Capitalizing on the New Wave of Hybrid ORs · 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

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Capitalizing on the New Wave of Hybrid ORs

SPECIAL REPORT

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report2

IntroductionAn increasing number of hospitals nationwide now have hybrid operating rooms. Building a new hybrid OR takes careful planning, requires specialized and advanced audiovisual and imaging equipment, and involves the collaboration of many decision makers. And once a hybrid OR is in place, procedures often require teams from several disciplines to work together as one. This process may be daunting, but the results may leave you in a better position to offer a variety of surgical procedures, enhance patient safety, and achieve long-term cost savings with improved efficiencies.

Regardless of whether you’re building a new hybrid OR or remodeling to accommodate the new room within existing space, you must commit considerable financial and human resources. This special report provides insights from professionals who have transitioned to a hybrid OR, offering tips and strategies to help you through the process. As with any transition, getting input from physicians, anesthesiologists, nurses, technical staff, and other members of your team is crucial to success. It is our hope that this report lays the groundwork for a successful conversion.

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Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 3

Table of Contents

Clear vision critical to successful hybrid OR development ........................ 4

Case Study: Operationalizing the hybrid OR .............................................. 6

Lessons learned from hybrid OR installations ............................................. 8

Specialized equipment serves hybrid and standard ORs equally well ..... 11

Endovascular hybrid ORs in community hospitals: Driving success ....... 13

Include infection prevention in your hybrid OR design .............................17

Perceptive leadership fosters collaboration among hybrid OR staff ....... 19

Building the business case for a hybrid OR ................................................ 23

3


Clear vision critical to successful hybrid OR development About 100 US hospitals now have a hybrid operat-ing room, and a 15% increase is projected over the next decade, according to experts who have man-aged installations at numerous facilities.

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 plan-ning. 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 con-sulting company in Franklin, Tennessee, Ingle has overseen several hybrid OR installations. As a for-mer 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, an-esthesia 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 in-fection 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 accommo-dating the imaging equipment within the room plus the control room from which procedures are moni-tored. 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 two separate clinical teams, Ingle explains.

ProceduresThe list of procedures that can be performed in a hy-brid 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 replace-ment, 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 capa-bilities for converting to an open procedure if need be,” Ingle says.

Form and functionThe most common configuration for a hybrid OR includes a single-plane angiographic x-ray imag-ing 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. Place-ment 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 pur-chased 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 imag-


ing system. Some OR vendors offer a table with a fixed base and two tabletops—one for surgical pro-cedures and one 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 sur-geon needs.

As an example of the efficiency gain that’s achieved with a hybrid OR, Ingle says, troubleshooting can be done in one place instead of moving the patient from room to room. “For cardiac surgery, some-times 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 pa-tient 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 ar-eas. 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 cardi-ologists, 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 se-nior vice president of operations, Dignity Health Ne-vada. 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 south-ern California, Ingle says. Installation of the hy-brid OR allowed them to have TAVR without hav-ing to travel.

The futureIn 2013, 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 tradi-tional OR,” according to Andrew Kirkpatrick, MD, Alberta Health Services’ medical director of trauma services. The angiography equipment, which al-lows 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-defini-tion 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 com-munity hospitals have added or are planning to add at least one hybrid OR, Ingle says.

—Elizabeth Wood

ReferencesCalgary Herald. Specialized operating room for trauma patients

opens. March 28, 2013.www.strosehospitals.org.


Case Study: Operationalizing the hybrid ORYou’ve cleared the hurdle of installing a new hybrid operating room, but now another hurdle looms: put-ting it into operation.

The good news is you likely have already built a collaborative relationship among key players. “Get-ting everyone on the same page to justify the OR sets the team up for success,” says T. Brett Reece, MD, a faculty member in the division of cardiotho-racic surgery for the University of Colorado Hospi-tal (UCH) in Aurora, which opened its hybrid OR in April 2012. About 30 to 40 cases, mostly endo-vascular, are done each month, with utilization be-tween 66% to 80% during weekday business hours.

You’ll need to build on that collaboration in four areas: education, staffing, supplies/billing, and co-ordination. Here’s how UCH did it.

Ramping up“We used multiple opportunities to educate staff,” says Tamara Mayne, BSN, RN, cardiothoracic sur-gery service specialist for the UCH OR. “The edu-cators in interventional services and the OR part-nered because they had the knowledge of how it would function and what information staff needed.”

The hybrid OR was open for a full week before the first case, giving staff and physicians time for train-ing and learning about the equipment, which in-cludes fluoroscopy imaging, a surgical table, equip-ment booms, and general imaging. Everyone on the OR staff was oriented to the hybrid OR to provide flexibility, although the vascular team members work there most frequently.

Education included how to set up the room. “We adapted current space to the hybrid OR, so we had to fit everything in so that it would work,” Mayne says. That attention to detail is important for a successful case. For example, she adds, “If you don’t move the C-arm correctly, you can’t move the lights.”

Physician preference added to the complexity. “You have to have a way to set up every room for every case for every physician,” says Dr Reece. Mayne turned to the traditional preference card as a tool, but with a twist. “We have lots of pictures and 3-D drawings showing how everything needs to be po-sitioned,” she says. Mayne keeps the images on her

office computer.

Education helped ease what Dr Reece feels was the most challenging part of the startup—anxiety among those in the room. “The consistency that Ta-mara provided made it work,” he says.

“We overcame anxiety through repetition in edu-cation and leading by example,” Mayne adds. “Now anxiety is low. People have a good idea of how to fit everything in the room and how the pro-cess works.”

A blended staff“We use a blended staffing model for the hybrid OR,” says Katherine Halverson-Carpenter, MBA, RN, CNOR, patient care services director for ob-stetrics and perioperative series at UHC. Staffing is based on case type. Staff from the cardiovascular (CV) center and the OR handle combined cardiol-ogy and surgical procedures, with the CV center nurses supporting the cardiologists with imaging and documentation. A radiology technician from the interventional radiology (IR) department fills that role for IR procedures done in the hybrid OR. One challenge has been the finite number of radi-ology technicians with the skill set to work in the hybrid OR, Halverson-Carpenter says.

Supply and billing needs“Managing supplies is a challenge,” says Mayne. Vascular surgeons (some of whom were new to UCH), interventional radiologists, and interven-tional cardiologists had to feel confident that the supplies they needed would be available, while OR leaders needed to reduce redundancy as much as possible. The OR is working on obtaining high-vol-ume supplies on consignment to avoid replicating supplies in the IR and CV center suites.

Billing processes also had to be established. The IR department and CV center bill by the procedure, but the OR bills by time. “We got the finance team together and decided we would bill by the minute because the procedure was done in the OR,” says Halverson-Carpenter. If the procedure is done in in-terventional radiology or the CV center, billing is done by procedure.


Coordination“The greatest challenge of a hybrid OR is the co-ordination,” says Halverson-Carpenter. At UCH a hybrid steering committee provides oversight and helps work through problems. Halverson-Carpenter and Dr Reece, who allocate the block time, cochair the committee. Among members are those who per-form procedures in the room, nursing staff, nurse managers, and perioperative business managers from the IR department, OR, and CV center.

Halverson-Carpenter says the committee reviews utilization of the room both during regular business hours and after hours, which cases are being done by which physicians, supply needs, billing, and any operational issues. “It’s important to track your vol-ume and who is using the room so you can readjust your block time allocation,” she notes.

