in the OR. Other outcomes were the incidences of hypercapnia in the PACU and severe hypercapnia (TcCO2 > 90mm Hg), factors possibly related to hypercapnia (patient, surgery, or anesthesia factors), and the incidence of perioperative adverse events. A total of 30 patients were enrolled. The median [interquartile range (IQR)] age was 3.5 [1.5-8.0] yr. The incidence of hypercapnia was 100% in the OR and 60% in the PACU. Five cases (17%) presented with severe hypercapnia in the OR. The highest median [IQR] TcCO2 was 69 [61-79] mm Hg. The most common adverse event was oxygen desaturation (57%, 17/30). Patients with severe hypercapnia had long stays in the PACU. Hypercapnia was a frequent event in children undergoing rigid bronchoscopy and severe hypercapnia was associated with a long PACU stay. Further studies are needed to assess the utility of TcCO2 monitoring in guiding ventilatory interventions during these cases.

Impact of Applying PDCA Circulation Method on Surgical Care Interventions in the Operating Room on Patients Undergoing Cardiothoracic Surgery: A Retrospective Study

Background: The Plan-Do-Check-Act (PDCA) cycle is a widely recognized methodology for continuous quality improvement. This study evaluated the impact of applying the PDCA cycle on surgical care interventions in the operating room for patients undergoing cardiothoracic surgery. Methods: A retrospective study was conducted on the treatment of patients who underwent continuous cardiothoracic surgery in our Hospital from July 2020 to June 2023. Participants were divided into control and PDCA groups on the basis of the application of the PDCA cycle in their surgical care. Various outcomes were assessed, including psychological well-being (Hospital Anxiety and Depression Scale [HAMA] and Hamilton Depression Rating Scale [HAMD] scales), quality of life (using the QLQ-C30 tool), patient satisfaction, incidence of adverse accidents, clinical parameters, and laboratory measures. Results: The study comprised 133 patients, with 62 in the control group and 71 in the PDCA group. The psychological well-being, as measured by the HAMA and HAMD scales, of the PDCA group showed significant improvements compared with that of the control group (p &lt; 0.05). The Quality-of-Life scores were higher in the PDCA group than in the control group (p &lt; 0.05). In the PDCA group, the patient satisfaction scores related to hospital satisfaction were significantly higher than that in the control group, and the incidence of adverse accidents was lower (all p &lt; 0.05). No significant differences were noted in clinical parameters (ejection fraction and B-type natriuretic peptide levels) nor laboratory measures (serum protein and C-reactive protein (CRP) levels) between the groups (p &gt; 0.05 for all). Conclusion: The implementation of the PDCA cycle in the operating room for patients undergoing cardiothoracic surgery significantly improved psychological well-being and patient satisfaction and reduced the incidence of adverse accidents in the operating room, indicating that this quality improvement approach can enhance patient care experience. Although no significant differences were observed in clinical and laboratory parameters, the findings suggest that the PDCA cycle's strengths lie in its systematic approach to care process optimization and patient-centered outcomes.

A Primer on Optimizing Ergonomics in the Operating Room

This Viewpoint outlines ergononmical best practices in surgery and advocates for adherance to these best practices for surgeons’ longevity and comfort.

Understanding the challenges of robotic-assisted surgery adoption: Perspectives from stakeholders and the general population on human-interaction, built environment, and training

This study aims to explore adoption barriers from three aspects critical to facilitating robotic-assisted-surgery (RAS) adoption: the human-robot-interaction, built-environment, and training. Guidelines for research and design are identified from these perspectives. This study consisted of three phases: 1) surveys to RAS stakeholders and a crowd-sourcing survey; 2) stakeholder focus groups; and 3) a workshop with subject-matter experts to prioritize future research for RAS. Barriers from the human-robot-interaction perspective include hesitancy among clinicians to trust automation and physical discomfort during prolonged RAS. Barriers impeding communication and workflow disruptions were identified considering the built-environment. Training barriers were exemplified by varying curriculums from formal (courses) to informal (peer training) for surgeons. Crowd-sourced survey results suggest socio-economic status plays a role in RAS perception. Design guidelines include: 1) improved ergonomics; 2) deliberate introduction of automation; 3) sufficient in-room storage for prospective operating rooms; and 4) the development of compact RAS devices for older/smaller rooms.