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Current Innovations

A Paper Submitted in Partial Fulfillment of the Requirements

For NURS5324

In the School of Nursing

The University of Texas at Tyler

by

Jennifer Davis

July 27, 2018

Technology is everywhere and constantly growing. As a nurse in the operating room I have seen many technical advances in surgery.  In the small town of Tyler, TX I have been a part of some of the first robotic surgical procedures.  One of the newest techniques for training in the operating room is virtual reality. Many different virtual reality programs are being used to train doctors and nurses on how to perform certain procedures.

Multiple advantages have been noted using virtual reality techniques in training operating room staff.  Virtual reality programs allow a person to practice at their own pace and repeat areas lacking sufficiency.  Another advantage in using virtual reality for training is cost. Many programs have been able to reduce cost in training by using virtual reality programs. Using virtual reality allows for mistakes.  Virtual reality programs allow the trainee to make errors and repeat steps without the harm to an actual patient due to error.

As great as virtual reality programs are there are several disadvantages to using a virtual reality programs for training of operating room staff.  The gold standard for training in the operating room is still hands on training with an actual patient. It has been said that nothing can replace the true feeling of instrumentation in hand working on a patient. The tactile feedback with virtual reality is still up for debate.

Virtual reality training still has many unknown pieces. No one knows the true value of virtual reality training in the operating room.  The one think known is that technical advances continue to be on the forefront of medicine.

References

Aïm, F., Lonjon, G., Hannouche, D., & Nizard, R. (2016). Effectiveness of Virtual Reality Training in Orthopaedic Surgery. Arthroscopy: The Journal of Arthroscopy & Related Surgery, 32(1), 224-232. doi:10.1016/j.arthro.2015.07.023

Forgione, A., & Guraya, S. Y. (2017). The cutting-edge training modalities and educational platforms for accredited surgical training: A systematic review. Journal Of Research In Medical Sciences, 22(1), 1-9. doi:10.4103/jrms.JRMS_809_16

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I am an achiever, activator, arranger, consistent, and learner. I have no problem in activating a plan of action. I will do whatever it takes to achieve my goals. I might have a little OCD/arranger abilities. My list helps me to organize and maximize best plan of action. I love to learn new skills. Anyone who works with me will tell you that I am consistent following rules set in place.

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My team would include Alice, Andrew, Carter, Daisy, and Daniel.
Andrew is the right person to get our project started with his ability of activation. Daisy and Alice will be able to get the project in motion. Carter's ability to communicate with others will help keep the team on track and organize our project. Daniel will make sure the everyone is held accountable for their contribution to the project. Each team member brings special characteristics that will allow optimization of our project.

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The Johnson & Johnson Institute has recently launched a virtual reality training program designed to prepare orthopedic surgeons and nurses for a couple common procedures. The program will expand to other surgeries, but for now it's focusing on total knee replacement with direct anterior approach and hip fracture treatment with a proximal femoral nail. The hope is that using virtual reality to learn and practice surgical techniques will help improve clinical outcomes for patients.

We spoke with David Badri, Virtual Reality and WW Professional Education at Johnson & Johnson, about the new program and what it means for clinicians, patients, and how its unique among other virtual reality offerings.

David Badri, J&J: The J&J Institute VR training program is designed to help enhance surgical techniques and drive greater patient outcomes. VR enables surgeons and nurses to train in a safe environment, providing them with flexibility, repeatability and direct feedback to enhance surgical techniques, reduce travel costs and save time. With VR, surgeons, nurses and residents can practice at their own pace and as often as they want until they master a procedure. This is especially critical for residents, given the few training hours they typically have because of their heavy workloads and work hour restrictions.

The program currently includes three unique VR training modules for orthopaedic surgery - Total Knee Replacement, Total Hip Replacement with Direct Anterior Approach and Hip Fracture Treatment with a Proximal Femoral Nail. With a variety of modules that meet clear educational needs, the program allows surgeons and nurses to refine their techniques, which can help enhance patient outcomes.

All instruments and implants in the VR training modules are designed to simulate real-world experiences in a fully immersive operating room, while anatomy and biomechanics provide an accurate scenario for the user.

Badri: I lead Global Educations Solutions for Johnson & Johnson Medical Devices, as well as the Johnson & Johnson Institute, which provides medical education for surgeons and other healthcare professionals around the world. One of the teams under my leadership focuses on further developing our digital ecosystem for which our VR training is a part.

For some background, in 2016, the Trauma department had developed a Virtual Reality simulation to showcase one of our new products in a gamified way. At this time, our team felt that this technology could be highly valuable for education. Together with our Global Marketing Department and one of our long-term external technology and design partners, we started to build a surgical module for total knee arthroplasty (TKA) that allowed for a full surgical procedure with the original instruments. We demonstrated it to our regional management and to some surgeons. Simultaneously, a second module on total hip arthroplasty (THA) was developed by Global Marketing. The reaction was so positive that we decided to bring the VR module to orthopedic congresses to gather additional feedback. One of our GES members did her Master's thesis on this project and found that 80 percent of 107 interviewed orthopaedic surgeons would like to use VR frequently for training after going through our module, and more than 90 percent would recommend this VR training to their peers. ¹

In the middle of 2017, different regions started pilots with our VR system. Later that year, it became clear that this would become a globally focused project.