One discussion centered on the use of the hybrid OR for traditional surgical procedures. Recently UCH opened four new ORs; once they are fully staffed, the hybrid OR will be dedicated to hybrid cases.

Halverson-Carpenter credits the success of the committee and the hybrid OR to a meeting she and the chair of surgery cochaired early in the plan-ning process. The meeting focused on the princi-ples of collaboration and included key stakehold-ers, such as the medical director of IR, section head of vascular surgery, chair of cardiothoracic surgery, chair of cardiology, all physicians and surgeons who would be working in the room, and administrators for the OR and CV center. “Estab-

lishing the framework clarified our mutual goals and purpose,” Halverson-Carpenter says. “It be-came an expectation that people would collabo-rate.” The group met with the vendors, conducted site visits, and worked with designers during the process.

That spirit of collaboration carried over into opera-tions meetings among centers, where details were hammered out. The team had to consider current practices while determining how to best work to-gether, something they continue to do. “We respect the practices and philosophies of each of the indi-vidual units,” Halverson-Carpenter says. “That’s helped us come together as a team.”

Satisfaction and future directionStaff, physicians, and patients are satisfied with the hybrid OR at UCH. “We are able to do cases now that we weren’t able to do safely previously,” says Dr Reece. Those include fenestrated grafts for pa-tients with complex anatomy and percutaneous car-diac valves. “We can reinvent what we provide to patients.”

“Everyone working together has made the program successful,” adds Mayne. “We’ve been a tight-knit group.” That success is expected to pay off; the UCH team is in the process of justifying a second hybrid OR.

—Cynthia Saver, MS, RN


Lessons learned from hybrid OR installationsThe cost investment, space and equipment needs, and learning curve involved in adding a hybrid OR can seem daunting, but the increased flexibility and efficiency that can be achieved suggest the effort is worthwhile. Staff at 3 East Coast hospitals who have been through the process reflect on their ex-periences and describe what a hybrid OR project entails.

Building the first hybrid OR was a “leap of faith,” says James E. McGowan, DHA, MBA, RRT, vice president of procedural care services at the Univer-sity of Maryland Medical Center (UMMC) in Bal-timore, which has 4 hybrid ORs. Procedures per-formed in these ORs range from standard coronary artery bypass grafting and valve cases to endovas-cular and minimally invasive valve procedures.

Initial interest in investing in a hybrid OR was sparked by a surgeon who often worked in robotic surgery and who had formed a partnership with a faculty interventionalist at that time, says Mc-Gowan. UMMC recognized the future potential of such an OR and played the odds.

“If I were to try to dial back time … I wouldn’t have even had on my radar the fact that we would be floating valves into people’s hearts in a room that has to have a team of OR nurses and a team of nurses from the cath lab plus radiologic technolo-gists,” says McGowan. Two of the 4 hybrid ORs at UMMC are now consistently in use for 80% of prime time hours, and the majority of this utiliza-tion is for hybrid cases, he notes.

Honing skillsMost hybrid procedures involve teams from sev-eral disciplines working together in the same room. More staff members are required in the hybrid room, and everyone must be aware of the equip-ment setup and roles of their team members. Ad-ditionally, the procedures performed in the hybrid OR often require techniques that are unique to the minimally invasive nature of the procedure—tech-niques that may test the skill set of the average cath lab technician or radiology technologist.

UMMC initially trained radiology technologists in a standard equipment training program offered by the vendor.

“As our program has matured and we’re doing high-er acuity, more sophisticated cases, we are discov-ering that [the old] skill set is not enough. We are going back to the drawing board to say ‘we need to collaborate with our radiology cath lab staff around a new staffing model to better support the technol-ogy and the interventionalist,’” says McGowan.

UMMC’s current goal is to create an environment that is seamless for physicians who are moving from a standard procedure outside of an operating room to a hybrid procedure within one. Regardless of whether they work in a traditional or a hybrid OR, nurses have similar responsibilities; however, other staff tend to require more training to accom-plish their tasks within the operating room environ-ment. McGowan points to someone who is “very well trained and understands interventional radiol-ogy and a cath lab environment from a radiology technologist perspective” as an example of the skill set required of staff focused on operating the tech-nology in this type of environment.

OR staff no longer perceive the hybrid room as dif-ferent from any other room, McGowan says. When it was new, some people took a dim view of the hy-brid OR and the changes it demanded of OR staff, but over time they’ve come to accept it. “So much of cardiac surgery is becoming minimally invasive that [the proliferation and frequent use of the hybrid OR] is just a sign of the times,” he says.

Taking ownershipStrong group training, team leaders, and collabo-ration helped Massachusetts General Hospital (MGH) prepare for many of the challenges that come with adopting a new system, says Joanne Ferguson, RN, director of operational planning and EOC, perioperative services at Massachu-setts General Hospital. MGH has two hybrid ORs containing single-plane C-arm units in the new Lunder Building. These hybrid ORs, which were planned and designed through the collaboration of surgery, radiology, and nursing staff, support a full range of open, interventional, and hybrid procedures.

Countless simulations were performed before these rooms were opened, allowing the interdisciplinary


team to understand the workflows and processes in a hybrid OR well before the team cared for its first patient.

“Because this team of people had been together for close to 3 years during the design phase and many of us had traveled together to look at other sites, we had a very collaborative multidisciplinary team with a united focus that designed every inch of these ORs,” says Ferguson. “By the time the construction was nearing completion and we were preparing for the simulations in these new ORs, the team natu-rally took ownership as a team, not as individuals.”

The original core group helped integrate new mem-bers of the team, providing education, training, and support to get everyone up to speed, notes Scott Far-ren, nurse manager of vascular and neuro services.

“I think because of the team building that had hap-pened ahead of time and the lessons learned during the simulations [we had a good start],” agrees Fer-guson. “I would say that we now have such a strong core team that when someone new joins the team, it is typically a very smooth transition.”

Selecting and locating the various types of equip-ment in these spaces is important, Ferguson says, noting that the lessons learned with their first hybrid OR made it much easier to plan for a new cardiac hybrid OR. A key lesson was that the hybrid OR needed to be outfitted for both open and hybrid pro-cedures. At MGH, a limiting factor in the original hybrid OR was the OR table. “When we designed our two new vascular hybrid ORs, we had the op-portunity to select an OR table that worked for both open and hybrid procedures. The flexibility of our vascular hybrid ORs confirmed for us the viability of a cardiac hybrid OR,” says Ferguson.

“We are currently performing the cardiac hybrid procedures in our cardiac cath lab, a suboptimal setting for surgery. The team recognized the need to move these procedures to the OR setting, and we developed a plan to build the new cardiac hybrid OR. The 2 years’ experience we have in our vascu-lar hybrid ORs has made planning for and design-ing a new cardiac hybrid OR a very positive experi-ence for all.”

McGowan likewise sees hybrid ORs in a positive light: “The newer rooms have a lot of capabilities

with the beds and the C-arm—you can actually do other cases in the room, so it does allow you to [ar-gue] the business case pretty quickly.”

Farren estimates that the MGH hybrid ORs accom-modate roughly 100 procedures each month, despite what official documentation shows. “Once staff get in there and see the utility of the room, almost every single one of our cases now turn into some sort of hybrid case for vascular,” Farren says.

