The Cardiac Hybrid OR

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Nov 13, 2013 (3 years and 11 months ago)

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The Cardiac Hybrid OR

A Platform for Collaboration

Objectives



Summarize key steps in the development and
operation of a Cardiac Hybrid OR


Highlight Hybrid OR best practices


Provide resources and references for
additional information about Hybrid ORs


Table of Contents


A Paradigm Shift in Cardiovascular Care



The Cardiac Hybrid OR


A Platform for Collaboration


Key Steps in Building and Operating


References & Resources

A Paradigm Shift in Cardiovascular Care

Image courtesy of
Maquet

Hybrid Cardiovascular Procedures

The number of hybrid and
minimally invasive cardiovascular
procedures is expanding rapidly



Hybrid
and minimally invasive
procedures have resulted in
decreased
morbidity and mortality of
elderly patients


Minimally
invasive procedures reduce
hospital stays and recovery time


The
success of these procedure has increased the need for increased
collaboration between cardiothoracic surgeons, vascular surgeons, and
interventional cardiologists

References: Byrne 2008,
Kpodonu

2009,
Nollert

2010

Most Common Targets of Hybrid

Cardiac Procedures


Multidisciplinary Cardiovascular Team

Old Paradigm

Emerging Paradigm

Interventionalist

Patient

Cardiologist

Surgeon

Patient

Interventionalist

Cardiologist

Surgeon

To ensure the success of the hybrid approach, the multidisciplinary team
approach has developed



Facilitates joint pre
-
operative decision
-
making and intra
-
operative
collaboration between surgery and cardiology


Reference:
Maisano

20120

The Cardiac Hybrid OR

Image courtesy of Maquet

What is a Hybrid OR?


Fully equipped surgical suite that facilitates collaborative and
efficient patient care


Combines all components of a
cath

lab and surgical OR


The ideal setting to enable hybrid procedures to be done singly,
sequentially, or concurrently

Reference:
Kpodonu

2009,
Odle

2011

Potential Benefits


Facilitates interdisciplinary
approaches to care


May improve outcomes and safety


Streamlines patient flow by eliminating
patient transfers and staging


May increase access to care by
expanding population for specific
procedures


Flexibility for future innovation in care
delivery and procedures


Requires cross
-
specialty
alignment


Increases operational complexity
(including staffing and training)


Large capital investment



Potential Challenges

2012 ACCF/SCAI Expert Consensus
h
ighlights the benefits of a hybrid suite:


A Platform for Collaboration


“Although
the hybrid suite
is designed
to meet the needs of an
increasingly
complex patient
population, it also serves as a
platform for
collaborative work
between
subspecialists.”



Multi
-
functionality


“In
some hybrid
suites, operators
can perform cardiovascular
procedures
ranging from
the most straightforward PCI to aortic
arch
reconstruction. As
a result, different teams across different
subspecialties can
benefit from the hybrid suite
.”

2012 American College of Cardiology
Foundation/Society
for Cardiovascular Angiography
and
Interventions
Expert
Consensus Document on
Cardiac

Catheterization
Laboratory Standards Update

“With the hybrid room, you have something that’s much greater,
much larger than each piece.


It really is amazing to see, once it comes together, how the
thought process of everybody involved changes. You’re no
longer thinking in terms of what any individual person or
discipline does but really more in terms of what we do together
and that in the end is a clear benefit to the patients.”

Newell Robinson, M.D.

