Anatomy of a Hybrid OR
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The hybrid OR at St. Joseph Hospital Heart and Vascular Center in Orange, Calif., was designed to accommodate cardiac, vascular, interventional and surgical procedures.
Hybrid operating rooms (ORs) promise to deliver multiple benefits. The ability to shift from a diagnostic or interventional procedure to a surgical one may trim procedure and recovery times. The rooms open the door to novel transcatheter therapies, and help organizations support subspecialist surgeons and interventionalists. Given these pluses, it’s no surprise that the hybrid OR market is booming and is expected to see an average growth rate of 15 percent annually through 2016, according to Millennium Research Group. However, hybrid ORs represent a hefty investment and require meticulous planning.

Construction of a hybrid room is not for the faint-of-heart, evidenced by price tags ranging from $3.5 million to $5 million, according to Ashley Ford, research consultant for The Advisory Board, Technology Insights, in Washington, D.C. Some hybrid construction projects top the $5 million mark. St. Joseph Hospital (SJH) Heart and Vascular Center in Orange, Calif., opened its $5.5 million room in 2010 after a four-year planning process.

The jaw-dropping price tag is far from the only pain point associated with a hybrid suite. Success hinges on previously unseen levels of collaboration among an array of specialists in interventional radiology; cardiac, vascular and neurovascular surgery and cardiac catheterization. Buried in among decisions about high-value imaging and display systems are mundane details, such as types of electrical outlets and equipment carts. However, the most significant challenge is not identifying, purchasing and installing equipment, says Renee Mazeroll, RN, MSN, executive director of the Heart and Vascular Center at SJH. The bigger question is, “How do you operationalize the room so that it is efficient [and profitable],” she says.

Many hybrid suites have not realized the high utilization they expected, with usage of the room peaking at a mere three to four times a week. In contrast, the hybrid suite at SJH is booked solid and averages 2.5 patients per day. The center’s hybrid volume is approximately two-thirds vascular and one-third cardiac procedures.

While utilization can be measured, other metrics are more complex. University of Virginia Health System (UVA) in Charlottesville, has not measured return on investment for its hybrid room, which opened in January 2011. “The room gives capacity for the program. It is not going to bring patients in by itself. It is a link in the chain of handling new directions in cardiac surgery,” says Scott Lim, MD, co-director the UVA Cardiac Valve Center.

Catholic Health in Buffalo, N.Y., applies a different spin to its pro forma. The health system launched a pair of hybrid ORs at Mercy Hospital in June 2011 and plans to open three more across its system by the end of 2012. “It made sense from an economic standpoint. We were at capacity and unable to accommodate all of the surgeons and interventionalists who wanted to work here. It’s easier to justify a multi-purpose room than a single-purpose room,” says John S. Sperrazza, CNMT, vice president of imaging services at Catholic Health.  

Expense Line Item Estimated Cost
Angiography System (Single-plane, Base Model) $1,500,000
Demolition, Miscellaneous Construction $500,000
Cost for Space1 $400,000
Heart/Lung Machine $250,000
HVAC $250,000
General Equipment2 $200,000
Integrated Booms $175,000
Lead Shielding $100,000
Ceiling Reinforcement $75,000
Angiography Equipment/Software $50,000
Medical Gasses $50,000
Radiolucent Tables $50,000
Plumbing $10,000
Cabinets/Room Storage $7,500
Total Cost $3,617,500
1- Assumes 800 square foot room, cost of $500 per square foot
2- Anesthesia equipment, lights, electrical units, etc.
Source: The Advisory Board, Technology Insights

The OR: Dissected

The hybrid OR includes a dizzying assortment of infrastructure, with the imaging equipment serving as the centerpiece.

At SJH, Mazeroll and colleagues aimed for a universal room to support maximum use. Six years ago, when the plan was conceived, Mazeroll estimated relatively weak demand for the suite. Initial interest stemmed from the need to support the pediatric and adult congenital heart program with percutaneous valves. However, volume was very low. At the same time, Mazeroll was working to expand vascular services. The hybrid presented the perfect environment to perform the true vascular hybrid procedure. Again, potential volume was low.

“If we were going to justify the cost of the room, we had to position it for multiple purposes,” Mazeroll says. The final proposal incorporated a design that would support adult or pediatric, cardiac or vascular, interventional and/or surgical patients.
The goal created a challenge as most existing x-ray imaging systems fell short of the multi-purpose bar. Congenital programs typically use bi-plane imaging systems, which are not ideal for vascular work and occupy space on either side of the patient, which is critical for open surgical options. With bi-plane imaging systems, one C-arm hangs from the ceiling, which creates a concurrent challenge: how to deliver proper airflow around the hardware to maintain OR infection control standards, says Gregory A. Wozneak, administrative director of invasive cardiology at UVA.

Traditional single-plane systems, which meet cath lab needs, often are too limited for transcatheter valve procedures. Some single-plane systems that work off of an articulating arm offer capabilities for transcatheter valve, but bring a fairly large footprint that can get in the way otherwise, says Lim.