Anticipating needsOverall utilization of the hybrid OR at Inova Heart and Vascular Institute in Falls Church, Virginia, is currently lower than anticipated because of the lim-ited equipment selection within the room, says Ed Schatz, RN, CRNFA. Inova opened a hybrid room in December 2010 as part of an 8-room cardiac sur-gery suite. However, with the benefit of hindsight, Schatz says, he would approach planning differ-ently today.

“If we were to build another one, we would look at all the possible cases we could do in a hybrid room and then make our equipment choices based on that,” says Schatz. “The one we have here is good for cardiac procedures, but not for some things that we should be able to do in that room.”

Successfully building a hybrid OR requires a great deal of preplanning and some flexibility on the part of planners, according to Ferguson. Technol-ogy is constantly evolving, and a particular piece of equipment the hospital plans to use may not be available for purchase when it is time to actually construct the room. Equipment size may also pose unexpected problems; MGH had to scrap plans for a third hybrid OR when 1 piece of equipment took far more space than anticipated. “No matter how much you’ve preplanned, technology will change. Know that, and you can deal with it effectively,” advises Ferguson.

Ferguson also recommends going on site visits to facilities with existing hybrid ORs, as well as those in the process of building one. Finished rooms can give visiting teams ideas for potential room layouts and equipment setup for their own hospitals, and hybrid rooms under construction will help them learn how to plan.


“We did this for the new building to engage the clin-ical staff at the very beginning of the design pro-cess,” notes Ferguson. “Once you’re into the design development and past the schematic design, that’s when you have to engage the team, because that’s when the team begins to come together. It was huge for our success here.”

Despite the challenges involved in establishing a hybrid OR, some see the future demands of

health care as a reason to start investing now. “This is not about an optional exercise,” says McGowan. “You’re just going to have to do it because that’s where health care is going. Have an organized approach for when to build them and how to build them, manage that process, and come out on the other side with something that actually works.”

—Steven Dashiell


Specialized equipment serves hybrid and standard ORs equally wellThe advanced audiovisual and imaging equipment used in hybrid operating rooms allows clinicians to complete minimally invasive and interventional procedures in less time, leading to improved patient safety and outcomes.

But this equipment is not just for hybrid rooms. It can also enhance efficiency and increase physician satisfaction when placed in regular ORs.

While awaiting completion of 10 new ORs, Sarato-ga Hospital in Saratoga Springs, New York, needed to upgrade an existing OR for minimally invasive and robotic procedures.

The 170-bed facility had a steel building struc-ture that didn’t allow for monitors and equipment booms to be suspended from the ceiling. The small OR also lacked space for an audiovisual equipment closet where the hardware for a visualization sys-tem would normally be located.

A multidisciplinary team responsible for choos-ing equipment for the 10 new ORs began evalu-ating different options for the existing OR. They decided on a floor-mounted boom that could be easily installed with only a couple of days’ down-time.

The boom has four high-definition monitors with touchscreen-controlled visualization that routes and displays signals from cameras, endoscopes, naviga-tion systems, ultrasound, C-arms, PACS (picture achieving and communication) systems, and other input sources. It also has visualization system hard-ware enclosed, so a separate equipment closet isn’t needed.

“These booms are not just for hybrid ORs, they benefit any room,” according to Sharman Lisieski, BS, RN, CNOR. “Your nurses will no longer be ‘hunters and gatherers’ because all of the equipment that used to be on separate towers is consolidated on shelves on the boom,” says Lisieski, director of the OR and PACU (postanesthesia care unit) at Sara-toga Hospital.

Because nurses are not moving towers full of equip-ment in and out of the room, turnover times have decreased and on-time starts have increased, she says. In addition, she says, “the images the boom

provides are phenomenal. It is a complete satisfier for both nurses and surgeons.”

Outfitting older roomsThe floor-mounted boom is a good way to outfit an older or smaller room with advanced imaging tech-nology in a cost-effective manner, says Lisieski.

For ceiling-mounted booms, all of the wiring has to go into the ceiling. Those booms may be impossible or difficult to install because of lack of space.

With the floor-mounted booms, all of the wiring is easily accessible in the back of the unit. The visu-alization hardware also is in the back of the unit rather than having to be housed in a closet outside the OR.

“Our experience with the floor-mounted boom is that it has the same amount of flexibility as ceiling-mounted systems,” notes Lisieski. The relationship between the patient and equipment shelves is the same because of the cord length of the cameras. “As long as the monitor booms can reach where the surgeon needs them, either boom style works,” she says.

The vendors came into the hospital and were avail-able to the staff until everyone was trained on the boom.

Adding new roomsThe boom eventually will be moved to one of the new ORs, and then another four rooms will also be video-integrated rooms for minimally invasive sur-gery. Eventually two interventional rooms will be added.

“Even though we are not to that interventional stage, there are many advantages to this boom,” says Lisieski.

For example, “when we do a laser lithotripsy we have the four monitors around the OR table—we put our PACS on number 1, the patient’s x-rays on number 2, and then we can put the endoscope im-age and C-arm image side by side on number 3 and number 4,” she says. “It really is a sweet system.”


Another example of its versatility is that at the end of a case the surgeon can view x-ray images on one of the monitors from a patient in the emergency de-partment (ED) who may need urgent surgery and have a telephone consultation with a radiologist or ED physician. All x-rays are digital and can be seen on any monitor.

“For OR managers, this equipment is worth look-ing into, depending on what their needs are,” says Lisieski. “If they are looking for a way to get video integration into their ORs in a small, tight spot, it could be the answer.”

—Judith M. Mathias, MA, RN


Endovascular hybrid ORs in community hospitals: Driving successEndovascular hybrid operating rooms are no longer limited to university medical centers, as commu-nity hospitals expand their cardiovascular services. According to Dorothy Urschel, MS, MBA, RNFA, ACNP-C, NEA-BC, three main trends are stimulat-ing the growth of hybrid ORs: “Cardiac surgery is becoming less invasive, interventional cardiology is becoming more invasive, and vascular surgery continues to be minimally invasive and use catheter techniques combined with radiology techniques.” Urschel is cardiac and vascular service line director at St Peter’s Health Partners, a system of four com-munity hospitals in Albany, New York.

ECRI Institute, which assists hospitals with strate-gic planning and technology assessment, has seen about a 10% annual growth in requests related to hybrid ORs among its 3,500 hospital members. The trend of more hybrid ORs—including those in com-munity hospitals—is likely to continue.

But a successful hybrid program requires careful analysis and planning by a multidisciplinary team. “Start with the patient, and work your way back to determine what you need,” says Thomas Skorup, MBA, FACHE, vice president of applied solutions

for ECRI Institute. “Technology supports practice, it doesn’t drive it.”

New proceduresIn its report “Hybrid Operating Rooms with a Focus on Endovascular Hybrid ORs,” ECRI Institute says hybrid ORs are a good fit for high-risk, minimally invasive cardiovascular procedures that require ad-vanced imaging and may require transition to open surgery.

