Capitalizing on the New Wave of Hybrid Ors

SPECIAL REPORT Capitalizing on the New Wave of Hybrid ORs

Published by OR Manager and Access Intelligence Introduction www.ormanager.com SENIOR VP/GROUP PUBLISHER Jennifer Schwartz • 301-354-1702 An increasing number of hospitals nationwide now have hybrid [email protected] PUBLISHER, DEFENSE AND HEALTHCARE operating rooms. Building a new hybrid OR takes careful planning, Thomas A. Sloma-Williams • 301-354-1696 requires specialized and advanced audiovisual and imaging [email protected] EDITOR equipment, and involves the collaboration of many decision Elizabeth Wood • 301-354-1786 [email protected]

makers. And once a hybrid OR is in place, procedures often require CLINICAL EDITOR teams from several disciplines to work together as one. This process Judith M. Mathias, MA, RN CONTRIBUTING WRITERS may be daunting, but the results may leave you in a better position Paula DeJohn, Cynthia Saver, MS, RN WEBINAR COORDINATOR to offer a variety of surgical procedures, enhance patient safety, and Ellen Lord, MS, RN, CNOR CONFERENCE DIRECTOR achieve long-term cost savings with improved efficiencies. Jess Tyler

ART DIRECTOR Regardless of whether you’re building a new hybrid OR or Yelena Shamis remodeling to accommodate the new room within existing space, [email protected] SENIOR PRODUCTION MANAGER you must commit considerable financial and human resources. Joann M. Fato • 301-354-1681 [email protected]

This special report provides insights from professionals who have ADVERTISING transitioned to a hybrid OR, offering tips and strategies to help National Advertising Manager Jamila Zaidi Account Executive, OR Manager you through the process. As with any transition, getting input from [email protected] 301-354-1678 physicians, anesthesiologists, nurses, technical staff, and other Fax: 301-340-7136 members of your team is crucial to success. It is our hope that this REPRINTS Wright’s Media report lays the groundwork for a successful conversion. 877-652-5295 • [email protected]

OR Manager (ISSN 8756-8047) is published monthly by Access Intelligence, LLC. Periodicals postage paid at Rock- ville, MD and additional post offices. POSTMASTER: Send address changes to OR Manager, 4 Choke Cherry Road, 2nd Floor, Rockville, MD 20850. Super subscription (includes electronic issue and weekly electronic bulletin) rates: $219 (plus $10 shipping for domestic and Canadian; $20 shipping for foreign). Single issues: $39. For subscription inquiries or change of address, contact Client Services, [email protected]. Tel: 888-707-5814, Fax: 301-309-3847. Copyright © 2015 by Access Intelligence, LLC. All rights reserved. No part of this publication may be reproduced without written permission. OR Manager is indexed in the Cumulative Index to Nursing and Allied Health Literature and MEDLINE/PubMed.

Access Intelligence, LLC President & CEO Don Pazour Chief Operating Officer Heather Farley Executive Vice President & Chief Financial Officer Ed Pinedo Exec. Vice President, Human Resources & Administration Macy L. Fecto Senior Vice President, Chief Information Officer Rob Paciorek Senior VP, Customer Acquisition and Retention Sylvia Sierra Senior Vice President, Digital Development Alison Johns VP, Production, Digital Media & Design Michael Kraus Vice President, Financial Planning and Internal Audit Steve Barber Vice President/Corporate Controller Gerald Stasko

4 Choke Cherry Road, Second Floor Rockville, MD 20850 • www.accessintel.com

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

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 3 Clear vision critical to successful hybrid OR development About 100 US hospitals now have a hybrid operat- converting to an open procedure, so they must be ing room, and a 15% increase is projected over the large enough to accommodate staff and equipment next decade, according to experts who have man- for two separate clinical teams, Ingle explains. aged installations at numerous facilities. Whether your hospital is considering converting a Procedures conventional operating room into a hybrid OR or The list of procedures that can be performed in a hy- building a brand new room, it’s important to know brid OR is growing. Among these are many cardiac where you want to end up before you take the first procedures that in the past have been done in the step to get there. cath lab, but Ingle notes that “hybrid ORs should not “Knowing what you want to accomplish—having be glorified cath labs.” Newer procedures include a business plan—is the most critical part of plan- transcatheter aortic valve replacement (TAVR) and ning. Just knowing that you want to have a hybrid mitral valve clipping, endoscopic abdominal aortic OR isn’t very helpful,” says Lynne Ingle, MHA, aneurysm, and aortic arch repair. BS, RN, CNOR. As a project manager with Gene Burton & Associates, a health care technology con- Some hospital leaders have mistakenly believed sulting company in Franklin, Tennessee, Ingle has that for a procedure such as an aortic valve replace- overseen several hybrid OR installations. As a for- ment, a cath lab can be turned into a hybrid room, mer director of surgical services, she is well versed she says. However, some valve vendors won’t enter in the kinds of improvements hospitals hope to into a contract with a hospital if these procedures achieve with the new technology. are to be performed outside the restricted area of the surgical suite. “You need to have all the capabilities for converting to an open procedure if need Planning be,” Ingle says. Key players in the planning process are hospital administration, interventional cardiologists, open Form and function heart and vascular physicians, neurosurgeons, anesthesia providers, department heads and staff from The most common configuration for a hybrid OR the cardiac catheterization lab and the OR, a charge includes a single-plane angiographic x-ray imag- nurse, a staff nurse, and information technology, ing system and surgical equipment for open cardiac Ingle says. Participants from the nonclinical side surgery. include architects, vendors, and engineers. And for Lights for the hybrid OR must have a longer arm any remodeling project, it’s critical to consider in- reach, especially depending on who’s doing the fection prevention, she emphasizes. imaging, Ingle says. Whether a ceiling-mounted or Start by determining just how your hospital defines floor-mounted C-arm is the best choice depends on “hybrid.” Consider questions such as: which procedures will be done in the room. Place- ment of lights and booms is important because • What is the hospital’s goal? anesthesia staff must be able to have access to the • Who is driving the function of the space? head of the table. • What procedures are planned? Knowing how the space will be used is especially important for determining the type of table that’s • What is the budget? needed. If most procedures will be interventional, A traditional OR is about 700 square feet, whereas at the table selected should be one that communicates least 1,000 square feet is needed for a hybrid room, with the imaging system, which is typically pur- and 1,200 square feet is preferable for accommo- chased from the imaging vendor. If the room will dating the imaging equipment within the room plus function primarily as an OR, however, the table the control room from which procedures are moni- should be appropriate for surgical procedures and tored. Hybrid ORs must allow for the possibility of thus it won’t be able to communicate with the imag-

