Clear vision critical to successful hybrid OR development

About 100 US hospitals now have a hybrid operating room, and a 15% increase is projected over the next decade, according to experts who have managed installations at numerous facilities.

Hybrid ORs combine surgical equipment and instrumentation for open procedures with a fixed and dedicated imaging system as well as an imaging-compatible surgical table, lights, and surgical booms to accommodate open, minimally invasive, and interventional procedures.

Whether your hospital is considering converting a conventional operating room into a hybrid OR or building a brand new room, it’s important to know where you want to end up before you take the first step to get there.

“Knowing what you want to accomplish—having a business plan—is the most critical part of planning. Just knowing that you want to have a hybrid OR isn’t very helpful,” says Lynne Ingle, MHA, BS, RN, CNOR. As a project manager with Gene Burton & Associates, a health care technology consulting company in Franklin, Tennessee, Ingle has overseen several hybrid OR installations. As a former director of surgical services, she is well versed in the kinds of improvements hospitals hope to achieve with the new technology.

Planning

Key players in the planning process are hospital administration, interventional cardiologists, open heart and vascular physicians, neurosurgeons, anesthesia providers, department heads and staff from the cardiac catheterization lab and the OR, a charge nurse, a staff nurse, and information technology, Ingle says. Participants from the nonclinical side include architects, vendors, and engineers. And for any remodeling project, it’s critical to consider infection prevention, she emphasizes.

Start by determining just how your hospital defines “hybrid.” Consider questions such as:

*What is the hospital’s goal?

*Who is driving the function of the space?

*What procedures are planned?

*What is the budget?

A traditional OR is about 700 square feet, whereas at least 1,000 square feet is needed for a hybrid room, and 1,200 square feet is preferable for accommodating the imaging equipment within the room plus the control room from which procedures are monitored. Hybrid ORs must allow for the possibility of converting to an open procedure, so they must be large enough to accommodate staff and equipment for 2 separate clinical teams, Ingle explains.

Procedures

The list of procedures that can be performed in a hybrid OR is growing. Among these are many cardiac procedures that in the past have been done in the cath lab, but Ingle notes that “hybrid ORs should not be glorified cath labs.” Newer procedures include transcatheter aortic valve replacement (TAVR) and mitral valve clipping, endoscopic abdominal aortic aneurysm, and aortic arch repair.

Some hospital leaders have mistakenly believed that for a procedure such as an aortic valve replacement, a cath lab can be turned into a hybrid room, she says. However, some valve vendors won’t enter into a contract with a hospital if these procedures are to be performed outside the restricted area of the surgical suite. “You need to have all the capabilities for converting to an open procedure if need be,” Ingle says.

Form and function

The most common configuration for a hybrid OR includes a single-plane angiographic x-ray imaging system and surgical equipment for open cardiac surgery.

Lights for the hybrid OR must have a longer arm reach, especially depending on who’s doing the imaging, Ingle says. Whether a ceiling-mounted or floor-mounted C-arm is the best choice depends on which procedures will be done in the room. Placement of lights and booms is important because anesthesia staff must be able to have access to the head of the table.

Knowing how the space will be used is especially important for determining the type of table that’s needed. If most procedures will be interventional, the table selected should be one that communicates with the imaging system, which is typically purchased from the imaging vendor. If the room will function primarily as an OR, however, the table should be appropriate for surgical procedures and thus it won’t be able to communicate with the imaging system. Some OR vendors offer a table with a fixed base and two tabletops—1 for surgical procedures and 1 for imaging procedures.

Well-funded facilities may have a dedicated wall for imaging. But in general, facilities need to have a “live” monitor and a reference monitor from the imaging vendor, displays at the OR table for the surgeon and assistant, and displays on the wall—as few or as many as hospitals can afford or want, Ingle says.

Knowing the visuals needed in the control room is an important factor in deciding on vendors, she notes, because the technician in the control room must be able to see and understand what the surgeon needs.

Benefits of a hybrid room include:

*shorter patient recovery time due to elimination of the physiologic stress related to multiple procedures with anesthesia

*decreased length of stay due to elimination of staging between multiple procedures and reduction in resources needed for patient management

*streamlined care delivery, with fewer clinical staff involved in patient care and an improvement in cross-specialty communication

*minimized risk for communication-related errors across clinical specialties

*lower overall cost of care

*potential for revenue growth—use of a hybrid OR frees interventional suites and standard ORs for additional procedures.

As an example of the efficiency gain that’s achieved with a hybrid OR, Ingle says, troubleshooting can be done in 1 place instead of moving the patient from room to room. “For cardiac surgery, sometimes a patient is taken from the cath lab directly to the OR, and measurements are taken for vessels behind the heart, which can’t be seen. If the patient then moves to the ICU but isn’t doing well, the patient must go back to the cath lab for imaging and then back to the OR,” she says. “If everything were done in the hybrid OR, the surgeon would see the vessels right there because imaging would be done. That would cut down on morbidity, infection, and cost, and the patient could be discharged in a more timely manner.”

Hybrid ORs can also benefit patients in remote areas. Ingle was involved in a $3 million hybrid OR installation at St. Rose Dominican Hospital Siena Campus in Henderson, Nevada, in 2012.

“A multi-disciplinary ‘TAVR Heart Team,’ led by cardiothoracic surgeons and interventional cardiologists, has been through a comprehensive training program that includes procedure and complication management,” according to Rod Davis, president and CEO of St. Rose Dominican Hospitals and senior vice president of operations, Dignity Health Nevada. TAVR allows cardiac specialists to deliver and place a new aortic heart valve in the heart through a noninvasive procedure that doesn’t require cutting through the sternum or stopping the patient’s heart.

Previously, patients in that area of Nevada who were too ill to undergo aortic valve replacement with an open procedure usually had to go to southern California, Ingle says. Installation of the hybrid OR allowed them to have TAVR without having to travel.

The future

Earlier this year, the interventional trauma operating room (ITOR)—a $6-million 1,600-square-foot hybrid operating suite—opened at the Foothills Medical Center in Calgary, Alberta, Canada. The facility is “the first of its kind designed specifically for trauma patients [and] is more than twice the size of a traditional OR,” according to Andrew Kirkpatrick, MD, Alberta Health Services’ medical director of trauma services. The angiography equipment, which allows surgical and diagnostic imaging teams to work on patients at the same time, makes it possible for patients with severe bleeding to go directly to the ITOR for treatment.

Whether future hybrid ORs in the US will be built specifically for trauma patients remains to be seen, but Ingle says it’s a good bet that more spinal procedures will be done in hybrid ORs of the future.

“A hybrid OR lends itself to spinal surgery because it has real-time data with the C-arm and high-definition 3D pictures,” she explains. “You can’t see those as well with a mobile C-arm that must be rolled into the room. The hybrid room equipment allows the surgeon to see on the screen where to place surgical components like screws and plates.”

While most hybrid ORs initially were installed in university hospitals, an increasing number of community hospitals have added or are planning to add at least 1 hybrid OR, Ingle says.

—Elizabeth Wood

References

Calgary Herald. Specialized operating room for trauma patients opens. March 28, 2013.

www.strosehospitals.org. Accessed July 29, 2013.