A Natural and Immersive Virtual Interface for the Surgical
Safety Checklist Training
Andrea Ferracani, Daniele Pezzatini, Alberto Del Bimbo Universit degli Studi di Firenze - MICC Firenze, Italy [name.surname]@uni.it ABSTRACT Serious games have been widely exploited in medicine train- ing and rehabilitations. Although many medical simulators exist with the aim to train personal skills of medical oper- ators, only few of them take into account cooperation be- tween team members. After the introduction of the Surgical Safety Checklist by the World Health Organization (WHO), that has to be carried out by surgical team members, several studies have proved that the adoption of this procedure can remarkably reduce the risk of surgical crisis. In this paper we introduce a natural interface featuring an interactive virtual environment that aims to train medical professionals in fol- lowing security procedures proposed by the WHO adopting a serious game approach. The system presents a realistic and immersive 3D interface and allows multiple users to interact using vocal input and hand gestures. Natural interactions between users and the simulator are obtained exploiting the Microsoft Kinect TM sensor. The game can be seen as a role play game in which every trainee has to perform the correct steps of the checklist accordingly to his/her professional role in the medical team. Categories and Subject Descriptors H.5.2 [Information Systems Applications]: Information Interfaces and PresentationMiscellaneous; J.3 [Computer Applications ]: Life and Medical SciencesHealth General Terms Gaming, edutainment, human factors, health Keywords Serious games, medical training, immersive environments, Surgical Safety Checklist Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for prot or commercial advantage and that copies bear this notice and the full cita- tion on the rst page. Copyrights for components of this work owned by others than ACM must be honored. Abstracting with credit is permitted. To copy otherwise, or re- publish, to post on servers or to redistribute to lists, requires prior specic permission and/or a fee. Request permissions from Permissions@acm.org. SeriousGames14, November 07 2014, Orlando, FL, USA Copyright 2014 ACM 978-1-4503-3121-0/14/11. $15.00. http://dx.doi.org/10.1145/2656719.2656725. 1. INTRODUCTION The concept of serious games has been used since the 1960s whenever referring to solutions adopting gaming with educational purpose rather than pure players entertainment [1]. Among the several elds on which serious games have been exploited, medicine is one the most prolic [12] count- ing a large number of applications that feature Immersive Virtual Environments (IVEs). Improvements in medical training using gaming and IVEs have been brought out es- pecially in the eld of surgical education where IVEs already play a signicant role in training programmes [20][7]. The O-Pump Coronary Artery Bypass (OPCAB) game [8] and the Total Knee Arthroplasty game [9], for exam- ple, focus on the training of decision steps in a virtual op- erating room. Serious games featuring IVEs about dier- ent topics are Pulse! [6], for acute care and critical care, CAVE TM triage training [3] or Burn Center TM for the treat- ment of burn injuries [17]. Though all these medical training simulators focus on individual skills, an important aspect of healthcare to be taken into account is that, for the most, it has to be provided by teams. Common techniques of team training in hospitals include apprenticeship, role playing and rehearsal and involve high costs due to the required per- sonnel, simulated scenarios that often lack realism, and the large amount of time needed. Several serious games fea- turing IVEs for team training have also been developed in the last years. 3DiTeams [6], CliniSpace TM [18], HumanSim [22], Virtual ED [26] and Virtual ED II [14] are some ex- amples of games in team training for acute and critical care whose main objective is to identify and reduce the weak- nesses in operational procedures. A virtual environment for training combat medics has been developed by Wiederhold and Wiederhold [25] to prevent the eventuality of post trau- matic stress disorder. Medical team training for emergency rst response has been developed as systems distributed over the network by Alverson et al. [2] and Kaufman et al. [16]. IVEs have proved to be an eective educational tool. Tasks can be repeated in a safe environment and as often as re- quired. IVEs, in fact, allow to realistically experience a wide range of situations that would be impossible to replicate in the real world due to danger, complexity and impracti- cability. Though IVEs have been traditionally associated with high costs due to the necessary hardware, especially to provide realtime interactivity (multiple projectors, input devices etc.), and have always presented a dicult setup, in the last years these issues have been partially solved by the availability of cheap and easily deployable devices such as Nintendos Wii or Microsoft Kinect TM . Moreover 