Chairman
, Department of Cardiothoracic and Vascular Surgery

St.
Francis Hospital, Roslyn, NY


The Cardiac Hybrid OR

Key Steps in Building and Operating

Key Steps in Building & Operating a Hybrid OR


Institutional Fit


Financial Analysis


Planning Team


Vendor
Collaboration


Site Visits







Location & Space


Room
Design


Table


Imaging


Audiovisual &
Communications


IT System




Staffing


Training


Scheduling


Protocols


Hybrid
OR
Committee


Inventory
Management






Phase I

Planning

Design &

Construction

Staffing &

Operations

Phase II

Phase III

Vendor Collaboration

Institutional Fit

The following potential benefits should be considered when
assessing the value of a Hybrid OR:



New interdisciplinary
approaches to
care


Enhanced
imaging capabilities enable more advanced
procedures



Potential to improve
outcomes & safety


Fewer handoffs between teams


Fewer
episodes of anesthesia


Reduced radiation exposure and use of contrast


Immediate surgical option possible if required as
backup



Flexibility
for future innovation in care delivery and procedures


Growing number of hybrid procedures and indications


Hybrid
OR may be especially suited to robotic procedures


Institutional Fit

Planning Team


Site
Visits


Financial Analysis

Reference:
Odle

2011

The Hybrid OR has the potential to transform
an institution’s cardiac
patient
care,
but
increases
operational complexity and requires a culture of
collaboration.

Financial Analysis


The cost to build a Hybrid OR typically ranges from $1
-
$5M


Most projects take a total of 12
-
18 months for design and build.


Institution needs to
have the
right type and volume of
procedures
to justify the cost


Equipment vendors can provide
an ROI
calculator

Not
every institution will have the right type and volume of procedures to make
the project financially viable

Vendor Collaboration

Institutional Fit

Planning Team


Site
Visits


Financial Analysis

References:
Belkin

2009, Kpodonu 2010,
Deshchenko

2011


MDs that will use the
facility


Anesthesiology


Radiology and echo


Perfusion technician


OR and
cath

lab
nurse/nurse managers


Infection control specialist

Early
collaboration among cross
-
functional stakeholders
will help prevent
design flaws and friction


Hospital
administration


B
usiness managers


Internal applications
technology specialist


Information
technology
specialist



Architect


Interior designer


Internal hospital facilities
manager


Building construction
manager

Planning Team

A large group of stakeholders needs to be brought together at the earliest
stages of the planning process

Vendor Collaboration

Institutional Fit

Planning Team


Site
Visits


Financial Analysis

Administration

Medical
Staff

Design/Engineer
/
Construction

References: Hirsch 2008,
Odle

2011

Design and Equipment Vendors


Use of an overall designer/architect is important


A consulting engineer can help craft detailed lists of
requirements and detailed RFPs as planning advances


Review of proposals should include the
c
ore planning team

Because each Hybrid room is different, design and equipment vendors play a
fundamental role in helping the institution identify the room suited to its
unique needs

Vendor Collaboration

Institutional Fit

Planning Team


Site
Visits


Financial Analysis

Reference: Hirsch 2008

Site Visits


Visiting an operational Hybrid OR is an important step in the
planning process


Dozens
of decisions
go
into
the development
of a Hybrid
OR


Once
the room is built, it will be difficult to make
changes


Site visits allow the team to understand the “whys” behind decisions
made by other institutions, and what
they would have done
differently




V
isits should include a multidisciplinary subgroup of the core
planning team.

Site visits are an
essential
step
to
help the planning team leverage the
experiences of other institutions

Vendor Collaboration

Institutional Fit

Planning Team


Site
Visits


Financial Analysis

Reference:
Belkin

2009

Key Takeaways: Planning Phase


The Hybrid OR has the potential to transform an institution’s
cardiac patient care, but increases operational complexity and
requires a culture of
collaboration.



Not
every institution will have the right type and volume of
procedures to make the project financially viable



Early collaboration among cross
-
functional stakeholders will
help prevent design flaws and friction



Because
each Hybrid room is different, design
and equipment
vendors
play a fundamental role in helping
the institution
identify the room suited to its unique needs



Site visits are an essential step to help the planning team
leverage the experiences of other institutions



Institutional Fit


Financial Analysis


Planning Team


Vendor
Collaboration


Site Visits







Location & Space


Room
Design


Table


Imaging


Audiovisual &
Communications


IT System







Staffing


Training


Scheduling


Protocols


Hybrid
OR
Committee


Inventory
Management






Phase II

Planning

Design &

Construction

Staffing &

Operations

Phase I

Phase III

Key Steps in Building & Operating a Hybrid OR

Location
&

Space


The Hybrid room is ideally collocated near
cath

lab and ORs


If ORs are separated from
cath

labs, it is more common to collocate near
other ORs for quick access to equipment and personnel