4 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs ing system. Some OR vendors offer a table with a Previously, patients in that area of Nevada who fixed base and two tabletops—one for surgical pro- were too ill to undergo aortic valve replacement cedures and one for imaging procedures. with an open procedure usually had to go to south- ern California, Ingle says. Installation of the hy- Well-funded facilities may have a dedicated wall brid OR allowed them to have TAVR without hav- for imaging. But in general, facilities need to have ing to travel. 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— The future as few or as many as hospitals can afford or want, In 2013, the interventional trauma operating room Ingle says. (ITOR)—a $6-million 1,600-square-foot hybrid Knowing the visuals needed in the control room operating suite—opened at the Foothills Medical is an important factor in deciding on vendors, she Center in Calgary, Alberta, Canada. The facility is notes, because the technician in the control room “the first of its kind designed specifically for trauma must be able to see and understand what the sur- patients [and] is more than twice the size of a tradi- geon needs. tional OR,” according to Andrew Kirkpatrick, MD, As an example of the efficiency gain that’s achieved Alberta Health Services’ medical director of trauma with a hybrid OR, Ingle says, troubleshooting can services. The angiography equipment, which al- be done in one place instead of moving the patient lows surgical and diagnostic imaging teams to work from room to room. “For cardiac surgery, some- on patients at the same time, makes it possible for times a patient is taken from the cath lab directly patients with severe bleeding to go directly to the to the OR, and measurements are taken for vessels ITOR for treatment. behind the heart, which can’t be seen. If the patient Whether future hybrid ORs in the US will be then moves to the ICU but isn’t doing well, the pa- built specifically for trauma patients remains to tient must go back to the cath lab for imaging and be seen, but Ingle says it’s a good bet that more then back to the OR,” she says. “If everything were spinal procedures will be done in hybrid ORs of done in the hybrid OR, the surgeon would see the the future. vessels right there because imaging would be done. “A hybrid OR lends itself to spinal surgery because That would cut down on morbidity, infection, and it has real-time data with the C-arm and high-defini- cost, and the patient could be discharged in a more tion 3D pictures,” she explains. “You can’t see those timely manner.” as well with a mobile C-arm that must be rolled into Hybrid ORs can also benefit patients in remote ar- the room. The hybrid room equipment allows the eas. Ingle was involved in a $3 million hybrid OR surgeon to see on the screen where to place surgical installation at St. Rose Dominican Hospital Siena components like screws and plates.” Campus in Henderson, Nevada, in 2012. While most hybrid ORs initially were installed in “A multi-disciplinary ‘TAVR Heart Team,’ led by university hospitals, an increasing number of com- cardiothoracic surgeons and interventional cardi- munity hospitals have added or are planning to add ologists, has been through a comprehensive training at least one hybrid OR, Ingle says. program that includes procedure and complication —Elizabeth Wood management,” according to Rod Davis, president and CEO of St. Rose Dominican Hospitals and senior vice president of operations, Dignity Health Ne- vada. TAVR allows cardiac specialists to deliver and References place a new aortic heart valve in the heart through Calgary Herald. Specialized operating room for trauma patients a noninvasive procedure that doesn’t require cutting opens. March 28, 2013. through the sternum or stopping the patient’s heart. www.strosehospitals.org.

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 5 Case Study: Operationalizing the hybrid OR You’ve cleared the hurdle of installing a new hybrid office computer. operating room, but now another hurdle looms: put- Education helped ease what Dr Reece feels was ting it into operation. the most challenging part of the startup—anxiety The good news is you likely have already built a among those in the room. “The consistency that Ta- collaborative relationship among key players. “Get- mara provided made it work,” he says. ting everyone on the same page to justify the OR “We overcame anxiety through repetition in edu- sets the team up for success,” says T. Brett Reece, cation and leading by example,” Mayne adds. MD, a faculty member in the division of cardiotho- “Now anxiety is low. People have a good idea of racic surgery for the University of Colorado Hospi- how to fit everything in the room and how the pro- tal (UCH) in Aurora, which opened its hybrid OR cess works.” in April 2012. About 30 to 40 cases, mostly endovascular, are done each month, with utilization between 66% to 80% during weekday business hours. A blended staff You’ll need to build on that collaboration in four “We use a blended staffing model for the hybrid areas: education, staffing, supplies/billing, and co- OR,” says Katherine Halverson-Carpenter, MBA, ordination. Here’s how UCH did it. RN, CNOR, patient care services director for ob- stetrics and perioperative series at UHC. Staffing is based on case type. Staff from the cardiovascular Ramping up (CV) center and the OR handle combined cardiol- “We used multiple opportunities to educate staff,” ogy and surgical procedures, with the CV center says Tamara Mayne, BSN, RN, cardiothoracic sur- nurses supporting the cardiologists with imaging gery service specialist for the UCH OR. “The edu- and documentation. A radiology technician from cators in interventional services and the OR part- the interventional radiology (IR) department fills nered because they had the knowledge of how it that role for IR procedures done in the hybrid OR. would function and what information staff needed.” One challenge has been the finite number of radiology technicians with the skill set to work in the The hybrid OR was open for a full week before the hybrid OR, Halverson-Carpenter says. first case, giving staff and physicians time for training and learning about the equipment, which includes fluoroscopy imaging, a surgical table, equip- Supply and billing needs ment booms, and general imaging. Everyone on the “Managing supplies is a challenge,” says Mayne. OR staff was oriented to the hybrid OR to provide Vascular surgeons (some of whom were new to flexibility, although the vascular team members UCH), interventional radiologists, and interven- work there most frequently. tional cardiologists had to feel confident that the Education included how to set up the room. “We supplies they needed would be available, while OR adapted current space to the hybrid OR, so we had to leaders needed to reduce redundancy as much as fit everything in so that it would work,” Mayne says. possible. The OR is working on obtaining high-vol- That attention to detail is important for a successful ume supplies on consignment to avoid replicating case. For example, she adds, “If you don’t move the supplies in the IR and CV center suites. C-arm correctly, you can’t move the lights.” Billing processes also had to be established. The Physician preference added to the complexity. “You IR department and CV center bill by the procedure, have to have a way to set up every room for every but the OR bills by time. “We got the finance team case for every physician,” says Dr Reece. Mayne together and decided we would bill by the minute turned to the traditional preference card as a tool, because the procedure was done in the OR,” says but with a twist. “We have lots of pictures and 3-D Halverson-Carpenter. If the procedure is done in in- drawings showing how everything needs to be po- terventional radiology or the CV center, billing is sitioned,” she says. Mayne keeps the images on her done by procedure.

