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Capitalizing on
the New Wave
of Hybrid ORs
Published by OR Manager and Access Intelligence
Introduction www.ormanager.com
SENIOR VP/GROUP PUBLISHER
operating rooms. Building a new hybrid OR takes careful planning, PUBLISHER, DEFENSE AND HEALTHCARE
Thomas A. Sloma-Williams • 301-354-1696
requires specialized and advanced audiovisual and imaging tawilliams@accessintel.com
EDITOR
equipment, and involves the collaboration of many decision Elizabeth Wood • 301-354-1786
ewood@accessintel.com
makers. And once a hybrid OR is in place, procedures often require CLINICAL EDITOR
CONTRIBUTING WRITERS
may be daunting, but the results may leave you in a better position Paula DeJohn, Cynthia Saver, MS, RN
members of your team is crucial to success. It is our hope that this REPRINTS
While awaiting completion of 10 new ORs, Sarato- For ceiling-mounted booms, all of the wiring has to
ga Hospital in Saratoga Springs, New York, needed go into the ceiling. Those booms may be impossible
to upgrade an existing OR for minimally invasive or difficult to install because of lack of space.
and robotic procedures. With the floor-mounted booms, all of the wiring is
The 170-bed facility had a steel building struc- easily accessible in the back of the unit. The visu-
ture that didn’t allow for monitors and equipment alization hardware also is in the back of the unit
booms to be suspended from the ceiling. The small rather than having to be housed in a closet outside
OR also lacked space for an audiovisual equipment the OR.
closet where the hardware for a visualization sys- “Our experience with the floor-mounted boom is
tem would normally be located. that it has the same amount of flexibility as ceiling-
A multidisciplinary team responsible for choos- mounted systems,” notes Lisieski. The relationship
ing equipment for the 10 new ORs began evalu- between the patient and equipment shelves is the
ating different options for the existing OR. They same because of the cord length of the cameras.
decided on a floor-mounted boom that could be “As long as the monitor booms can reach where the
easily installed with only a couple of days’ down- surgeon needs them, either boom style works,” she
time. says.
The boom has four high-definition monitors with The vendors came into the hospital and were avail-
touchscreen-controlled visualization that routes and able to the staff until everyone was trained on the
displays signals from cameras, endoscopes, naviga- boom.
tion systems, ultrasound, C-arms, PACS (picture
achieving and communication) systems, and other Adding new rooms
input sources. It also has visualization system hard-
ware enclosed, so a separate equipment closet isn’t The boom eventually will be moved to one of the
needed. new ORs, and then another four rooms will also be
video-integrated rooms for minimally invasive sur-
“These booms are not just for hybrid ORs, they gery. Eventually two interventional rooms will be
benefit any room,” according to Sharman Lisieski,
added.
BS, RN, CNOR. “Your nurses will no longer be
‘hunters and gatherers’ because all of the equipment “Even though we are not to that interventional
that used to be on separate towers is consolidated on stage, there are many advantages to this boom,”
shelves on the boom,” says Lisieski, director of the says Lisieski.
OR and PACU (postanesthesia care unit) at Sara- For example, “when we do a laser lithotripsy we
toga Hospital. have the four monitors around the OR table—we
Because nurses are not moving towers full of equip- put our PACS on number 1, the patient’s x-rays on
ment in and out of the room, turnover times have number 2, and then we can put the endoscope im-
decreased and on-time starts have increased, she age and C-arm image side by side on number 3 and
says. In addition, she says, “the images the boom number 4,” she says. “It really is a sweet system.”
endovascular procedures, most cases are vascular. “Each hospital has a different case mix,” Skorup
Urschel notes a number of factors have contributed says. “You need to take a surgical time-out to define
to the program’s success, starting with multidisci- the case mix you expect and use that as a template
plinary planning. for your planning efforts. You then have a greater
likelihood of engaging the right people and having
A planning team success.” He recommends considering all options.
“If you plan for only one specialty, you have limited
St Peter’s created a hybrid OR steering committee the future of the room and may not have the volume
composed of key players, including vascular and you need to be successful,” he says.
cardiovascular surgeons, cardiologists, OR nursing
leaders, and supply chain managers. “You need to “Hospitals don’t have money to lose.” For example,
have physician buy in by having them at the table,” Urschel says, St Peter’s had a second OR fitted for
Urschel notes. hybrid capability at the same time as the first. “Then
we can just add the robotic C-arm when we have
Becky Chalupa, MS, RN, CNOR, associate chief
sufficient volume to justify its purchase.”
nursing officer at Methodist Sugar Land Hospital in
Texas, adds that other needed players are anesthesia Urschel says the steering committee developed a
and facility managers. Methodist has 243 beds, 18 list of procedures to be performed in the hybrid OR,
ORs, and one endovascular hybrid OR that opened which helped smooth some of the later bumps in the
in December 2012. road when it came to scheduling block time.