3D technologies used in IVEs oer several ad- vantages in medical education training. In this context it is essential to provide realistic representation of the environ- ment and several points of view in order to create in learners the correct mental model and to reinforce the memorability of a specic procedure. On the basis of the constructivism theory [11], one of the main feature of educational IVEs is the possibility of providing highly interactive experiences ca- pable to intellectually engage trainees in carrying out tasks and activities they are responsible for. The opportunity to navigate educational scenarios as rst person controllers al- lows learners to have direct awareness of the interaction con- text and of their responsibilities than in sessions mediated through an un-related element such as a graphical user in- terface or an other symbolic representation. In this regard IVEs present a less cognitive eort in elaborating the con- text and stimulate imagination. This is even more true in scenarios where not only skills are learned in the environ- ment where these will be applied, but also the tasks can be carried out by the trainee acting in a natural way without the mediation of any device (e.g. keyboard, mouse or other controllers). It is also pointed out by constructivists that learning is enhanced when gaming, group-work activity and cooperation are provided [10]. Interacting with humans is more interesting and involving than interacting with a com- puter and it implies personal responsibility. Each learner is expected by others to account for his/her actions and to contribute to the achievement of the team goal. The use of gaming techniques in education is called edutainment and it is preferred by trainees to the traditional ones because it increases students motivation and engagement in the learn- ing context [15]. Anyway, despite the perceived advantages and the good appreciation of serious games featuring IVEs for training, the adoption of such system is still poor in real medical fa- cilities. This is due to the fact that some open issues still exists in systems usability, such as the facility to get lost due to the possibility of free movement or the diculty to pro- vide contextual and signicant set of options in the environ- ment without switching to traditional device controlled 2D interfaces (panels visualizing multiple choices or drop-down menus). In particular it is an essential negative aspect of all the mentioned system for team training that, for the most part, trainees have to interact with the interface via com- puter monitors or head mounted displays. This reduces the immersive eect and hinders the desired natural collabora- tiveness of participants in the simulation. In this regard we think that serious games could benet a lot adopting natural interaction techniques and exploiting new low-cost devices available on the market for navigating and controlling IVEs. In this paper we introduce a serious game set in an immer- sive virtual environment with the aim to train profession- als in surgery to carry out eciently the Surgical Security Checklist (SSC) introduced by the World Health Organiza- tion in 2009. The system features natural interaction tech- niques and it is easily deployable requiring only a standard PC, a projector and a Kinect TM sensor. The proposed sys- tem is so part of the vocational training systems where the need is to train an activity usual in the everyday job of sur- geons. The paper is organized as follows: Sect. 2 describes in details the SSC guidelines and denes the proposed sim- ulation scenario. In Sect. 3 the architecture and the main modules of the system are discussed along with some imple- mentation details. Finally, conclusions are drawn in Sect. 4. 2. SURGICAL CHECKLIST SIMULATION Surgical-care is a central part of health-care throughout the world, counting an estimated 234 million operations per- formed every year [24]. Although surgical operations are essential to improve patients health conditions, they may lead to considerable risks and complications. In 2009, the World Health Organization (WHO) published a set of guide- lines and best practices in order to reduce surgical compli- cations and to enhance team-work cooperation [13]. The WHO summarised many of these recommendations in the Surgical Safety Checklist, shown in Fig. 1. Starting form the proposed guidelines, many hospitals have implemented their own version of the SSC in order to better match re- quirements of internal procedures. The SSC identies three main distinct phases correspond- ing to a specic period during the execution of an operation: before the induction of anaesthesia, before the incision of the skin, before the patient leaves the operating room. In each phase, the surgical team has to complete the listed tasks before it proceeds with the procedure. All the actions must be veried by a checklist coordinator who is in charge to guarantee the correctness of the procedure. The goal is to ensure patient safety checking machinery state and patient