If modifying or combining existing rooms:


OR advantage is that surgical core already exists


Cath

lab advantage is that lead lining is in place



Average
room
is ~1000
sq

ft

to
accommodate
people
and
equipment


There may be up to 20
-
25 people in the room during a procedure


Need enough space for two teams to prep


Headroom is crucial with at least 10 feet clearance

Existing space and the cost of retrofitting
will determine
whether an institution
should modify or build a completely new room

Location & Space


Audiovisual &
Communications

IT System

Imaging

Table

References:
Kpodonu

2009,
Bashore

2012

Room Design

Room Design: Floor Plan


Building a
full
-
scale cardboard mockup in an unused space
reveals workflow
and equipment
space issues


Vendors can develop 3D layout but this still doesn’t give as
comprehensive an understanding as a mockup


All stakeholders need to be involved with this exercise which
typically results in changes to the room’s layout



Flexibility and versatility of the hybrid room is very important


Need to accommodate varying procedural requirements: different
teams, variable table positions, and various imaging modalities



Making key decisions up front will allow team to understand,
rather than guessing, how all of the variables will work together



Making equipment and design decisions up front, along with building a full
-
scale cardboard mockup of the room, will optimize the plan prior to
construction

Location & Space


Audiovisual &
Communications

IT System

Imaging

Room Design

Table

Room Design: Ceiling Plan


The ceiling plan represents one of the most
challenging steps in the planning of
a

hybrid suite



Key considerations for a very tight space


Surgical lighting


Monitor
booms


Laminar flow ceiling


Cameras


C
-
arm (if ceiling mounted)



Headroom
is crucial with at least 10 feet
clearance required



The ceiling plan is one of the most challenging steps requiring many components
to fit into a very tight space

Location & Space


Audiovisual &
Communications

IT System

Imaging

Table

Reference:
Kpodonu

2009

Getty Images

Room Design

Table


Table design must
accommodate and optimize
usefulness
and
safety of
imaging
equipment


Floating tables, similar to those used in the cardiac
cath

lab allow full coverage of the body in most situations


Lead shields should be incorporated into the table to
reduce radiation exposure to the
operators



Table needs to meet the requirements of both
interventional cardiologists and surgeon


Tradeoffs will likely need to be made


e.g. surgeon’s preference for a breakable tabletop



Many hybrid rooms position the table diagonal
to the room in order to maximize space

The table must accommodate the needs of various stakeholders and will
likely require tradeoffs

Location & Space


Audiovisual &
Communications

IT System

Imaging

Table

References:
Belkin

2009,
Bashore

2012

Image courtesy of
Maquet

Room Design

Imaging


Hybrid suite imaging system will include most
advanced imaging systems for preoperative
planning and intraoperative use:


Superior image quality


Quick and detailed information


Minimal X
-
ray exposure


Image
routing, storage and management


Delay
Obsolescence



Displays are ideally available in all four
quadrants of the room

State of the art imaging systems may represent up to half the cost of the project

Location & Space


Audiovisual &
Communications

IT System

Imaging

Table

References:
Kpodonu

2009, Nollert 2010

Image courtesy of
Maquet

Room Design

Audiovisual and Communications


Requires integration of all imaging modalities and media


Two
-
way audio communication between hybrid room and control
room is important


Real
-
time observation and education with remote
-
site conferencing
are especially important for academic institutions


Including a telephone router allows for hands
-
free direct
conversations with consulting colleagues and referral physicians

Location & Space


Audiovisual &
Communications

IT System

Imaging

Table

References: Hirsch 2008,
Belkin

2009

Room Design


Image integration


DICOM
-
compatible system for image transfer and archiving


Capability to route images into and out of the room


A PACS can allow retrieval and viewing of multi
-
modal images


Angiography is very data
-
intensive; need to provide for storage beyond
the short
-
term