Badri: We are using off the shelf hardware that was designed for the consumer market. Therefore, the technology can be used anywhere. The only thing you need is electricity and a room that is big enough to move in a safe way. This allows us to train people with VR inside or outside of our J&J facilities easily. All hardware fits into a quite small suitcase, so it's very light and flexible to transport.

Badri: We see different companies doing VR today. It's an available and affordable technology that triggers the imagination. When it comes to why we are creating a VR surgical trainer, there is a commonly accepted idea in the medical field about the importance of new technologies that allow HCPs to train efficiently and effectively.

Amongst all those solutions on the market, differentiation lies in the visual design of the modules, the way the procedures look & feel, instrumentation (which is easy for us as we develop and market these), the didactics, metrics and other factors. Standing out therefore challenges our creative spirit, especially since this is such a fast-moving technology. Still, I think we play a strong and potentially leading role in this space. Our big strength, however lies in one of the J&J core competencies and values: To provide the best possible education to our customers. This allows us to fully integrate our VR simulation into our educational curriculums and scale-up very quickly on a global level.
Medgadget: How does the experience compare to using real instruments and peg boards?
Badri: Real instruments and specimen labs are still the gold standard in surgical education. We are not aiming to replace this. Our goal is to cognitively prepare surgeons for their specimen training or surgery, allowing them to go through the procedure in a safe way as often as they want until they are comfortable with the procedure. This also includes some basic psychomotor skills. Interestingly, most surgeons that I've led through our VR modules would qualify this type of training as "hands-on", which is great feedback for us, as it shows how immersive the VR training is. If we are doing our job well, however, we might be able to reduce the number of specimens needed, which would be an outstanding achievement.

Badri: There is minimal tactile feedback. For example, when you drill or saw with a power tool, then you can feel the vibration in the handles. Otherwise, it's challenging to replicate haptic feedback with the standard handles (no matter if it's HTC Vive, Oculus or other systems). This would require additional hardware. We consciously sacrificed this type of haptic feedback for the benefit of being highly flexible and modular, as this way we can replicate almost every possible scenario without the need of additional hardware components. Of course, we sometimes hear that more tactile feedback would be great to have, that's easy to understand. However, I've rarely seen a (VR) medical simulator designed with tactile feedback that was REALLY giving you a clinically accurate feeling. And if you want to go there, you need to accept significantly less modularity by at the same time increasing the simulator costs by factor X. Interestingly, when asking surgeons after testing our VR modules if they have missed the tactile feedback, I quite often hear: Oh, there was none? The VR experience does something in the brain that gives people the impression that they feel something, which is truly astonishing.

Badri: We are partnering with Pixelmolkerei, a Swiss company with whom we've been working for the last 17 years in the orthopedic space. They are top notch 3D designers and have provided 3D media and technical innovation to us in this space for many years. They know us inside-out, share our culture and are also deep in VR. Together with them we develop our modules, the overall learner experience, the technical background systems etc.

Badri: As mentioned, we developed the VR system together with a long-term digital partner and started in 2016. This partner has worked with us for quite some time - 16 years in the orthopedic space. Orthopedic procedures are well suited for the VR technology for two major reasons: First, orthopedic surgeries are often open procedures (compared to laparoscopic procedures) which is optimal as you can use the handles like your hands to operate with different instruments, and you have a direct view on the surgical field. Second, bones are static objects that are easier to animate than organs.

From a strategic side, it was important for us to demonstrate that this is not just a technical gimmick, or a game. It's a real medical simulator. This was well accepted by surgeons right away once they tested it. They immediately understand the value and potential for their own training, and that of the younger surgeons and their OR staff.

From a technical side, we need to see that the current consumer headsets are still new technologies. Most of them have been launched just in the last 2 years. They are good to work with but not yet where we want them to be in terms of visual resolution, set-up and costs. However, this is a fast evolution, so we're looking forward to headsets that provide advanced performances and are simple plug-and-play.

Badri: From a hardware perspective, we are using off-the shelf technology that can be bought in electronic stores. This includes high-end gaming laptops , since the modules have 4K resolution and run with 90 fps. The high frame rate is important to allow a comfortable VR experience for the users. From a VR headset perspective, we have started to work with HTC Vive in 2016 as we felt that the tracking and movement flexibility was the best in class at that time. However, there is no perfect headset on the market yet. This is a fast-moving evolution and we are constantly scanning the market for the best next system. Our system is designed in a way that we can use whatever headset will be launched, using the same computers as the core platform. From a software perspective, the modules are programmed in "Unity", which also is general standard. The magic lies in what you are able to creatively do with this technology. We are dedicated to always push the boundaries in all technical and didactical dimensions to provide a first class learning experience.
More from J & J...
¹ Beke, Libi. "Exploring surgeon's acceptance of Virtual Reality headset for training." 2017.

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Orthopedic Surgeons are Training in Virtual Reality : Interview with J&J's David Badri |

# data[].attributes.attachment_link.description
The Johnson & Johnson Institute has recently launched a virtual reality training program designed to prepare orthopedic surgeons and nurses for a couple common procedures. The program will expand to other surgeries, but for now it's focusing on total knee replacement with direct anterior approach and hip fracture treatment with a proximal femoral nail.