6 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs Coordination lishing the framework clarified our mutual goals and purpose,” Halverson-Carpenter says. “It be- “The greatest challenge of a hybrid OR is the co- came an expectation that people would collabo- ordination,” says Halverson-Carpenter. At UCH a rate.” The group met with the vendors, conducted hybrid steering committee provides oversight and site visits, and worked with designers during the helps work through problems. Halverson-Carpenter process. and Dr Reece, who allocate the block time, cochair the committee. Among members are those who per- That spirit of collaboration carried over into opera- form procedures in the room, nursing staff, nurse tions meetings among centers, where details were managers, and perioperative business managers hammered out. The team had to consider current from the IR department, OR, and CV center. practices while determining how to best work together, something they continue to do. “We respect Halverson-Carpenter says the committee reviews the practices and philosophies of each of the indi- utilization of the room both during regular business vidual units,” Halverson-Carpenter says. “That’s hours and after hours, which cases are being done helped us come together as a team.” by which physicians, supply needs, billing, and any operational issues. “It’s important to track your volume and who is using the room so you can readjust Satisfaction and future direction your block time allocation,” she notes. Staff, physicians, and patients are satisfied with the One discussion centered on the use of the hybrid OR hybrid OR at UCH. “We are able to do cases now for traditional surgical procedures. Recently UCH that we weren’t able to do safely previously,” says opened four new ORs; once they are fully staffed, Dr Reece. Those include fenestrated grafts for pa- the hybrid OR will be dedicated to hybrid cases. tients with complex anatomy and percutaneous car- Halverson-Carpenter credits the success of the diac valves. “We can reinvent what we provide to committee and the hybrid OR to a meeting she and patients.” the chair of surgery cochaired early in the plan- “Everyone working together has made the program ning process. The meeting focused on the princi- successful,” adds Mayne. “We’ve been a tight-knit ples of collaboration and included key stakehold- group.” That success is expected to pay off; the ers, such as the medical director of IR, section UCH team is in the process of justifying a second head of vascular surgery, chair of cardiothoracic hybrid OR. surgery, chair of cardiology, all physicians and surgeons who would be working in the room, and administrators for the OR and CV center. “Estab- —Cynthia Saver, MS, RN

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 7 Lessons learned from hybrid OR installations The cost investment, space and equipment needs, “As our program has matured and we’re doing high- and learning curve involved in adding a hybrid OR er acuity, more sophisticated cases, we are discov- can seem daunting, but the increased flexibility and ering that [the old] skill set is not enough. We are efficiency that can be achieved suggest the effort going back to the drawing board to say ‘we need to is worthwhile. Staff at 3 East Coast hospitals who collaborate with our radiology cath lab staff around have been through the process reflect on their ex- a new staffing model to better support the technol- periences and describe what a hybrid OR project ogy and the interventionalist,’” says McGowan. entails. UMMC’s current goal is to create an environment Building the first hybrid OR was a “leap of faith,” that is seamless for physicians who are moving says James E. McGowan, DHA, MBA, RRT, vice from a standard procedure outside of an operating president of procedural care services at the Univer- room to a hybrid procedure within one. Regardless sity of Maryland Medical Center (UMMC) in Bal- of whether they work in a traditional or a hybrid timore, which has 4 hybrid ORs. Procedures per- OR, nurses have similar responsibilities; however, formed in these ORs range from standard coronary other staff tend to require more training to accom- artery bypass grafting and valve cases to endovas- plish their tasks within the operating room environ- cular and minimally invasive valve procedures. ment. McGowan points to someone who is “very well trained and understands interventional radiol- Initial interest in investing in a hybrid OR was ogy and a cath lab environment from a radiology sparked by a surgeon who often worked in robotic technologist perspective” as an example of the skill surgery and who had formed a partnership with a set required of staff focused on operating the tech- faculty interventionalist at that time, says Mc- nology in this type of environment. Gowan. UMMC recognized the future potential of such an OR and played the odds. OR staff no longer perceive the hybrid room as different from any other room, McGowan says. When “If I were to try to dial back time … I wouldn’t it was new, some people took a dim view of the hy- have even had on my radar the fact that we would brid OR and the changes it demanded of OR staff, be floating valves into people’s hearts in a room but over time they’ve come to accept it. “So much that has to have a team of OR nurses and a team of of cardiac surgery is becoming minimally invasive nurses from the cath lab plus radiologic technolo- that [the proliferation and frequent use of the hybrid gists,” says McGowan. Two of the 4 hybrid ORs OR] is just a sign of the times,” he says. at UMMC are now consistently in use for 80% of prime time hours, and the majority of this utilization is for hybrid cases, he notes. Taking ownership Strong group training, team leaders, and collabo- Honing skills ration helped Massachusetts General Hospital (MGH) prepare for many of the challenges that Most hybrid procedures involve teams from sev- come with adopting a new system, says Joanne eral disciplines working together in the same room. Ferguson, RN, director of operational planning More staff members are required in the hybrid and EOC, perioperative services at Massachu- room, and everyone must be aware of the equip- setts General Hospital. MGH has two hybrid ORs ment setup and roles of their team members. Ad- containing single-plane C-arm units in the new ditionally, the procedures performed in the hybrid Lunder Building. These hybrid ORs, which were OR often require techniques that are unique to the planned and designed through the collaboration minimally invasive nature of the procedure—tech- of surgery, radiology, and nursing staff, support niques that may test the skill set of the average cath a full range of open, interventional, and hybrid lab technician or radiology technologist. procedures. UMMC initially trained radiology technologists in Countless simulations were performed before these a standard equipment training program offered by rooms were opened, allowing the interdisciplinary the vendor.