conditions, verifying that all the sta members are identi- able and accountable, avoiding errors in patient identity, site and type of procedure. In this way, risks endangering the well-being of surgical patients can be eciently minimized. Gawande et al. [4] conducted several simulations of a sur- gical crisis scenario in order to assess the benets obtained by the adoption of the SSC. Results have shown that the execution of the SSC improves medical teams performance and that failure to adhere to best practices during a surgical crisis is remarkably reduced. Figure 1: The Surgical Safety Checklist proposed by the WHO in 2009. The proposed system is a serious game featuring an IVE to train and practice users in the accomplishment of the sur- gical checklist. It adopts natural interaction via gestures and voice. The system de facto acts as the checklist coordinator of the surgical team. The simulation involves multiple trainees (up to three), each of them associated with his/her role, and guide them throughout a complete SSC in a surgical operation scenario. Three actors (surgeon, anesthesiologist and the nurse), ex- pected to complete the checklist, are automatically detected by the system when approaching the IVE and can interact gesturing and speaking as in the real life. Interactions and choices are not mediated by haptic devices or other con- trollers but mimic how the real procedure should be. 2.1 Simulation scenario The virtual simulation allows the three health profession- als who are going to execute a surgical operation to com- plete the SSC, with respect of their professional role. The IVE was designed with the objective to help the trainees to understand the correct procedures to be followed. Professionals (i.e. trainees) stand in front of the simu- lation interface (see Fig. 2). The simulator associate users with a professional role on the basis of their position in the physical space. In practice, the user standing on left will be associated with the anesthesiologist, the one in the centre will be the surgeon and one on the right will be the nurse. Figure 2: Avatar selection: the trainee can choose which role to enact standing on the left, on the cen- tre or on the right of the IVE. Once every user is associated with a role, the IVE is shown and the simulation can start. The rst environment repre- sents the pre-operating room, where usually the before the induction of anaesthesia part of the SSC takes place, with the patient and the three professionals avatars (see Fig. 3). From this moment, user can take control of the simulation by taking a step ahead. When one of the user has control, the environment is shown from his/her rst-person point of view (POV). Hence, the active user can interact via voice or gesture in order to carry out the specic step of the SSC procedure. Interactions can be performed both by voice and hand gestures. Voice-based interactions are used during the SSC when one of the professionals is expected to communicate with the patient or with another teams member. For in- stance, one step of the SSC simulation contemplates the nurse conrming to other team members the site of the op- eration, lets imagine it to be the right arm. Accordingly, the user enacting the nurse should take a step ahead and say something like we are going to operate the right arm or a similar sentence. As soon as the sentence is pronounced, Figure 3: A 3D pre-operating room environment from a rst-person POV, showing the patient and other professionals avatars. the system veries if the site of the operation is correct, it updates the SSC and it gives feedback in order to continue with the simulation. Hand gestures instead (e.g. hand pointing and push) are used for other types of interaction, such as to touch the patient, to check the state of the medical equipment or to activate virtual menus. In thebefore the induction of anaes- thesia part of the procedure the nurse has to indicate with his/her hand the part of the body to be operated. The IVE displays the patient with a view from above lying on the bed in order to allow the trainee a better precision of movement in the 3D space. Contextually an hand pointer is shown, mapped to the real position of the nurses hand, which al- lows him/her to select the body part as shown in Fig. 4. Figure 4: The nurse indicates the patients body part to be operated pointing his/her hand. Furthermore, during the simulation, the active user can perform a swipe gesture with his/her hand to activate a vir- tual overlay containing all the information about the pa- tient clinic history and the status of the SSC to be carried out. The overlay simulates the patients medical card, usu- ally available in the operation room. When all the steps of the checklist are correctly performed, feedback is given to trainees of the good outcome of the simulation and a sum- mary is presented with the time spent in completing the procedure and the recording of all the errors committed by each user. The system exploits these data in order to provide the simulation with some gaming aspects: 