Skorup, who says that “advanced imaging” typically refers to an angiography system—as opposed to CT or MRI—points to approval of the Sapien (Edwards Lifesciences) transcatheter aortic valve in 2011 as a major stimulus for endovascular hybrid ORs. Trans-catheter aortic valve replacement (TAVR) “exempli-fies what a hybrid OR is all about,” he says. “It’s not a traditional vascular intervention. We’re not per-forming an open procedure or reinforcing a vessel with a stent; we’re replacing a surgical procedure by performing a procedure through a catheter.” Before TAVR, nearly a third of patients with severe aortic disease weren’t candidates for surgery, so adding this

new procedure has expanded the mar-ket—and saved lives. “One random-ized, controlled trial showed that TAVR significantly reduced mortality rates at 1 year and at 2 years,” Skorup says.

Other procedures typically performed in an endovascular hybrid OR include combination coronary artery bypass graft (CABG)/percutaneous coronary intervention (PCI) and endovascular aneurysm repair. At St Peter’s Health Partners, physicians perform a wide range of procedures, including stent graft placement and various types of aortic surgery.

“It’s amazing what you can do,” says Urschel. “We have doubled the num-ber of procedures we anticipated when we were in the planning stage.” Block time is 75% efficient. Although their hybrid room is not exclusively for

Where the money goesImaging equipment is the largest expense when building a hybrid OR—typically at least half of the cost.

Source ©2013 ECRI Institute

25%

10%

7%3%

EQUIPMENT TYPE AVERAGE COST

Imaging $2,000,000

Operating $400,000

Life Support $300,000

Audio/Visual $200,000

Surgical $100,000

TOTAL EQUIPMENT $3,000,000

CONSTRUCTION $1,000,000**

TOTAL PROJECT $4,000,000

$1.0

$1.2

$1.4

$1.6

$1.8

$2.0$1.82

$1.73

$1.50

$1.30

$1.04

Siemens Artiszeego

GE DiscoveryIGS 730

Philips AlluraXper FD20

with FlexMove

Siemens Artiszee

Toshiba Infinix-i

Hybrid ORCath LabCardiovascular OR

TAVI

PercutaneoPCICABG/PCI

AtherectomyValve

PTCA

Peripheral Stenting

Valve RepairCartoid Stenting

CABG EVAR

Hybrid OR =900 to 1200 Sq. Ft.

Standard OR =500 to 800 Sq. Ft.

55%

6%18%

21%

Biplane (9%)

Single Plane, Ceiling (27%)

Single Plane, Floor (64%)

50%

milli

ons

5%

SIEM

ENS

GE

PHIL

IPS

SIEM

ENS

TOSHIBA

Where the Money Goes

**Typical construction costs can range from $0.5M to $2M.

Imaging equipment is the largest expense when building a hybrid OR—typically at least

half the total cost.

Imaging Equipment: $2MConstruction: $1M**OR Equipment: $0.4MLife Support Equipment: $0.3MAudio/Visual Equipment: $0.2MSurgical Equipment: $0.1M


endovascular procedures, most cases are vascular. Urschel notes a number of factors have contributed to the program’s success, starting with multidisci-plinary planning.

A planning teamSt Peter’s created a hybrid OR steering committee composed of key players, including vascular and cardiovascular surgeons, cardiologists, OR nursing leaders, and supply chain managers. “You need to have physician buy in by having them at the table,” Urschel notes.

Becky Chalupa, MS, RN, CNOR, associate chief nursing officer at Methodist Sugar Land Hospital in Texas, adds that other needed players are anesthesia and facility managers. Methodist has 243 beds, 18 ORs, and one endovascular hybrid OR that opened in December 2012.

“Each hospital has a different case mix,” Skorup says. “You need to take a surgical time-out to define the case mix you expect and use that as a template for your planning efforts. You then have a greater likelihood of engaging the right people and having success.” He recommends considering all options. “If you plan for only one specialty, you have limited the future of the room and may not have the volume you need to be successful,” he says.

“Hospitals don’t have money to lose.” For example, Urschel says, St Peter’s had a second OR fitted for hybrid capability at the same time as the first. “Then we can just add the robotic C-arm when we have sufficient volume to justify its purchase.”

Urschel says the steering committee developed a list of procedures to be performed in the hybrid OR, which helped smooth some of the later bumps in the road when it came to scheduling block time.

Examples of procedures done in endovascular hybrid ORs n Hybrid coronary interventions n High-risk catheter-based coronary intervention (eg, unprotected left main coronary artery disease) n On-table angiography for quality control in coronary artery bypass grafting n Endovascular interventions on the heart valves n Integrated surgical and catheter-based procedures for atrial septal defect II, ventricular septal defect re-pair, and coarctation of the aorta n Stenting or stent-graft placement in the thoracic aorta n Thoracic endovascular aneurysm repair (TEVAR) n Endovascular aneurysm repair (EVAR) n Hybrid procedures for treatment of atrial fibrillation n Endomyocardial biopsy

A Siemens Artis Zeego imaging system with a Maquet table at Methodist Sugar Land Hospital in Texas.

A hybrid OR at St. Peter’s Health Partners in Albany, New York.


People who need to be part of the planning process, but are sometimes forgotten, include perfusionists and radiology technicians, according to Skorup. “Having a surgeon working with an angiographic technician in the OR is a new working environ-ment,” he says. “You have to determine how the procedure will flow.” Of course, building manage-ment is also key, whether constructing a new OR or retrofitting an old OR for hybrid capability. For example, the floor has to be of sufficient strength to support the weight of the equipment, the ceiling support must be sufficient for hanging booms, and the room needs walls that provide radiation pro-tection. Skorup adds that the choice of floor versus ceiling mount ultimately comes down to physician preference.

As with most projects, planning takes time. Urschel says planning started 3 years before the OR opened. And, senior management will want a detailed busi-ness plan showing return on investment, especially since hybrid ORs aren’t cheap. Urschel says if no rebuilding is necessary, you’ll still need to plan on more than $3.5 million for the basic equipment.

Equipment decisionsTo choose equipment vendors, Skorup says you should “define what you want to accomplish, define your needs, and then determine which vendor fits those needs.” A common mistake is to allow a ven-dor to have early discussions with a single person who then becomes an advocate for a particular sys-tem and is not open to other options. Urschel adds that visiting other facilities with hybrid ORs helps identify what works and what doesn’t.

The hospital is now looking at options for changing equipment, but construction will be needed. Skorup says that standardization is difficult at this stage because system configurations aren’t “mature,” as is the case with CT scanners. However, that may change in the future.

Supply managementSkorup notes that many ORs forget to give the sup-ply chain the attention it requires. “Representatives from the supply chain need to be involved early,” he says. A top consideration is determining what will be stocked in the interventional cardiology lab and what will be stocked in the hybrid OR. “Consider the cost of replicating cath lab supply in the OR,” he notes. “But not replicating supplies can lengthen OR procedure time when personnel have to wait on supplies being obtained from the cath lab.”

Urschel agrees with the importance of supply chain management. The team ultimately decided to keep vascular wires on a cart that the interventional car-diology lab and OR can share.

Staffing and trainingOne of the biggest challenges for a hybrid OR is managing personnel. Depending on the procedure, those in the room might include the anesthesiolo-gist and anesthesia technician, vascular and car-diothoracic surgeons, interventional cardiologist,

Equipment needsIn addition to the usual OR equipment, the hybrid OR required the following:

n Radiologic C-arm device/angiography unit n Hybrid operating table n Video monitors n Control room n Contrast injector

All this equipment means that hybrid ORs are typ-ically about 500 sq. ft. larger than traditional ORs.