8 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs team to understand the workflows and processes in with the beds and the C-arm—you can actually do a hybrid OR well before the team cared for its first other cases in the room, so it does allow you to [ar- patient. gue] the business case pretty quickly.” “Because this team of people had been together for Farren estimates that the MGH hybrid ORs accom- close to 3 years during the design phase and many modate roughly 100 procedures each month, despite of us had traveled together to look at other sites, what official documentation shows. “Once staff get we had a very collaborative multidisciplinary team in there and see the utility of the room, almost every with a united focus that designed every inch of these single one of our cases now turn into some sort of ORs,” says Ferguson. “By the time the construction hybrid case for vascular,” Farren says. 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.” Anticipating needs Overall utilization of the hybrid OR at Inova Heart The original core group helped integrate new mem- and Vascular Institute in Falls Church, Virginia, is bers of the team, providing education, training, and currently lower than anticipated because of the lim- support to get everyone up to speed, notes Scott Far- ited equipment selection within the room, says Ed ren, nurse manager of vascular and neuro services. Schatz, RN, CRNFA. Inova opened a hybrid room “I think because of the team building that had hap- in December 2010 as part of an 8-room cardiac sur- pened ahead of time and the lessons learned during gery suite. However, with the benefit of hindsight, the simulations [we had a good start],” agrees Fer- Schatz says, he would approach planning differ- guson. “I would say that we now have such a strong ently today. core team that when someone new joins the team, it “If we were to build another one, we would look at is typically a very smooth transition.” all the possible cases we could do in a hybrid room Selecting and locating the various types of equip- and then make our equipment choices based on ment in these spaces is important, Ferguson says, that,” says Schatz. “The one we have here is good noting that the lessons learned with their first hybrid for cardiac procedures, but not for some things that OR made it much easier to plan for a new cardiac we should be able to do in that room.” hybrid OR. A key lesson was that the hybrid OR Successfully building a hybrid OR requires a great needed to be outfitted for both open and hybrid pro- deal of preplanning and some flexibility on the cedures. At MGH, a limiting factor in the original part of planners, according to Ferguson. Technol- hybrid OR was the OR table. “When we designed ogy is constantly evolving, and a particular piece our two new vascular hybrid ORs, we had the op- of equipment the hospital plans to use may not be portunity to select an OR table that worked for both available for purchase when it is time to actually open and hybrid procedures. The flexibility of our construct the room. Equipment size may also pose vascular hybrid ORs confirmed for us the viability unexpected problems; MGH had to scrap plans for of a cardiac hybrid OR,” says Ferguson. a third hybrid OR when 1 piece of equipment took “We are currently performing the cardiac hybrid far more space than anticipated. “No matter how procedures in our cardiac cath lab, a suboptimal much you’ve preplanned, technology will change. setting for surgery. The team recognized the need Know that, and you can deal with it effectively,” to move these procedures to the OR setting, and we advises Ferguson. developed a plan to build the new cardiac hybrid Ferguson also recommends going on site visits to OR. The 2 years’ experience we have in our vascu- facilities with existing hybrid ORs, as well as those lar hybrid ORs has made planning for and design- in the process of building one. Finished rooms can ing a new cardiac hybrid OR a very positive experi- give visiting teams ideas for potential room layouts ence for all.” and equipment setup for their own hospitals, and McGowan likewise sees hybrid ORs in a positive hybrid rooms under construction will help them light: “The newer rooms have a lot of capabilities learn how to plan.

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 9 “We did this for the new building to engage the clin- health care as a reason to start investing now. ical staff at the very beginning of the design pro- “This is not about an optional exercise,” says cess,” notes Ferguson. “Once you’re into the design McGowan. “You’re just going to have to do it development and past the schematic design, that’s because that’s where health care is going. Have when you have to engage the team, because that’s an organized approach for when to build them when the team begins to come together. It was huge and how to build them, manage that process, and for our success here.” come out on the other side with something that actually works.” Despite the challenges involved in establishing a hybrid OR, some see the future demands of —Steven Dashiell

10 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs Specialized equipment serves hybrid and standard ORs equally well The advanced audiovisual and imaging equipment provides are phenomenal. It is a complete satisfier used in hybrid operating rooms allows clinicians for both nurses and surgeons.” to complete minimally invasive and interventional procedures in less time, leading to improved patient safety and outcomes. Outfitting older rooms But this equipment is not just for hybrid rooms. It The floor-mounted boom is a good way to outfit an can also enhance efficiency and increase physician older or smaller room with advanced imaging tech- satisfaction when placed in regular ORs. nology in a cost-effective manner, says Lisieski. 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 hardware 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.”

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 11 Another example of its versatility is that at the end “For OR managers, this equipment is worth look- of a case the surgeon can view x-ray images on one ing into, depending on what their needs are,” says of the monitors from a patient in the emergency de- Lisieski. “If they are looking for a way to get video partment (ED) who may need urgent surgery and integration into their ORs in a small, tight spot, it have a telephone consultation with a radiologist or could be the answer.” ED physician. All x-rays are digital and can be seen —Judith M. Mathias, MA, RN on any monitor.

12 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs Endovascular hybrid ORs in community hospitals: Driving success Endovascular hybrid operating rooms are no longer for ECRI Institute. “Technology supports practice, limited to university medical centers, as commu- it doesn’t drive it.” nity hospitals expand their cardiovascular services. According to Dorothy Urschel, MS, MBA, RNFA, ACNP-C, NEA-BC, three main trends are stimulat- New procedures ing the growth of hybrid ORs: “Cardiac surgery is In its report “Hybrid Operating Rooms with a Focus becoming less invasive, interventional cardiology on Endovascular Hybrid ORs,” ECRI Institute says is becoming more invasive, and vascular surgery hybrid ORs are a good fit for high-risk, minimally continues to be minimally invasive and use catheter invasive cardiovascular procedures that require ad- techniques combined with radiology techniques.” vanced imaging and may require transition to open Urschel is cardiac and vascular service line director surgery. at St Peter’s Health Partners, a system of four com- Skorup, who says that “advanced imaging” typically munity hospitals in Albany, New York. refers to an angiography system—as opposed to CT ECRI Institute, which assists hospitals with strate- or MRI—points to approval of the Sapien (Edwards gic planning and technology assessment, has seen Lifesciences) transcatheter aortic valve in 2011 as a about a 10% annual growth in requests related to major stimulus for endovascular hybrid ORs. Trans- hybrid ORs among its 3,500 hospital members. The catheter aortic valve replacement (TAVR) “exempli- trend of more hybrid ORs—including those in com- fies what a hybrid OR is all about,” he says. “It’s not munity hospitals—is likely to continue. a traditional vascular intervention. We’re not performing an open procedure or reinforcing a vessel But a successful hybrid program requires careful with a stent; we’re replacing a surgical procedure by analysis and planning by a multidisciplinary team. performing a procedure through a catheter.” Before “Start with the patient, and work your way back to TAVR, nearly a third of patients with severe aortic determine what you need,” says Thomas Skorup, disease weren’t candidates for surgery, so adding this MBA, FACHE, vice president of applied solutions new procedure has expanded the market—and saved lives. “One random- Where the money goes ized, controlled trial showed that TAVR Imaging equipment is the largest expense when building a hybrid significantly reduced mortality rates at OR—typically at least half of the cost. 1 year and at 2 years,” Skorup says. Other procedures typically performed Where the Money Goes in an endovascular hybrid OR include combination coronary artery bypass Imaging Equipment: $2M graft (CABG)/percutaneous coronary 5% 3% Construction: $1M** intervention (PCI) and endovascular 7% OR Equipment: $0.4M Life Support Equipment: $0.3M aneurysm repair. At St Peter’s Health Audio/Visual Equipment: $0.2M Partners, physicians perform a wide 10% Surgical Equipment: $0.1M range of procedures, including stent

50% **Typical construction costs can graft placement and various types of range from $0.5M to $2M. aortic surgery. Imaging equipment is the Biplane (9%) 25% largest expense when building “It’s amazing what you can do,” says a hybrid OR—typically at least Single Plane, CeilingUrschel. (27%) “We have doubled the num- half the total cost. ber of procedures we anticipated when Single Plane, Floorwe (64%) were in the planning stage.” Block time is 75% efficient. Although their Source ©2013 ECRI Institute hybrid room is not exclusively for