EMR integration


System should link to archived images



Inventory
-
management


RFID beginning to appear



Scheduling software

Location & Space


Audiovisual &
Communications

IT System

Imaging

Room Design

Table

IT System

Reference: Hirsch 2008

Key Takeaways: Design & Construction


Existing space
and
the cost of retrofitting will determine
whether an
institution
should
modify
or build a completely new room



Making equipment and design decisions up front, along with
building a full
-
scale cardboard mockup of the room, will optimize
the plan prior to construction



The ceiling plan is one of the most challenging steps requiring
many components to fit into a very tight
space



The table
must accommodate
the needs of various stakeholders
and will likely require tradeoffs



State of the art imaging systems may represent up to half the cost
of the project


Institutional Fit


Financial Analysis


Planning Team


Vendor
Collaboration


Site Visits







Location & Space


Room
Design


Table


Imaging


Audiovisual &
Communications


IT System







Staffing


Training


Scheduling


Protocols


Hybrid
OR
Committee


Inventory
Management






Phase II

Planning

Design &

Construction

Staffing &

Operations

Phase I

Phase III

Key Steps in Building & Operating a Hybrid OR

Staffing: Two Models


Dedicated
multidisciplinary team model

-
Members
usually recruited from current OR
or

cath
-
lab staff

-
Reduces
redundancy

-
Can be difficult to maintain over
time

-
Leads to the development of unique hybrid
skills

Scheduling

Training

Staffing

Protocols

Inventory
Management

Hybrid OR

Committee

The choice of a dedicated or flexible staffing model will be driven by the unique
needs of each institution


Flex
-
team (“pooled”) model

-
More common today

-
Cross
-
training of current OR and
cath
-
lab staff

-
Requires close
scheduling coordination

-
Blending/integrating staffs

-
May be less efficient


Significant didactic and hands
-
on education is required


Usually
3
-
6 weeks for both physicians and
staff



Cross
-
training gives an opportunity to strengthen relationships
within the extended team


Conducting several full
-
team mock cases that cover the spectrum
of procedures is valuable


Important to have formal full
-
team debriefing sessions after
procedures

Training

Training is
extensive, involving both didactic and hands
-
on
education

Scheduling

Training

Staffing

Protocols

Inventory
Management

Hybrid OR

Committee

Scheduling


Some centers have gone to integrated OR scheduling, with open
-
block time in the hybrid


For others, a structured approach has been more effective


e
.g. certain days per week assigned to different specialties


Teamwork and flexibility is critical due to unpredictability of
scheduling



Priority should be given
to truly hybrid cases and those possibly
requiring conversion

While Hybrid procedures should take precedent, from a practical/volume
standpoint most institutions will also need to utilize the room as a functional
OR
or

cath

lab

Scheduling

Training

Staffing

Protocols

Inventory
Management

Hybrid OR

Committee

Protocols


Joint review and development by all the clinical teams is
essential


Some centers have an ongoing best
-
practices team that
meets monthly and is responsible for updates and education

With multiple teams working in the hybrid OR, protocol development
requires compromise and adaptation

Scheduling

Training

Staffing

Protocols

Inventory
Management

Hybrid OR

Committee

Hybrid OR Committee


Include key stakeholders


Start by drawing from members of planning team



Monthly hybrid OR conference can be useful:


Discuss cases


Review operations, including performance metrics


Identify and address problems


Learn about new technologies

An ongoing Hybrid OR committee can optimize operations, address
unforeseen issues, and help with the introduction of new technologies

Scheduling

Training

Staffing

Protocols

Inventory
Management

Hybrid OR

Committee

Inventory Management


A designated inventory
-
manager can partner with
cath

lab and
surgical OR counterparts to ensure proper stocking


RFID
is beginning to appear in more
institutions


Some centers have additional inventory in the equipment
room adjacent to the hybrid OR