Elements to include in a business plan for a hybrid OR

n Executive summary n Strategic objective/planning n Program development overview (timeline) n Marketing n Technology review n Forecast of expected volume n Case mix (type and number of expected cases) n Planning considerations (eg, construction needs) n Equipment needed n Supplies n Financial impact

Source: Dorothy Urschel


physician assistant, scrub technician, circulator, interventional cardiology technician, and radiology technician. “It’s combining a cath lab and an OR team,” says Urschel, who notes she needed to add 4.2 full-time equivalent (FTE) employees to open the room.

Cross training between the OR and the interven-tional cardiology lab is essential and requires good management skills. “They have to learn how to work with a different team, so you have to explain how each team works,” says Urschel. “You need to work with the team very closely.” She adds that training staff in “radiation hygiene” should be a key component. Chalupa says Methodist has a core team for the hybrid room. Two backup radiology technicians are available on the day shift, and there is an evening technician who is trained for the hy-brid OR. The technicians take call.

To educate staff, Chalupa had a radiology techni-cian attend training provided by the manufacturer, and both radiology technicians and nurses spent time in hybrid ORs in other hospitals within the Methodist system. Chalupa held three dry runs before the first case. The dry runs turned up prob-lems: Neither the equipment needed to perform bolus chasing nor the intercom system had been installed as requested. The dry runs also helped determine the room setup, which Chalupa says varies according to type of case as well as physi-cian and anesthesia preferences.

CompetencySkorup notes that data show a “strong correlation between a recommended number of procedures

and maintaining competence” for surgical robot-ics teams, and he expects that to extend to trans-catheter procedures such as TAVR. It’s important to have a plan for determining staff and physician competence in the procedures being performed. In some cases, guidelines are available. For example, the Centers for Medicare and Medicaid Services outlines requirements that must be met to obtain re-imbursement for TAVR. These include specific vol-ume guidelines for the cardiovascular surgeon and the interventional cardiologist.

On the horizonBefore looking ahead, Urschel recommends look-ing back. “Conduct a financial and operational analysis 1 year after you open the OR to see where you are,” she says. For example, the analysis at St Peter’s resulted in staffing adjustments.

In the future, the use of hybrid ORs is likely to con-tinue expanding. Skorup expects to see more mul-tiple interventions for individual patients. “Some centers are doing vessel verification after a CABG procedure,” he says. He adds that physicians in Eu-rope are performing transcatheter mitral valve re-pair, and he expects the procedure to emerge in 2 to 3 years.


ReferencesCenters for Medicare and Medicaid Services. Decision Memo

for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430N). May 1, 2012.

ECRI Institute. Hybrid Operating Rooms with a Focus on Endovascular Hybrid ORs. 2013.


Include infection prevention in your hybrid OR design If a hybrid operating room is likely to be part of your hospital’s future, a critical part of the planning is to decide where it will be located. Variables such as available space, funding, and type of procedures to be performed will drive the decision, but a common component of all hybrid OR projects—whether new constructions or renovations—is infection prevention.

“Infection prevention needs to be a part of the de-sign process, not just the department that you con-tact when you need to have an ICRA [infection con-trol risk assessment] form completed,” says Heather Hohenberger, BSN, RN, CIC, CNOR. As the qual-ity improvement coordinator, perioperative services at Indiana University (IU) Health, Hohenberger is trying to raise awareness about the importance of infection prevention when designing hybrid ORs.

In January 2012, she was involved in assessing the hybrid room that opened in 2010 within the cardiac catheter lab space at Riley Hospital for Children, a freestanding pediatric academic center that is part of the IU Health system. Her observations and rec-ommendations led to elimination of surgical site infections (SSIs) among hybrid patients as well as changes in workflow and staff training.

“Infection prevention provides the guiding principle for what barriers need to be in place for a demoli-tion, renovation, or any type of construction process to decrease the risk of infection from the dust and debris,” she explains.

These efforts protect not only existing patients but also future patients. “If infection prevention staff aren’t involved from the onset, the potential for re-work increases,” she notes.

Cath lab conversionRiley Hospital has 14 ORs located in a section of the hospital that was built in the mid-1980s, where pediatric neurosurgery, cardiovascular, orthopedic, general, gastrointestinal, genitourinary, and ENT procedures are performed. Little space and block time were available among those ORs and the cath lab equipment was becoming outdated, so the deci-sion was made to open a hybrid room within the cath lab space.

Cardiologists approached hospital leaders, and once approval was granted, a biplane was purchased for fixed angiography and a control room and equip-ment room were built. Monitors for fluoroscopy, patient data monitors, an injector, a sterile back table, a Mayo stand, anesthesia equipment, and me-chanical ventilation equipment were needed along with diagnostic tools for cardiac procedures.

A new exterior wall was built to allow space for the additional equipment, Hohenberger says.

Design and construction teams met weekly with the end users, equipment manufacturers, and contrac-tors. Infection prevention staff, however, weren’t consulted as a part of the design process until af-ter initial demolition, when questions about air ex-changes and room ventilation raised concerns about converting to open procedures.

A hybrid room, especially if it’s built in an interven-tional radiology (IR) or cardiac cath lab space, must have a minimum of 15 air exchanges per hour, Ho-henberger says. A Class A operating room has 15 air exchanges per hour, and class B and C rooms must have a minimum of 20 per hour. The architect—and likewise the end users (nurses, cardiologists, and hospital leadership)—may be unaware of the differ-ences in infection prevention requirements between diagnostic and open surgical procedures.

“If conversion to an open procedure is needed, the room must be designed to provide the required number of air exchanges for that procedure,” Ho-henberger emphasizes. “If you’re renovating an old cardiac cath lab space, you need to know how many air exchanges exist because you may need to increase that number.”

Staff trainingWhen a hybrid OR is located in a cath lab or IR area, staff must be trained in the infection preven-tion measures that are second nature to OR staff.

“Infection prevention efforts start when a patient comes into the room, not when a diagnostic proce-dure changes to a surgical procedure,” Hohenberger says. This mindset reflects a fundamental difference


between OR staff and those who work in other de-partments.

“If you’re in a cath lab space, make sure staff know it’s not just a diagnostic procedure, it’s a surgical intervention. Little things like wearing a surgical mask while walking from the control room to the procedural space and thinking about sterility in the entire environment—not just the table but the whole field—are important,” she notes. “We shouldn’t just assume that people know this.”

Among the topics that should be covered during training are:

• operative attire

• hand antisepsis

• setting up the sterile field

• patient skin prep

• draping techniques

• traffic patterns

• surgical conscience.

At Riley, there wasn’t a designated educator for the cath lab/hybrid room staff when the new room opened in 2010. Later on, concern about the occur-rence of SSIs among patients treated in the hybrid room prompted cardiology and the medical director of infection prevention to request observation of the procedures performed within the space. In January 2012, Hohenberger observed the hybrid staff and recommended some changes. Since then, there have been no SSIs from that area.

What changed? Hohenberger says they needed to “go back to the basics” of infection prevention. An OR educator was brought in to provide orientation checklists such as how to perform a proper hand scrub.