SJH opted for an imaging system that incorporates seven articulating joints, robotics and a software program used in conjunction with a rotational angiogram that creates 3D-rendered images. “It has met 90 to 95 percent of our needs,” confirms Mazeroll.

Other sites take a focused approach. “You can’t be all things to all people. You need to focus on some primary goals, whether it’s transcatheter valve therapies or electrophysiology,” says Lim. For this reason, UVA limited the number of stakeholders on the planning team, including only representatives from cardiology, anesthesia, cardiac surgery, radiology and technical support staff.

Although it may be wise to control the number of stakeholders on the planning team, it is important to survey all of the subspecialty practices who will be working in the room about their needs, says Sperrazza. “Each specialty has unique nuances, and it’s best to address these upfront, in the planning phase.” Mercy Hospital had to retrofit one of its rooms with additional shielding and overhead lighting to accommodate electrophysiologists.

SJH took the assessment process one step further and created a cardboard mockup in the hospital basement. Physicians, nurses and staff toured the room to better visualize the layout. With their input, the construction team fine-tuned details, such as counter length and workstation locations.

Some hospitals bypass the universal or focused approach decision by constructing more than one hybrid OR. Take for example Mercy Hospital, which opened a pair of hybrid rooms. One is equipped with a bi-plane imaging system and primarily handles neurosurgical and neurovascular procedures. The second, outfitted with a single-plane system, is used for interventional radiology, diagnostic and interventional cardiology and vascular and endovascular interventions.

Additional imaging infrastructure at Mercy includes portable ultrasound. However, the hospital plans to add intravascular ultrasound (IVUS) by mid-2012. The goal is to limit movable equipment and integrate as many systems as possible, including x-ray, hemodynamic monitoring equipment and display systems, says Sperrazza. Initially, at a beefy 750 to 1,000-square-feet, hybrid ORs seem large. However, factor in multiple imaging, clinical and display systems  along with three to eight clinicians, and space becomes precious. “Be conscious of movable equipment, and try to get equipment off the floor and wires out of the way,” says Sperrazza.

The space vs. equipment dilemma is particularly confounding with respect to display systems. “It’s almost impossible to have too many displays,” says Lim. A surgeon might need it on the left side of the table, a cardiologist on the right, and an anesthesiologist or echocardiologist may require visibility from the head of the table. Add in the variety of images and data—fluoroscopy, echo, hemodynamic monitoring—and the need for flexible capacity becomes clear.

UVA placed 12 LCD monitors in its hybrid suite, learning a lesson about timing in the process. “By the time we were almost done, a number of companies had developed novel video solutions that would have been quite useful,” says Lim. His advice? “Try to anticipate the availability of near-future technology during the planning stage.”

Part of Mercy’s solution to the display dilemma is a 55-inch system that can be partitioned multiple ways for viewing imaging and hemodynamic data. It’s boom-mounted, so it can be moved as needed. SJH’s suite is outfitted with three boom-mounted display systems and two large flat-panel systems on the wall to present larger images and patient data.

Finishing details

The combination of limited space and multiple users in a hybrid OR creates supply constraints. Many sites turn to mobile carts, designating each cart for a specific end use, such as peripheral vascular procedures, and stocking the cart with the appropriate stents, balloons and wires. This model frees up space that would be reserved for supply cabinets.

SJH uses a radiofrequency identification (RFID) tagging system to track inventory. “It was a bit onerous to learn on the front-end,” admits Mazeroll, but it has streamlined processes . Each piece of high-dollar inventory is RFID-tagged. When a user goes to the cabinet and inputs the desired equipment, such as a specific 15 mm stent, the system provides the exact location via cabinet number and shelf. It also facilitates both re-ordering and billing, as the technology is interfaced with the billing system.

Other details that can flummox a project are the seemingly mundane, such as the number and type of outlets, says Lim. The hybrid OR requires a minimum of 24 outlets compared with eight in a cardiac cath lab, according to “Making the Case for the Hybrid Operating Room,” a report compiled by The Advisory Board.

The people factor

“One of my best decisions was to advocate for a dedicated hybrid team,” says Mazeroll, who made the critical decision after hearing about technologists’ frustration with their lack of expertise with the imaging equipment. Highly trained technologists adept with advanced systems and capable of performing advanced techniques, such as 3D image manipulation and multi-modality image fusion, are essential, adds Sperrazza.

Mazeroll insisted on training for all physicians who wanted to use the room and covered everything from scheduling to equipment use. “Small details can have a large impact.” After a mock case, one of the perfusionists, who happened to be petite, realized she would need a stool to reach her equipment on the boom.

An auxiliary benefit of the room, says Mazeroll, is that it has helped foster collaboration among specialists and erode existing silos. Early in the process, SJH insisted that its hybrid suite did not belong to any single person or department, but instead was available to credentialed and hybrid OR-trained physicians.

The formula for success in the hybrid OR is complex and specific to each institution. However, the inputs are constant, comprising imaging and display technology, lighting, carts and staffing resources. Thorough planning and goal-setting, coupled with painstaking attention to detail throughout the process, can go a long way toward setting the stage for success. HI