Inventory management is essential to smooth operations but is often
overlooked during the planning phase

Reference:
Belkin

2009

Scheduling

Training

Staffing

Protocols

Inventory
Management

Hybrid OR

Committee

Key Takeaways: Staffing & Operations


The
choice of a dedicated or flexible staffing model will be driven by the
unique needs of each institution



Training is extensive, involving both didactic and hands
-
on education



While Hybrid procedures
should take
precedent, from a practical
/
volume
standpoint most institutions will also need to utilize the room as
a functional OR
or

cath

lab



With
multiple teams working in the hybrid OR, protocol development
requires compromise and adaptation



An ongoing Hybrid OR committee can optimize operations, address
unforeseen issues, and help with the introduction of new technologies



Inventory management is essential to smooth operations but is often
overlooked during the planning phase




Summary



Hybrid ORs are becoming a standard part of
cardiovascular
programs and have the potential to improve patient
care



There is no standard model that can be broadly applied today



The decision whether to build, how to build, and how to manage a
hybrid OR will need to be customized to the unique circumstances
of a particular institution



Hybrid ORs require close
cooperation by a cross
-
specialty
team



The cost is typically $1
-
$5M
and requires an
18
-
month
total
planning process





Acknowledgements

Banner
Good Samaritan Medical
Center


Phoenix
, AZ


Portneuf

Medical Center


Pocatello, ID


St.
Francis
Hospital


Roslyn
, NY


University
of Kansas
Hospital


Kansas
City,
KS

This overview was developed with input from personnel at the following
institutions:

The Cardiac Hybrid OR

References & Resources

Published References

Bashore

TM,
Balter

S,
Barac

A, et al. 2012 American College of Cardiology Foundation/
Society for Cardiovascular Angiography and
Interventions Expert Consensus
Document on
Cardiac

Catheterization Laboratory Standards Update. J Am
Coll

Cardiol

2012;59: 2221
-
305

Byrne JG et al. Hybrid cardiovascular procedures. JACC
Cardiol

Interv

2008;1:459
-
68.

Hirsch R. The Hybrid
C
ardiac
C
atheterization
L
aboratory for Congenital
H
eart
D
isease:
F
rom Conception to Completion.
Cath

Cardiovasc

Interven

2008;71:418
-
28.

Klein LW et al. The catheterization laboratory and interventional vascular suite of the
future: anticipating innovations in design and function. Catheter
Cardiovasc

Interv

2011;77:447
-
55.

Maisano F et al. Hybrid rooms
for
transcatheter

valve interventions: rationale, vision and
technical requirements.
Intervent

Cardiol

2010;2(10):503
-
10.

Kpodonu J.
H
ybrid
C
ardiovascular
S
uite: The
O
perating
R
oom of the
F
uture. J Card
Surg

2010;25:704
-
9.

Kpodonu J and Raney A. The cardiovascular hybrid room a key component for hybrid
interventions and image
-
guided surgery in the emerging specialty of cardiovascular
hybrid surgery. Interact
Cardiovasc

Thrac

Surg

2009;9:688
-
92.

Odle

TG. Managing transition to a
H
ybrid
O
perating Room.
Radiol

Technol

2011;83(2):
165CI
-
181CI.



Online References

Belkin

M. The design and implementation of hybrid operating rooms.
Veith

Symposium
2009 (
www.veithsymposium.org/pdf/vei/2761.pdf)
.

Deshchenko

O. Special report: the case for the hybrid OR. DOTmed.com (August 2011)

Nollert G et al. The cardiovascular hybrid OR: clinical and technical considerations.
CTSNet.org (March, 2010).



From theHeart.org:

Vassiliades

TA and
Zimrin

DA. Hybrid revascularization: the best of both worlds.
(www.theheart.org/documents/sitestructure/en/content/programs/1065241/transcript
.pdf)

Miller R. Hybrid revascularization strategy driven by new technology, and soon, new
data. January 31, 2011. (
www.theheart.org/article/1179057.do
)



From
Cath

Lab Digest (CathLabDigest.com):

Kerr JF. Keys to success in designing a hybrid
cath

lab. 2009;17(3).