Because the room location and nature of the proce-dures differ among hospitals, there is neither a con-sistent staffing matrix nor workflow, Hohenberger points out. Workflow is specific to each facility, and the location and surgical specialty utilizing the hy-brid room dictate the staffing needs.

“If the hybrid room is in the OR space, there will be a circulator and a scrub nurse trained specifically for that room, but in a cardiac cath lab space, there may be a team that’s available by page to come as needed—for example, a cardiac cath RN acting in a circulator role, or another RN scrub helping to pass instruments to the operating or diagnostic team,” she explains. Anesthesiologists and physicians are the only consistent staff.

Lessons learnedEfforts to raise awareness about infection preven-tion efforts among hybrid room staff fostered a sense of collaboration and understanding between the hybrid and OR teams. “By building a relation-ship with the OR staff, hybrid staff were able to see that they weren’t alone—there’s a larger group of people who understand the kinds of issues they have while providing patient care,” Hohenberger says.

“If you’re looking to open a hybrid room, opening it within the OR is the best option because it elimi-nates so many factors that could eventually cause problems,” she adds. “Each facility is different, and for some it may be necessary to open the hybrid room within a cath lab or IR space, so it’s impor-tant to understand the infection prevention practices that need to be in play at the very beginning of the process.”

—Elizabeth Wood


Perceptive leadership fosters collaboration among hybrid OR staffThe expanded volume of interventional cardiology in recent years has played a major role in the growing prevalence of hybrid ORs. As a result, many periop-erative services leaders have had to develop systems for managing hybrid ORs along with traditional ORs.

“Management of hybrid ORs is really a collision of traditional hospital management and service line management,” says David Wyatt, MA, MPH, BSN, RN, CNOR.

“We are starting to talk seriously about the business case for hybrid ORs, along with interprofessional standards and how we are staffing these rooms,” says Wyatt, administrative director of perioperative services at Vanderbilt University Medical Center (VUMC), Nashville, Tennessee.

Cardiovascular services has been at the forefront of service line development, with the focus primar-ily on getting cardiac surgeons and cardiologists to work together to refer patients to the hospital. “For many years, that did the trick,” says Wyatt.

But now more procedures are being performed in the cath lab than in the OR, and cardiac surgeons and interventional cardiologists are credentialed to do some of the same procedures. These changes have created tension between surgeons and cardiol-ogists, and turf wars have cropped up not only in the cardiovascular world but also in neuro intervention, which is performed by neurologists, neurosurgeons, and neuroradiologists.

“The neuro intervention specialties are even more complicated to deal with than cardiac,” notes Wy-att, “because they don’t have the background in col-laboration that cardiac has had over the years.”

Collaboration between service linesSuccessful management of hybrid ORs and their utilization begins with collaboration between the service line and operations administrators, notes Wyatt.

A cardiology (service line) nurse administrator and Wyatt, the perioperative (operations) administrator share the top spot on the management structure for cardiac hybrid ORs at VUMC (sidebar, p 20).

The director of the cath lab, electrophysiology (EP) lab, and cardiac surgery reports to both Wyatt and the cardiology administrator, and a matrix report goes to both service line and operational management.

This management structure also holds true for the neuro and vascular hybrid ORs, with Wyatt as the operations administrator over all 3.

The service line approach is very provider- and patient-centric, notes Wyatt. Though service line administrators may not fully understand operations, they do understand how to promote the flow of re-ferrals between physicians and the hospital, how to bolster collaboration among physicians, and how to ensure optimal patient flow through the system, he

Specialist EP Cardiothoracic Surgeon

Interventional Cardiologist

Interventional Radiologist

Vascular Surgeon

Neurosurgeon

• Common Procedures

•Diagnostic Studies

•PCAPacemaker Implants

•ICD Implants•Arrhythmia•Ablations

§ CABG§ Aortic valve

replacement§ Mitral valve

repair§ VAD

implants§ Transplants

• Diagnostic caths

• PTCA, PCI• Peripheral

angioplasty, stenting Atherectomy

§ Balloon Angioplasty

§ Aortic Aneurysm

§ Stenting§ Carotid

Stenting§ Biliary

Drainage§ Line

Placement§ Vertebroplasty

§ AAA§ TAA§ CAS§ Peripheral

angioplasty, stenting

§ Peripheral bypass

§ Aneurysm coiling

§ Intracranial stenting

§ CAS§ Intra-arterial

TPA

Ownership§ Determine primary room use§ Determine the project owners as soon as possible!

Key Stakeholders


says. On the other hand, the service line ap-proach can become too costly for the system.

“We have had to bal-ance moving forward with new technology and services for our patients without drain-ing our resources,” says Wyatt.

Each new request for hybrid technology has brought forth change in how business is done in the OR and the need for a more systematic ap-proach to collaborating with services perform-ing image-based proce-dures.

“For example,” he says, “biplane imaging technology is tremendously ex-pensive, and you really have to think systematically about who will be using it or there may not be a return on investment.” VUMC has a stroke program that is highly dependent on hybrid ORs because of the need for biplane imaging by the neuro special-ists. Cardiac and vascular specialists may also use biplane or single plane imaging.

Before building new hybrid rooms, Wyatt says, they look at which specialists would potentially use the rooms, the like procedures they perform, the like equipment they use, and the best placement for each room (sidebar).

Placement of hybrid rooms, equipment is key Several years ago, VUMC built its first hybrid room adjacent to the cath lab on the first floor. The main OR suite (with 35 rooms) is on the third floor.

“When the cardiac nurses and anesthesiologists had to venture off the third floor, they were out of their comfort zone,” says Wyatt. “It took them a while to get comfortable doing coronary bypass surgery on the first floor because they knew if they ran into

an emergency situation, the cath lab staff weren’t much help, and they couldn’t go next door to get help.”

In early 2014, VUMC opened 4 new hybrid rooms on the fifth floor of the hospital—2 are used primar-ily for EP cases and 2 primarily for interventional cardiology cases, and the surgeons are able to use any of them for open cases if necessary.

The third floor main OR suite has a neuro interven-tional hybrid room and a vascular hybrid room. An-other neuro interventional and potentially a cardiac surgery hybrid room will be built on the third floor this year, and the urologists also want a room, says Wyatt.

The rationale for building the cardiac hybrid room on the third floor is that it will allow cases that are primarily surgical with some imaging rather than cases that are primarily imaging with the potential for open to be performed close to the rest of the cardiac surgery and anesthesia teams.

“When we built our first hybrid OR on the first floor, we learned a lot about space and placement of equipment,” notes Wyatt. Cardiologists were more involved in the initial design than was the surgical

Cardiac Hybrid Suite Management Structure

Cardiology Administrator

Perioperative Administrator

Cath LabAssistant manager

Cath LabAssistant manager

ChangeNurse

ChangeNurse

ChangeNurse

ChangeNurse

ChangeNurse

DirectorCath & EP Lab, Cardiac

Surgery

Cardiac SurgeryManager

Source: Vanderbilt University Medical Center, Nashville, Tennessee.


team, and the perfusionists had limited space for the pump and their equipment. “The perfusionists had a lot more input in our design of the fifth-floor hybrid rooms,” he says.

Input from the anesthesiologists is also important, he adds. “Placement of anesthesiology equipment can make or break you.”