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 13

6% $2.0 18% $1.82

millions $1.8 $1.73 55% $1.6 $1.50 21%

$1.4 $1.30 $1.2 $1.04

$1.0 SIEMENS GE PHILIPS SIEMENS TOSHIBA Siemens Artis GE Discovery Philips Allura Siemens Artis Toshiba zeego IGS 730 Xper FD20 zee Infinix-i with FlexMove

CABG EVAR TAVI PTCA Valve Repair CABG/PCI PCI Cartoid Stenting Percutaneo Atherectomy Valve Peripheral Stenting EQUIPMENT TYPE AVERAGE COST Hybrid OR Imaging $2,000,000 Cardiovascular OR Cath Lab Operating $400,000 Life Support $300,000 Audio/Visual $200,000 Hybrid OR = Standard OR = Surgical $100,000 900 to 1200 500 to 800 TOTAL EQUIPMENT $3,000,000 Sq. Ft. Sq. Ft. CONSTRUCTION $1,000,000** TOTAL PROJECT $4,000,000 A Siemens Artis Zeego imaging system with a Maquet A hybrid OR at St. Peter’s Health Partners in Albany, table at Methodist Sugar Land Hospital in Texas. New York.

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.

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

14 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs Equipment needs Elements to include in a business In addition to the usual OR equipment, the hybrid plan for a hybrid OR OR required the following: nn Executive summary nn Radiologic C-arm device/angiography unit nn Strategic objective/planning nn Hybrid operating table nn Program development overview (timeline) nn Video monitors nn Marketing nn Control room nn Technology review nn Contrast injector nn Forecast of expected volume All this equipment means that hybrid ORs are typ- nn Case mix (type and number of expected cases) ically about 500 sq. ft. larger than traditional ORs. nn Planning considerations (eg, construction needs) nn Equipment needed nn Supplies People who need to be part of the planning process, nn Financial impact but are sometimes forgotten, include perfusionists Source: Dorothy Urschel and radiology technicians, according to Skorup. “Having a surgeon working with an angiographic technician in the OR is a new working environ- The hospital is now looking at options for changing ment,” he says. “You have to determine how the equipment, but construction will be needed. Skorup procedure will flow.” Of course, building manage- says that standardization is difficult at this stage ment is also key, whether constructing a new OR because system configurations aren’t “mature,” as or retrofitting an old OR for hybrid capability. For is the case with CT scanners. However, that may example, the floor has to be of sufficient strength change in the future. 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- Supply management tection. Skorup adds that the choice of floor versus Skorup notes that many ORs forget to give the sup- ceiling mount ultimately comes down to physician ply chain the attention it requires. “Representatives preference. from the supply chain need to be involved early,” he As with most projects, planning takes time. Urschel says. A top consideration is determining what will says planning started 3 years before the OR opened. be stocked in the interventional cardiology lab and And, senior management will want a detailed busi- what will be stocked in the hybrid OR. “Consider ness plan showing return on investment, especially the cost of replicating cath lab supply in the OR,” since hybrid ORs aren’t cheap. Urschel says if no he notes. “But not replicating supplies can lengthen OR procedure time when personnel have to wait on rebuilding is necessary, you’ll still need to plan on supplies being obtained from the cath lab.” more than $3.5 million for the basic equipment. Urschel agrees with the importance of supply chain Equipment decisions management. The team ultimately decided to keep vascular wires on a cart that the interventional car- To choose equipment vendors, Skorup says you diology lab and OR can share. 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- Staffing and training dor to have early discussions with a single person One of the biggest challenges for a hybrid OR is who then becomes an advocate for a particular sys- managing personnel. Depending on the procedure, tem and is not open to other options. Urschel adds those in the room might include the anesthesiolo- that visiting other facilities with hybrid ORs helps gist and anesthesia technician, vascular and car- identify what works and what doesn’t. diothoracic surgeons, interventional cardiologist,

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 15 physician assistant, scrub technician, circulator, and maintaining competence” for surgical robot- interventional cardiology technician, and radiology ics teams, and he expects that to extend to trans- technician. “It’s combining a cath lab and an OR catheter procedures such as TAVR. It’s important team,” says Urschel, who notes she needed to add to have a plan for determining staff and physician 4.2 full-time equivalent (FTE) employees to open competence in the procedures being performed. In the room. some cases, guidelines are available. For example, Cross training between the OR and the interven- the Centers for Medicare and Medicaid Services tional cardiology lab is essential and requires good outlines requirements that must be met to obtain re- management skills. “They have to learn how to imbursement for TAVR. These include specific vol- work with a different team, so you have to explain ume guidelines for the cardiovascular surgeon and how each team works,” says Urschel. “You need the interventional cardiologist. to work with the team very closely.” She adds that training staff in “radiation hygiene” should be a On the horizon key component. Chalupa says Methodist has a core team for the hybrid room. Two backup radiology Before looking ahead, Urschel recommends look- technicians are available on the day shift, and there ing back. “Conduct a financial and operational is an evening technician who is trained for the hy- analysis 1 year after you open the OR to see where brid OR. The technicians take call. you are,” she says. For example, the analysis at St Peter’s resulted in staffing adjustments. To educate staff, Chalupa had a radiology technician attend training provided by the manufacturer, In the future, the use of hybrid ORs is likely to con- and both radiology technicians and nurses spent tinue expanding. Skorup expects to see more mul- time in hybrid ORs in other hospitals within the tiple interventions for individual patients. “Some Methodist system. Chalupa held three dry runs centers are doing vessel verification after a CABG before the first case. The dry runs turned up prob- procedure,” he says. He adds that physicians in Eu- lems: Neither the equipment needed to perform rope are performing transcatheter mitral valve re- bolus chasing nor the intercom system had been pair, and he expects the procedure to emerge in 2 installed as requested. The dry runs also helped to 3 years. determine the room setup, which Chalupa says —Cynthia Saver, MS, RN varies according to type of case as well as physician and anesthesia preferences. References Centers for Medicare and Medicaid Services. Decision Memo Competency for Transcatheter Aortic Valve Replacement (TAVR) (CAG- 00430N). May 1, 2012. Skorup notes that data show a “strong correlation ECRI Institute. Hybrid Operating Rooms with a Focus on between a recommended number of procedures Endovascular Hybrid ORs. 2013.