Kpodonu J. The cardiovascular hybrid surgical room: evolving into the future of
cardiovascular surgery. 2012;20(3).

Rihal

CS. Hybrid lab planning and perspectives. 2010;18(11).





Online References

From Endovascular Today (EVToday.com):

Peeters

P et al. The catheterization lab of the future (March 2008).

Benjamin ME. Building a modern endovascular suite (March 2008).

Eagleton MJ and Schaffer JL. The vascular surgery operating room (August 2007).


From Imaging Technology News (ITNonline.com):

Fornell

D. Planning for a Hybrid Suite (July 8, 2010).

Fornell

D. How to Plan for a Hybrid OR (September 21, 2011).

Mateo D. Hybrid Suites Open Doors (March 3, 2010).



From Cardiovascular Business (CardioVascularBusiness.com):

Making the Case for a Hybrid Interventional OR (May 2011; article 27223).

ACCA: Making the Case for a Hybrid OR, How One Hospital Did It (April 2011; article
27258).

Cath

Lab Update: Hybrid Adoption and PCI Imaging Tools (August 2010; article
23370).



Related Guidelines

Coronary Revascularization Guidelines

Hillis

LD et al. ACCF/AHA guideline for coronary artery bypass graft surgery. JACC
2011;58(24):e123
-
e210.

Levine
GN et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary
intervention. JACC 2011;58(24):e44
-
e122.

Wijns

W et al. Guidelines on myocardial revascularization: the Task Force on Myocardial
Revascularization of the European Society of Cardiology (ESC) and the European
Association for Cardiothoracic Surgery (EACTS).
Eur

Heart J 2010;31:25
-
1
-
55.


Endovascular Guidelines

Fanelli

F and
Dake

MD. Standard of practice for the endovascular treatment of thoracic
aortic aneurysms and Type B dissections.
Cardiovasc

Intervent

Radiol

2009;32:849
-
60

Hodgson
KJ et al. Clinical competence statement on thoracic aortic repair (TEVAR):
multispecialty consensus recommendations, a report of the SVS/SIR/SCAI/SVMB
Writing Committee to develop a clinical competence standard for TEVAR. J
Vasc

Surg

2006;43(4):858
-
62.


Related Guidelines

Transcatheter

Aortic Valve Replacement Guidelines

Holmes DR and Mack MJ.
Transcatheter

valve therapy: a professional society overview
from the American College of Cardiology Foundation and the Society of Thoracic
Surgeons. Ann
Thorac

Surg

2011;92:380
-
89.

Tommaso

CL,
Bolman

RM, Feldman T, et al. SCAI/AATS/ACCF/STS
multisociety

expert
consensus statement: operator and institutional requirements for
transcatheter

valve
repair and replacement: Part 1 TAVR. J Am
Coll

Cardiol

2012
.


Cardiac Catheterization Laboratory Standards

Bashore

TM,
Balter

S,
Barac

A, et al. 2012
American College of Cardiology
Foundation/
Society
for Cardiovascular Angiography and
Interventions Expert Consensus
Document on
Cardiac

Catheterization Laboratory
Standards
Update.

J Am
Coll

Cardiol

2012;59: 2221
-
305



Additional Resources


For Hybrid OR case studies, visit
www.hybridOR.medtronic.com



For detailed information about Hybrid OR equipment, to take a virtual tour
of a Hybrid OR, or to find information about alliances that offer integrated
solutions, visit the websites of hybrid equipment manufacturers (partial list)*


GE


Siemens


Maquet


Philips


Skytron


STERIS


Toshiba



The Advisory Board Company (
www.advisory.com
) has developed
extensive Hybrid OR reports and analysis for member institutions




* Medtronic does not recommend or endorse any manufacturer or their equipment and appearing on this list should
not be construed as a recommendation or endorsement
.


UC201206539
EN © 2012 Medtronic, Inc.