Wyatt recommends having a construction crew build a mock room. Then move as much equipment as possible into the mock-up to see how everything fits.

“Your construction manager may not understand that a column that juts out of the wall only 12 small inches can [radically affect] placement of your ster-ile field and the anesthesiologists’ equipment,” he says.

VUMC hybrid rooms are typically larger than non-hybrid rooms. Wyatt recommends targeting a space that is 1,000 sq ft in order to accommodate the equipment and staff required to do these complex cases.

“The room will look as big as a football field when it is empty, but when all of the equipment is in, it looks so crowded it is amazing,” he says (photo).

Cross-training teams is challengingHistorically, when an interven-tional team and an OR team are both working in the same room for a hybrid case, 1 team is doing nothing while the other team is working.

“This made us start thinking about how to have more versatile teams and cross-training staff,” says Wyatt. A new interventional hybrid team model was designed that included staff competencies and standards of practice.

The difference in standards of practice between specialties caused problems early on. For example, in cases that are primar-

ily image-based, radiation exposure is a concern. Radiation detection devices need to be placed at the point where the team members are at the high-est risk—their hands—so they wear radiation de-tection rings under their gloves.

Because AORN recommends against wearing rings under sterile gloves, this practice made OR staff un-comfortable. “We had to educate the OR staff on the balance between putting staff and physicians at a higher risk by not allowing them to wear the de-tection rings or going against the standards,” says Wyatt.

On the other hand, staff from the interventional set-tings sometimes found themselves involved in pro-cedures that changed from percutaneous to open, and they did not have the skill sets to assist in these procedures. “They had to learn the supplies and equipment and sterile technique needed to transi-tion from a percutaneous to an open procedure.”

Cross-training began with staff from the cath lab; however, they found working in the OR challeng-

In the Cardiac Hybrid Suite, Collaboration is Key

Combining the tools of the Operating Room and the Cath Lab to provide care to an increasingly complex patient population

Source: Vanderbilt University Medical Center, Nashville, Tennessee.


ing and they had low competency scores. “What we failed to take into consideration was that people work in the cath lab because they like to do cath lab procedures, and people work in the OR because they like to work in open procedures,” says Wyatt.

Forcing OR staff to work in an environment where they are limited to handling wires and balloons all day is not satisfying for them. Taking nurses out of the cath lab or interventional suite where they were used to doing a variety of things, such as providing sedation and monitoring patients, was too big of a shift for them.

Instead of cross-training all staff, Wyatt says, they had to change their strategy and be more selective of the people they cross-trained.

“I have had to realize, the hybrid arena is a dif-ferent world,” says Wyatt. “People are working in new practice settings and with standards of practice that are new to them. We have to think very clearly about that and be sensitive to those differences to foster the collaboration needed to manage hybrid rooms successfully.”

—Judith M. Mathias, MA, RN


Building the business case for a hybrid ORHybrid ORs are proliferating in response to mar-ket, surgeon, and even patient demands, but build-ing the business case for this technology can be challenging.

“It’s a very expensive proposition,” says Lynne Ingle, MHA, BS, RN, CNOR, project manager for Gene Burton & Associates, a healthcare technol-ogy consulting company in Franklin, Tennessee, and a former director of surgical services. Costs can average from $3 million to $6 million, accord-ing to data from ECRI Institute and The Advisory Board Company.

With that much money at stake, the natural first question is, “Does our hospital need a hybrid OR?” When answering this question, OR managers should keep in mind that a hybrid OR is a long-term invest-ment; short-term profits are unlikely.

Staying competitive“I think we’re at the point that you need a hybrid OR to be competitive,” says Deborah Rideout, BSN, RN, CNOR, director of perioperative servic-es at Southcoast Hospitals Group in New Bedford, Massachusetts. The first hybrid OR in this four-fa-cility system opened in New Bedford in 2008, and another one is being built at their Fall River site. About 230 cases per year on average are performed at the New Bedford site.

Rohit Inamdar, senior medical physicist at ECRI Institute, agrees with Rideout. “Even if you are a small facility, minimally invasive surgery is here to stay, so if you don’t get on board with a hybrid OR or cath lab, you will be left behind,” says Inamdar, who has consulted with many hospitals developing hybrid rooms. “You need a hybrid OR to keep your cardiac surgery program.”

Although academic medical centers remain the most common site, Inamdar has seen a growing number of hybrid ORs being installed in commu-nity hospitals.

If hybrid ORs are a growing trend, how can OR managers build a business case that provides a rea-sonable return on investment? Inamdar says pro-gram, staffing, and patients form a three-legged

stool that supports the business case for a hybrid OR (sidebar).

Ensuring a robust programInamdar recommends that anyone considering a hybrid OR first determine if the facility has a ro-bust open-heart surgery program for valve replace-ment, given that currently the primary procedures performed in the hybrid OR are transcatheter aortic and mitral valve replacement (TAVR, TMVR).

OR managers should also consider other potential future uses of the hybrid OR. At Inova Fairfax in Falls Church, Virginia, for example, the endovascu-lar hybrid OR began as a location for TAVR, but has since expanded to include endovascular aneurysm repair, says Anne Cochrane, MSN, RN, CNOR, in-terim director of the cardiovascular OR. “You want to set up the room so it can be used for anticipated future procedures,” she says.

Planned future use also affects design and equip-ment needs. For instance, Ingle says, “Some neuro-surgeons want a biplane [angiograph imaging sys-tem], but endovascular surgeons use a single plane, and some neurosurgeons are OK with a single plane and don’t need a biplane.” These decisions will af-fect costs.

The geographic location of the hybrid room affects the bottom line. “CMS [Centers for Medicare & Medicaid Services] says you have to do TAVR in

This hybrid OR opened at Southcoast Hospitals Group in New Bedford, Massachusetts, in 2008.(Photo courtesy of Helio Rosa, Southcoast Hospitals Group.)


a hybrid room to receive reimbursement,” Inamdar says. CMS lists additional qualifications needed for reimbursement, including volume requirements. Third-party payers are also providing incremental reimbursement for TAVR. In 2014, CMS approved a technology add-on payment to cover TMVR.

To support the hybrid OR, the program must be supported by a good relationship with primary care physicians who will refer patients. “If you have good vascular surgeons but don’t have any primary care alliance, you could find yourself with an empty

room,” Rideout says. “You have to have strong pri-mary care alliances.”

Getting support from the experts“You should have cardiac surgeons who have expe-rience and expertise with TAVR because these pa-tients are considered high risk,” Inamdar says.

For hospitals without TAVR experience, CMS re-quires cardiovascular surgeons to have performed at least 100 career aortic valve replacements (AVRs),

Creating the business planWriting a business plan isn’t done in isolation, says Deborah Rideout, BSN, RN, CNOR, director of perioperative services at Southcoast Hospitals Group in New Bedford, Massachusetts. “It takes a team to collect the information you need and put it into one packet.”

The team should include surgeons, and staff from business, finance, engineering, imaging, and biomedi-cal, among others. Typically the plan projects break-ing even at 5 years.

“Sales reps can be helpful in identifying break-even points,” says Anne Cochrane, MSN, RN, CNOR, interim director of the cardiovascular OR at Inova Fairfax in Falls Church, Virginia.