Key Stakeholders
Ownership
§ Determine primary room use
§ Determine the project owners as soon as possible!
“For example,” he says, an emergency situation, the cath lab staff weren’t
“biplane imaging technology is tremendously ex- much help, and they couldn’t go next door to get
pensive, and you really have to think systematically help.”
about who will be using it or there may not be a
return on investment.” VUMC has a stroke program In early 2014, VUMC opened 4 new hybrid rooms
that is highly dependent on hybrid ORs because of on the fifth floor of the hospital—2 are used primar-
the need for biplane imaging by the neuro special- ily for EP cases and 2 primarily for interventional
ists. Cardiac and vascular specialists may also use cardiology cases, and the surgeons are able to use
biplane or single plane imaging. any of them for open cases if necessary.
Before building new hybrid rooms, Wyatt says, they The third floor main OR suite has a neuro interven-
look at which specialists would potentially use the tional hybrid room and a vascular hybrid room. An-
rooms, the like procedures they perform, the like other neuro interventional and potentially a cardiac
equipment they use, and the best placement for each surgery hybrid room will be built on the third floor
room (sidebar). this year, and the urologists also want a room, says
Wyatt.
Placement of hybrid rooms, equipment is key The rationale for building the cardiac hybrid room
on the third floor is that it will allow cases that are
Several years ago, VUMC built its first hybrid room primarily surgical with some imaging rather than
adjacent to the cath lab on the first floor. The main cases that are primarily imaging with the potential
OR suite (with 35 rooms) is on the third floor. for open to be performed close to the rest of the
“When the cardiac nurses and anesthesiologists had cardiac surgery and anesthesia teams.
to venture off the third floor, they were out of their “When we built our first hybrid OR on the first
comfort zone,” says Wyatt. “It took them a while floor, we learned a lot about space and placement of
to get comfortable doing coronary bypass surgery equipment,” notes Wyatt. Cardiologists were more
on the first floor because they knew if they ran into involved in the initial design than was the surgical
Cross-training teams is
challenging
Historically, 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.
Combining the tools of the Operating Room and the Cath Lab to
provide care to an increasingly complex patient population
The difference in standards of
practice between specialties
Source: Vanderbilt University Medical Center, Nashville, Tennessee. caused problems early on. For
example, in cases that are primar-
team, and the perfusionists had limited space for the ily image-based, radiation exposure is a concern.
pump and their equipment. “The perfusionists had a Radiation detection devices need to be placed at
lot more input in our design of the fifth-floor hybrid the point where the team members are at the high-
rooms,” he says. est risk—their hands—so they wear radiation de-
Input from the anesthesiologists is also important, tection rings under their gloves.
he adds. “Placement of anesthesiology equipment Because AORN recommends against wearing rings
can make or break you.” under sterile gloves, this practice made OR staff un-
Wyatt recommends having a construction crew comfortable. “We had to educate the OR staff on
build a mock room. Then move as much equipment the balance between putting staff and physicians at
as possible into the mock-up to see how everything a higher risk by not allowing them to wear the de-
fits. tection rings or going against the standards,” says
Wyatt.
“Your construction manager may not understand
that a column that juts out of the wall only 12 small On the other hand, staff from the interventional set-
inches can [radically affect] placement of your ster- tings sometimes found themselves involved in pro-
ile field and the anesthesiologists’ equipment,” he cedures that changed from percutaneous to open,
says. and they did not have the skill sets to assist in these
procedures. “They had to learn the supplies and
VUMC hybrid rooms are typically larger than non-
equipment and sterile technique needed to transi-
hybrid rooms. Wyatt recommends targeting a space
tion from a percutaneous to an open procedure.”
that is 1,000 sq ft in order to accommodate the
equipment and staff required to do these complex Cross-training began with staff from the cath lab;
cases. however, they found working in the OR challeng-
a hybrid room to receive reimbursement,” Inamdar room,” Rideout says. “You have to have strong pri-
says. CMS lists additional qualifications needed for mary care alliances.”
reimbursement, including volume requirements.
Third-party payers are also providing incremental
reimbursement for TAVR. In 2014, CMS approved
Getting support from the experts
a technology add-on payment to cover TMVR. “You should have cardiac surgeons who have expe-
rience and expertise with TAVR because these pa-
To support the hybrid OR, the program must be
tients are considered high risk,” Inamdar says.
supported by a good relationship with primary care
physicians who will refer patients. “If you have For hospitals without TAVR experience, CMS re-
good vascular surgeons but don’t have any primary quires cardiovascular surgeons to have performed at
care alliance, you could find yourself with an empty least 100 career aortic valve replacements (AVRs),