16 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs Include infection prevention in your hybrid OR design If a hybrid operating room is likely to be part of your Cardiologists approached hospital leaders, and once hospital’s future, a critical part of the planning is to approval was granted, a biplane was purchased for decide where it will be located. Variables such as fixed angiography and a control room and- equip available space, funding, and type of procedures to ment room were built. Monitors for fluoroscopy, be performed will drive the decision, but a common patient data monitors, an injector, a sterile back component of all hybrid OR projects—whether new table, a Mayo stand, anesthesia equipment, and me- constructions or renovations—is infection prevention. chanical ventilation equipment were needed along with diagnostic tools for cardiac procedures. “Infection prevention needs to be a part of the design process, not just the department that you con- A new exterior wall was built to allow space for the tact when you need to have an ICRA [infection con- additional equipment, Hohenberger says. trol risk assessment] form completed,” says Heather Design and construction teams met weekly with the Hohenberger, BSN, RN, CIC, CNOR. As the qual- end users, equipment manufacturers, and contrac- ity improvement coordinator, perioperative services tors. Infection prevention staff, however, weren’t at Indiana University (IU) Health, Hohenberger is consulted as a part of the design process until af- trying to raise awareness about the importance of ter initial demolition, when questions about air ex- infection prevention when designing hybrid ORs. changes and room ventilation raised concerns about In January 2012, she was involved in assessing the converting to open procedures. hybrid room that opened in 2010 within the cardiac A hybrid room, especially if it’s built in an interven- catheter lab space at Riley Hospital for Children, a tional radiology (IR) or cardiac cath lab space, must freestanding pediatric academic center that is part have a minimum of 15 air exchanges per hour, Ho- of the IU Health system. Her observations and rec- henberger says. A Class A operating room has 15 air ommendations led to elimination of surgical site exchanges per hour, and class B and C rooms must infections (SSIs) among hybrid patients as well as have a minimum of 20 per hour. The architect—and changes in workflow and staff training. likewise the end users (nurses, cardiologists, and “Infection prevention provides the guiding principle hospital leadership)—may be unaware of the differ- for what barriers need to be in place for a demoli- ences in infection prevention requirements between tion, renovation, or any type of construction process diagnostic and open surgical procedures. to decrease the risk of infection from the dust and “If conversion to an open procedure is needed, the debris,” she explains. room must be designed to provide the required These efforts protect not only existing patients but number of air exchanges for that procedure,” Ho- also future patients. “If infection prevention staff henberger emphasizes. “If you’re renovating an aren’t involved from the onset, the potential for re- old cardiac cath lab space, you need to know how work increases,” she notes. many air exchanges exist because you may need to increase that number.” Cath lab conversion Riley Hospital has 14 ORs located in a section of Staff training the hospital that was built in the mid-1980s, where When a hybrid OR is located in a cath lab or IR pediatric neurosurgery, cardiovascular, orthopedic, area, staff must be trained in the infection preven- general, gastrointestinal, genitourinary, and ENT tion measures that are second nature to OR staff. procedures are performed. Little space and block “Infection prevention efforts start when a patient time were available among those ORs and the cath comes into the room, not when a diagnostic proce- lab equipment was becoming outdated, so the deci- dure changes to a surgical procedure,” Hohenberger sion was made to open a hybrid room within the says. This mindset reflects a fundamental difference cath lab space.

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 17 between OR staff and those who work in other de- Because the room location and nature of the proce- partments. dures differ among hospitals, there is neither a consistent staffing matrix nor workflow, Hohenberger “If you’re in a cath lab space, make sure staff know points out. Workflow is specific to each facility, and it’s not just a diagnostic procedure, it’s a surgical the location and surgical specialty utilizing the hy- intervention. Little things like wearing a surgical brid room dictate the staffing needs. mask while walking from the control room to the procedural space and thinking about sterility in the “If the hybrid room is in the OR space, there will entire environment—not just the table but the whole be a circulator and a scrub nurse trained specifically field—are important,” she notes. “We shouldn’t just for that room, but in a cardiac cath lab space, there assume that people know this.” may be a team that’s available by page to come as needed—for example, a cardiac cath RN acting in a Among the topics that should be covered during circulator role, or another RN scrub helping to pass training are: instruments to the operating or diagnostic team,” • operative attire she explains. Anesthesiologists and physicians are • hand antisepsis the only consistent staff. • setting up the sterile field Lessons learned • patient skin prep Efforts to raise awareness about infection preven- • draping techniques tion efforts among hybrid room staff fostered a • traffic patterns sense of collaboration and understanding between the hybrid and OR teams. “By building a relation- • surgical conscience. ship with the OR staff, hybrid staff were able to see At Riley, there wasn’t a designated educator for that they weren’t alone—there’s a larger group of the cath lab/hybrid room staff when the new room people who understand the kinds of issues they have opened in 2010. Later on, concern about the occur- while providing patient care,” Hohenberger says. rence of SSIs among patients treated in the hybrid “If you’re looking to open a hybrid room, opening room prompted cardiology and the medical director it within the OR is the best option because it elimi- of infection prevention to request observation of the nates so many factors that could eventually cause procedures performed within the space. In January problems,” she adds. “Each facility is different, and 2012, Hohenberger observed the hybrid staff and for some it may be necessary to open the hybrid recommended some changes. Since then, there have room within a cath lab or IR space, so it’s impor- been no SSIs from that area. tant to understand the infection prevention practices What changed? Hohenberger says they needed to that need to be in play at the very beginning of the “go back to the basics” of infection prevention. An process.” OR educator was brought in to provide orientation checklists such as how to perform a proper hand scrub. —Elizabeth Wood

18 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs Perceptive leadership fosters collaboration among hybrid OR staff The expanded volume of interventional cardiology “The neuro intervention specialties are even more in recent years has played a major role in the growing complicated to deal with than cardiac,” notes Wy- prevalence of hybrid ORs. As a result, many periop- att, “because they don’t have the background in col- erative services leaders have had to develop systems laboration that cardiac has had over the years.” for managing hybrid ORs along with traditional ORs. “Management of hybrid ORs is really a collision Collaboration between service lines of traditional hospital management and service line Successful management of hybrid ORs and their management,” says David Wyatt, MA, MPH, BSN, utilization begins with collaboration between the RN, CNOR. service line and operations administrators, notes “We are starting to talk seriously about the business Wyatt. case for hybrid ORs, along with interprofessional A cardiology (service line) nurse administrator and standards and how we are staffing these rooms,” Wyatt, the perioperative (operations) administrator says Wyatt, administrative director of perioperative share the top spot on the management structure for services at Vanderbilt University Medical Center cardiac hybrid ORs at VUMC (sidebar, p 20). (VUMC), Nashville, Tennessee. The director of the cath lab, electrophysiology (EP) Cardiovascular services has been at the forefront lab, and cardiac surgery reports to both Wyatt and the of service line development, with the focus primar- cardiology administrator, and a matrix report goes to ily on getting cardiac surgeons and cardiologists to both service line and operational management. work together to refer patients to the hospital. “For many years, that did the trick,” says Wyatt. This management structure also holds true for the neuro and vascular hybrid ORs, with Wyatt as the But now more procedures are being performed in operations administrator over all 3. the cath lab than in the OR, and cardiac surgeons and interventional cardiologists are credentialed The service line approach is very provider- and to do some of the same procedures. These changes patient-centric, notes Wyatt. Though service line have created tension between surgeons and cardiol- administrators may not fully understand operations, ogists, and turf wars have cropped up not only in the they do understand how to promote the flow of re- cardiovascular world but also in neuro intervention, ferrals between physicians and the hospital, how to which is performed by neurologists, neurosurgeons, bolster collaboration among physicians, and how to and neuroradiologists. ensure optimal patient flow through the system, he