Elements to consider when writing the plan include:

nMarket intelligence. Rideout suggests answering questions like, Who else in the region has a hybrid OR? Where are they drawing the patients from?

nMarket share. Estimate what market share the hos-pital is losing because of not having a hybrid OR and whether the hospital has strong enough refer-ral relationships.

nPatient-related data. This includes payer mix and expected volume, including what percent of current cases will be converted into hybrid cases. Forecast predicted reimbursement based on payer mix and note savings from reduced length of stay.

nConstruction. Consider if you can upgrade an exist-ing OR or if you need to create a new one, keeping in mind that a hybrid OR averages 1,100 square feet, compared to 600 square feet for a standard OR.

nEquipment. To avoid missing something, meet with

hybrid team members, including surgeons and ra-diology staff, as well as vendors. Ask vendors for names of hospitals to call, and go on site visits. Use a bidding process to obtain the best price.

nUpgrades. “It’s best to plan for software and hard-ware upgrades on a rolling basis 5 to 10 years out so you have a good idea as to future capital ex-penses,” Cochrane says. “It’s not just the expenses up front.” The finance department can help with depreciation estimates, and the sales representative would be able to provide upgrade time frames.

nSupplies. The cost of implants such as those used in TAVR are significantly higher than the grafts used in an open procedure, so the plan will need to include expenditures for stock. “Until you are doing the program for about a year, you have to purchase the implants instead of buying on con-signment,” Cochrane says. She adds that it’s key to work with the finance department to ensure sup-plies are billed; some hospitals have set up a line item for a hybrid procedure.

nTimeline. Lynne Ingle, MHA, BS, RN, CNOR, recommends targeting no more than 6 months for making the decision as to what system to select. “It gives you time to make site visits and get people in agreement, but not so much time that you lose momentum,” says Ingle, project manager for Gene Burton & Associates, a healthcare technology consulting company in Franklin, Tennessee, and a former director of surgical services.

Cochrane also recommends working with finance to determine allocation of revenue and supply charges. For example, if a cardiologist and a surgeon are doing a case, who receives credit? Also, block scheduling is necessary for efficient operation of the hybrid.


including 10 high-risk patients, or at least 25 AVRs in 1 year, or at least 50 AVRs in 2 years, which in-clude at least 20 AVRs in the last year before TAVR initiation. Hospitals may need to recruit cardiovas-cular surgeons or interventional cardiologists to meet these numbers.

Surgeons need to maintain volume to ensure con-tinued reimbursement. CMS requires the surgeon and hospital to complete at least 20 TAVR proce-dures in a year, or at least 40 TAVR procedures in 2 years. The agency also has volume requirements for interventional cardiologists and the hospital’s cardiac catheterization lab. For example, the cath lab must perform at least 1,000 catheterizations per year, including at least 400 percutaneous coronary interventions per year.

In addition to physicians, CMS lists other mem-bers who must be part of the team, including echo-cardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, nurses, and social workers.

Above all, says Ingle, “The most critical part is hav-ing physician champion.”

Identifying eligible patientsTo analyze potential patient volume, Rideout sug-gests asking, “What is the market share that we aren’t getting because we don’t have a hybrid OR?” It’s helpful to list cases that will be done immedi-ately in the hybrid OR and those that will be added later.

“Look at the length of stay for those patients, and work with your business partners in the organiza-tion to calculate what the savings would be if those patients could be discharged sooner,” she adds.

Cochrane, who has several years of OR experience in a variety of OR settings, says the surgeons are good predictors of volume. “They really know their market and where their referral base is,” she says, adding, “It’s better to underanticipate than overan-ticipate the numbers.”

Because a limited number of procedures currently require a hybrid OR, hospitals can run into financial difficulties. “There can be a positive profit margin with TAVR, but it’s very small,” Inamdar says, not-ing that many facilities may struggle to break even.

Part of the difficulty is that only a small number of patients are currently eligible for the procedure, and those who are eligible are also high risk. “The national TAVR pool is about 20,000 to 30,000 in the entire US,” Inamdar notes.

Reimbursement for the procedure from CMS rang-es from $27,000 to $56,000, depending on the pa-tient’s severity and how he or she is treated. Consid-ering that the TAVR valve costs just over $30,000 and that the procedure cost ranges from $50,000 to $80,000, it’s clear that a hybrid OR “is not a money-making machine,” Inamdar says.

“If you’re armed with talented physicians who are aligned with you, have a solid cardiovascular pro-gram, and a market share that is validated to be leaving the area because you’re not offering certain services—that’s a good case for a hybrid OR,” says Rideout.

Making the numbers workBecause of the expense, it’s not easy to make the numbers work for a hybrid OR. “But because it [a hybrid OR] has become a standard, you have to find ways of being fiscally prudent while you’re doing it,” Rideout says.

One way of saving money is to choose vendors wisely, Ingle says. If, for instance, the cath lab is already using equipment from Toshiba, the OR manager might be able to obtain a discount by pur-chasing Toshiba equipment for the hybrid OR. “You will have multiple vendors, so coordination is really important,” she adds.

If your cardiac surgery program isn’t large enough for a hybrid OR, Inamdar suggests considering a hybrid cath lab or adding a hybrid interventional radiology (IR) suite.

The downside is that these rooms still require the staff, supplies, and sterility needed in the OR. “But it’s doable and it’s a lower price option,” Inamdar says.

Ingle adds, “My philosophy is that it should be behind the red line of the OR in case you have to open the patient, but I’ve seen it done both ways. It’s something hospitals have to discuss.” She notes that remodeling an existing OR is less expensive than building a new one.


To maximize the use of the hybrid OR, Inamdar recommends OR managers work with other phy-sicians such as vascular surgeons, neurosurgeons, and electrophysiologists, who use angiography im-aging systems. “You might be able to consolidate so you need fewer labs, and improve your financial equation a bit,” Inamdar says.

Keep in mind that when not in use for its hybrid capabilities, the OR can be used for certain other cases. At Inova, for instance, “the hybrid OR is built so it can be used for any patient who requires a by-pass pump,” Cochrane says.

Ingle reports that hybrid OR use is being expanded at many hospitals to include spinal and total joint replacement surgery, as well as other cardiovascular procedures, as physicians increasingly tap into the value of good imaging for a variety of procedures.

Another option for reducing costs is to choose a re-furbished angiography imaging system. Facilities that are downsizing or upgrading their systems may be trading in systems that are less than 5 years old.

Inamdar says the typical life span of these systems is 10 years, so facilities could save as much as $1

million by purchasing a refurbished model. “It will still meet your needs but won’t have all the bells and whistles,” he says. When exploring the refur-bished option, be sure to work with a reputable vendor.

Envisioning the futureInamdar notes that currently only one mitral valve contouring system is approved for use in the United States, but expects others currently being used in Europe to receive approval as well, further pushing demand for hybrid ORs. “Transcatheter devices are a growth area, and I don’t see it slowing down any-time soon,” he says.


ReferencesCenters for Medicare & Medicaid. Decision memo for trans-

catheter aortic valve replacement (TAVR) (CAG-00430N). http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=257.

The Advisory Board Company. System strategies for hybrid OR investment. http://www.advisory.com/Research/Service-Line-Strategy-Advisor/Original-Inquiry/System-Strategies-for-Hybrid-OR-Investment.

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Capitalizing on the New Wave of Hybrid ORs · 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