1) the team mem- bers share the goal to correctly complete the checklist in the shortest time (the system provides a ranking table of the best team scores); 2) each trainee competes with the other team members and his performance is measured by a scor- ing system which keeps track of all the individual errors and show the results at the end of the simulation. Although the SSC have been strictly dened and formalised by the WHO at an high level, the content of the simula- tion sessions (i.e. the patients anamnesis and clinic card) is fully congurable in the system. This means that instruc- tors can simulate, and trainees experience, all possible op- erations and risks, and therefore that specic scenarios can be created for teams of medical professionals in every eld. 3. THE SYSTEM The proposed simulation system is a natural interface that exploits a realistic 3D interface and natural interaction paradigms in order to train users to correctly execute the SSC. Users stand in front of a large-sized screen or projec- tion and can interact without using any wearable or hand- held device. Contrariwise they can use their voice and body as interface controller. The system is composed by two main modules: The Interaction Detection Module (IDM). The Immersive 3D Interface and the associated Game Status Controller (GSC). Figure 5 shows how these modules are organized from a log- ical point of view in the simulator. The remainder of this section describes in details the mod- ules. Finally, some technical implementation details are pro- vided. Figure 5: Logical system architecture: the IDM analyses motion and depth data coming from the Kinect TM sensor, it detects actions and communi- cates with the GSC that updates the IVE on the basis of the scenarios conguration. 3.1 Interaction Detection The interaction between users and the IVE is obtained tracking movements and identifying users actions by ex- ploiting the Microsoft Kinect TM sensor [27]. In particular, the interface can be controlled by trainees using their po- sition in the physical space, hand gestures and voice (see Fig. 6). The three dierent types of interaction can be ex- ecuted concurrently or are turned o/on depending on the phase of the simulated procedure. For instance, if the sim- ulator is waiting for a gesture input from the active user, the speech recognition module is temporarily switched o. The IDM is responsible of recognizing and notifying the user actions to the GSC module in order to proceed with the sim- ulation. Figure 6: Dierent types of interaction the system is able to detect. In details, the IDM is able to detect: Active user. The Kinect TM sensor is able to identity up to six human gures standing in front of the cam- era, but it can only track two skeletons simultaneously. Since the system is designed for three users, a policy is needed to dynamically dene which of them is con- trolling the simulation (i.e. the interface). From the depth map obtained by the sensor, the IDM detects which user is closer to the interface. When a trainee performs one step ahead, resulting in a reduction of the distance on the z-axis, the module noties a change of the active user. This detection is active during all the simulation session. Hand gestures. Once the active user is identied, skeleton tracking is exploited to detect his movements and, in particular, to track his/her hand position in the space. The hand position is used to map an hand pointer in the IVE used to interact with interface elements. The IDM tracks the active hand of the trainee and sends its spatial coordinates in the 3D space in order to update the interface. When the user needs to activate some virtual element on the interface, he/she must perform a push gesture with the open hand. This is somehow similar to a click on a mouse-based interface. Hands tracking and gesture updates can be switched on/o by the GSC, depending on the phase of the simulation. Furthermore, a swipe gesture has been provided that allows the user to open a virtual 2D overlay on the interface containing the patient case history and clinic card. This gesture is performed by moving the right arm from the right to the left. Speech inputs. The Kinect features an array of four sepa- rate microphones spread out linearly at the bottom of the sensor. By comparing each microphone response to the same audio signal, the microphone array can be exploited to determine the direction from which the signal is coming and therefore to pay more attention to the specic sound in that direction rather than in another. The module checks if the angle from where the vocal input is detected corresponds to the direction where the active user is, in order to ignore unexpected speech form other users. So, when the IDM has iden- tied the active user, it tries to understand his/her specic audio signal. In order to achieve this, back- ground noise removal algorithms are applied [23]. The Microsoft Speech SDK is used to verify the correctness of trainees answers when interacting via voice with the system. In particular, it is exploited