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

Specialist EP Cardiothoracic Interventional Interventional Vascular Neurosurgeon Surgeon Cardiologist Radiologist Surgeon • Common •Diagnostic § CABG • Diagnostic § Balloon § AAA § Aneurysm Procedures Studies § Aortic valve caths Angioplasty § TAA coiling •PCA replacement • PTCA, PCI § Aortic § CAS § Intracranial Pacemaker § Mitral valve • Peripheral Aneurysm § Peripheral stenting Implants repair angioplasty, § Stenting angioplasty, § CAS •ICD Implants § VAD stenting § Carotid stenting § Intra-arterial •Arrhythmia implants Atherectomy Stenting § Peripheral TPA •Ablations § Transplants § Biliary bypass Drainage § Line Placement § Vertebroplasty

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 19 says. On the other hand, the service line ap- Cardiac Hybrid Suite Management Structure proach can become too costly for the system. Cardiology Perioperative Administrator Administrator “We have had to balance moving forward with new technology and services for our patients without drain- Director Cath & EP Lab, Cardiac ing our resources,” says Surgery Wyatt. Each new request for hybrid technology has Cardiac brought forth change in Cath Lab Cath Lab Assistant Assistant Surgery how business is done in manager manager Manager the OR and the need for a more systematic ap- Change Change Change Change proach to collaborating Change Nurse Nurse Nurse Nurse Nurse with services performing image-based procedures. Source: Vanderbilt University Medical Center, Nashville, Tennessee.

“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

20 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs “The room will look as big as a In the Cardiac Hybrid Suite, football field when it is empty, but Collaboration is Key when all of the equipment is in, it looks so crowded it is amazing,” he says (photo).

Cross-training teams is challenging Historically, when an interventional 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-

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 21 ing and they had low competency scores. “What Instead of cross-training all staff, Wyatt says, they we failed to take into consideration was that people had to change their strategy and be more selective work in the cath lab because they like to do cath of the people they cross-trained. lab procedures, and people work in the OR because “I have had to realize, the hybrid arena is a dif- they like to work in open procedures,” says Wyatt. ferent world,” says Wyatt. “People are working in Forcing OR staff to work in an environment where new practice settings and with standards of practice they are limited to handling wires and balloons all that are new to them. We have to think very clearly day is not satisfying for them. Taking nurses out of about that and be sensitive to those differences to the cath lab or interventional suite where they were foster the collaboration needed to manage hybrid used to doing a variety of things, such as providing rooms successfully.” sedation and monitoring patients, was too big of a —Judith M. Mathias, MA, RN shift for them.

22 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs Building the business case for a hybrid OR Hybrid ORs are proliferating in response to market, surgeon, and even patient demands, but building 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 technology consulting company in Franklin, Tennessee, and a former director of surgical services. Costs can average from $3 million to $6 million, according to data from ECRI Institute and The Advisory Board Company. This hybrid OR opened at Southcoast Hospitals Group in With that much money at stake, the natural first New Bedford, Massachusetts, in 2008. question is, “Does our hospital need a hybrid OR?” (Photo courtesy of Helio Rosa, Southcoast Hospitals Group.) When answering this question, OR managers should keep in mind that a hybrid OR is a long-term invest- stool that supports the business case for a hybrid ment; short-term profits are unlikely. OR (sidebar).

Staying competitive Ensuring a robust program “I think we’re at the point that you need a hybrid Inamdar recommends that anyone considering a OR to be competitive,” says Deborah Rideout, hybrid OR first determine if the facility has a ro- BSN, RN, CNOR, director of perioperative servic- bust open-heart surgery program for valve replace- es at Southcoast Hospitals Group in New Bedford, ment, given that currently the primary procedures Massachusetts. The first hybrid OR in this four-fa- performed in the hybrid OR are transcatheter aortic cility system opened in New Bedford in 2008, and and mitral valve replacement (TAVR, TMVR). another one is being built at their Fall River site. OR managers should also consider other potential About 230 cases per year on average are performed future uses of the hybrid OR. At Inova Fairfax in at the New Bedford site. Falls Church, Virginia, for example, the endovascu- Rohit Inamdar, senior medical physicist at ECRI lar hybrid OR began as a location for TAVR, but has Institute, agrees with Rideout. “Even if you are a since expanded to include endovascular aneurysm small facility, minimally invasive surgery is here to repair, says Anne Cochrane, MSN, RN, CNOR, in- stay, so if you don’t get on board with a hybrid OR terim director of the cardiovascular OR. “You want or cath lab, you will be left behind,” says Inamdar, to set up the room so it can be used for anticipated who has consulted with many hospitals developing future procedures,” she says. hybrid rooms. “You need a hybrid OR to keep your Planned future use also affects design and equip- cardiac surgery program.” ment needs. For instance, Ingle says, “Some neuro- Although academic medical centers remain the surgeons want a biplane [angiograph imaging sys- most common site, Inamdar has seen a growing tem], but endovascular surgeons use a single plane, number of hybrid ORs being installed in commu- and some neurosurgeons are OK with a single plane nity hospitals. and don’t need a biplane.” These decisions will affect costs. If hybrid ORs are a growing trend, how can OR managers build a business case that provides a rea- The geographic location of the hybrid room affects sonable return on investment? Inamdar says pro- the bottom line. “CMS [Centers for Medicare & gram, staffing, and patients form a three-legged Medicaid Services] says you have to do TAVR in

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 23 Creating the business plan hybrid team members, including surgeons and radiology staff, as well as vendors. Ask vendors for Writing a business plan isn’t done in isolation, says names of hospitals to call, and go on site visits. Use Deborah Rideout, BSN, RN, CNOR, director of a bidding process to obtain the best price. perioperative services at Southcoast Hospitals Group nnUpgrades. “It’s best to plan for software and hard- in New Bedford, Massachusetts. “It takes a team to ware upgrades on a rolling basis 5 to 10 years out collect the information you need and put it into one so you have a good idea as to future capital ex- packet.” penses,” Cochrane says. “It’s not just the expenses The team should include surgeons, and staff from up front.” The finance department can help with business, finance, engineering, imaging, and biomedi- depreciation estimates, and the sales representative cal, among others. Typically the plan projects break- would be able to provide upgrade time frames. ing even at 5 years. nnSupplies. The cost of implants such as those used “Sales reps can be helpful in identifying break-even in TAVR are significantly higher than the grafts points,” says Anne Cochrane, MSN, RN, CNOR, used in an open procedure, so the plan will need interim director of the cardiovascular OR at Inova to include expenditures for stock. “Until you are Fairfax in Falls Church, Virginia. doing the program for about a year, you have to purchase the implants instead of buying on con- Elements to consider when writing the plan include: signment,” Cochrane says. She adds that it’s key to nnMarket intelligence. Rideout suggests answering work with the finance department to ensure sup- questions like, Who else in the region has a hybrid plies are billed; some hospitals have set up a line OR? Where are they drawing the patients from? item for a hybrid procedure. nnMarket share. Estimate what market share the hos- nnTimeline. Lynne Ingle, MHA, BS, RN, CNOR, pital is losing because of not having a hybrid OR recommends targeting no more than 6 months for and whether the hospital has strong enough refer- making the decision as to what system to select. “It ral relationships. gives you time to make site visits and get people nnPatient-related data. This includes payer mix and in agreement, but not so much time that you lose expected volume, including what percent of current momentum,” says Ingle, project manager for Gene cases will be converted into hybrid cases. Forecast Burton & Associates, a healthcare technology predicted reimbursement based on payer mix and consulting company in Franklin, Tennessee, and a note savings from reduced length of stay. former director of surgical services. nnConstruction. Consider if you can upgrade an exist- Cochrane also recommends working with finance to ing OR or if you need to create a new one, keeping determine allocation of revenue and supply charges. in mind that a hybrid OR averages 1,100 square feet, For example, if a cardiologist and a surgeon are doing compared to 600 square feet for a standard OR. a case, who receives credit? Also, block scheduling is nnEquipment. To avoid missing something, meet with necessary for efficient operation of the hybrid.

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 experience 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),

24 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs including 10 high-risk patients, or at least 25 AVRs Part of the difficulty is that only a small number in 1 year, or at least 50 AVRs in 2 years, which in- of patients are currently eligible for the procedure, clude at least 20 AVRs in the last year before TAVR and those who are eligible are also high risk. “The initiation. Hospitals may need to recruit cardiovas- national TAVR pool is about 20,000 to 30,000 in the cular surgeons or interventional cardiologists to entire US,” Inamdar notes. meet these numbers. Reimbursement for the procedure from CMS rang- Surgeons need to maintain volume to ensure con- es from $27,000 to $56,000, depending on the pa- tinued reimbursement. CMS requires the surgeon tient’s severity and how he or she is treated. Consid- and hospital to complete at least 20 TAVR proce- ering that the TAVR valve costs just over $30,000 dures in a year, or at least 40 TAVR procedures in and that the procedure cost ranges from $50,000 to 2 years. The agency also has volume requirements $80,000, it’s clear that a hybrid OR “is not a money- for interventional cardiologists and the hospital’s making machine,” Inamdar says. cardiac catheterization lab. For example, the cath “If you’re armed with talented physicians who are lab must perform at least 1,000 catheterizations per aligned with you, have a solid cardiovascular pro- year, including at least 400 percutaneous coronary gram, and a market share that is validated to be interventions per year. leaving the area because you’re not offering certain In addition to physicians, CMS lists other mem- services—that’s a good case for a hybrid OR,” says bers who must be part of the team, including echo- Rideout. cardiographers, imaging specialists, heart failure specialists, cardiac anesthesiologists, intensivists, Making the numbers work nurses, and social workers. Because of the expense, it’s not easy to make the Above all, says Ingle, “The most critical part is hav- numbers work for a hybrid OR. “But because it [a ing physician champion.” hybrid OR] has become a standard, you have to find ways of being fiscally prudent while you’re doing Identifying eligible patients it,” Rideout says. To analyze potential patient volume, Rideout sug- One way of saving money is to choose vendors gests asking, “What is the market share that we wisely, Ingle says. If, for instance, the cath lab is aren’t getting because we don’t have a hybrid OR?” already using equipment from Toshiba, the OR It’s helpful to list cases that will be done immedi- manager might be able to obtain a discount by pur- ately in the hybrid OR and those that will be added chasing Toshiba equipment for the hybrid OR. “You later. will have multiple vendors, so coordination is really important,” she adds. “Look at the length of stay for those patients, and work with your business partners in the organiza- If your cardiac surgery program isn’t large enough tion to calculate what the savings would be if those for a hybrid OR, Inamdar suggests considering a patients could be discharged sooner,” she adds. hybrid cath lab or adding a hybrid interventional radiology (IR) suite. Cochrane, who has several years of OR experience in a variety of OR settings, says the surgeons are The downside is that these rooms still require the good predictors of volume. “They really know their staff, supplies, and sterility needed in the OR. “But market and where their referral base is,” she says, it’s doable and it’s a lower price option,” Inamdar adding, “It’s better to underanticipate than overan- says. ticipate the numbers.” Ingle adds, “My philosophy is that it should be Because a limited number of procedures currently behind the red line of the OR in case you have to require a hybrid OR, hospitals can run into financial open the patient, but I’ve seen it done both ways. difficulties. “There can be a positive profit margin It’s something hospitals have to discuss.” She notes with TAVR, but it’s very small,” Inamdar says, not- that remodeling an existing OR is less expensive ing that many facilities may struggle to break even. than building a new one.

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 25 To maximize the use of the hybrid OR, Inamdar million by purchasing a refurbished model. “It will recommends OR managers work with other phy- still meet your needs but won’t have all the bells sicians such as vascular surgeons, neurosurgeons, and whistles,” he says. When exploring the refur- and electrophysiologists, who use angiography im- bished option, be sure to work with a reputable aging systems. “You might be able to consolidate vendor. so you need fewer labs, and improve your financial equation a bit,” Inamdar says. Envisioning the future Keep in mind that when not in use for its hybrid Inamdar notes that currently only one mitral valve capabilities, the OR can be used for certain other contouring system is approved for use in the United cases. At Inova, for instance, “the hybrid OR is built States, but expects others currently being used in so it can be used for any patient who requires a by- Europe to receive approval as well, further pushing pass pump,” Cochrane says. demand for hybrid ORs. “Transcatheter devices are Ingle reports that hybrid OR use is being expanded a growth area, and I don’t see it slowing down any- at many hospitals to include spinal and total joint time soon,” he says. replacement surgery, as well as other cardiovascular —Cynthia Saver, MS, RN procedures, as physicians increasingly tap into the value of good imaging for a variety of procedures. References Another option for reducing costs is to choose a re- Centers for Medicare & Medicaid. Decision memo for transcatheter aortic valve replacement (TAVR) (CAG-00430N). furbished angiography imaging system. Facilities http://www.cms.gov/medicare-coverage-database/details/nca- that are downsizing or upgrading their systems may decision-memo.aspx?NCAId=257. be trading in systems that are less than 5 years old. The Advisory Board Company. System strategies for hybrid OR investment. http://www.advisory.com/Research/Service- Inamdar says the typical life span of these systems Line-Strategy-Advisor/Original-Inquiry/System-Strategies- is 10 years, so facilities could save as much as $1 for-Hybrid-OR-Investment.

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