to asses whether users vocal input corresponds to a correct value for the current SSC step. The GSC dynamically loads sets of possible keywords that are correct for the current step from the Scenario Conguration le. Based on these sets, the module checks the audio input and computes a condence value for the speech-to-text match. If the detected condence is greater than a threshold value, the correct interaction is notied to the GSC and the simulation can continue to the next step. 3.2 Game Status Controller The GSC is the module responsible of the logic behind the whole simulation system. On simulation start-up the con- troller parses an external Scenario Conguration le con- taining all the phases and correct answers for the train- ing session. On the basis of the conguration, it initializes the 3D interface setting up the environment (e.g. the pre- operating room) and the characters. For each simulation phase and each SSC procedure step, it communicates to the IDM which type of interaction must be detected. In case of vocal input, the controller also evaluates a set of correct keywords to be recognised in the current phase of the simu- lation. The GSC receives interactions information and uses them to verify if the actions are correct or wrong according to the Scenario Conguration and the SSC. The controller then updates the interface in order to give positive/negative feedback to trainees and, consequently, to trigger animations and 3D cameras/points-of-view changes. All the actions and errors are recorded and stored in order to provide teams and trainees performance feedback. 3.3 Implementation details The system is composed by two modules: the GSC/IVE and the IDM. The GSC module and the 3D immersive inter- face have been developed within the Unity3D 1 environment using both C# and JavaScript programming languages to add interactivity support. The controller is in charge to load and parse a Scenario Conguration le that contains the SSC procedure structure, the patient case history and clinic card in a JSON syntax. The IDM exploits Microsoft Kinect TM SDK to detect userss interactions. It is develop with C# language and uses a network socket to communi- cate with the main program. Scenes and characters have been created with Autodesk Maya. The system can run on every normal Windows based workstation. 1 http://unity3d.com/ 4. CONCLUSIONS In this paper we present a work in progress immersive virtual environment, featuring gaming techniques, designed to train medical operators and professionals in the adoption and in the correct execution of the procedures suggested by the WHO in the Surgical Safety Checklist. The importance of the adoption of the SSC during surgical operations has been proved by several studies, showing improvements in medical teams performance and in the reduction of surgi- cal crisis. The main objective of the proposed system is therefore the design and implementation of a natural and immersive interface, suciently realistic and easy-to-use, to be actually adopted in medical education courses of study. In the immersive interface theres no possibility of free nav- igation because the environment is controlled and exploited as a means for the trainee to play his/her role in the game and to follow a strictly dened procedure. Trainees are re- quired to decide who is in charge of carrying out each of the activities of the SSC and this improves awareness and sense of responsibility. According to its functionalities the developed system can be described using the taxonomy proposed by Wattanasoon- torn et al., as shown in Table 1. Wattanasoontorn et al. extended the classication system dened by Rego et al. [19] who identied a taxonomy of criteria for the classi- cation of serious games for health (application area, inter- action technology, game interface, number of players, game genre, adaptability, progress monitoring, performance feed- back and game portability). Table 1: System classication by functionality ac- cording to Wattanasoontorns taxonomy. Functionality Solution Application area Cognitive Interaction Technology Microsoft Kinect Game Interface 3D Number of Players Multiplayer (up to 3 roles) Game Genre Role Play Adaptability No Performance Feedback Yes Progress monitoring No Game portability Yes Game Engine Unity 3D / Kinect SDK Platform PC Game Objective Professionals training Connectivity No During the entire design and development process of the serious game, medical professionals have been involved in order to reproduce scenarios and procedures that are highly compliant with real surgical operations. Future works will include several assessments of the system exploiting both usability tests [5] and heuristic evaluations of the natural and immersive virtual interface [21]. 5. REFERENCES [1] C. C. Abt. Serious games [by] Clark C. Abt. Viking Press New York, 1970. [2] D. C. Alverson, S. S. Jr, T. P. Caudell, K. Summers, Panaiotis, A. Sherstyuk, D. Nickles, J. Holten, T. Goldsmith, S. Stevens, K. Kihmm, S. Mennin, S. 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