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The Cardiac Hybrid OR A Platform for Collaboration.

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Presentation on theme: "The Cardiac Hybrid OR A Platform for Collaboration."— Presentation transcript:

1 The Cardiac Hybrid OR A Platform for Collaboration

2 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

3 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

4 A Paradigm Shift in Cardiovascular Care Image courtesy of Maquet

5 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

6 Multidisciplinary Cardiovascular Team Old Paradigm Emerging Paradigm Interventionalist Patient CardiologistSurgeon 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

7 The Cardiac Hybrid OR Image courtesy of Maquet

8 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

9 2012 ACCF/SCAI Expert Consensus highlights 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

10 “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

11 The Cardiac Hybrid OR Key Steps in Building and Operating

12 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 IIPhase III

13 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 TeamSite 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.

14 Financial Analysis The cost to build a Hybrid OR typically ranges from $1-$5M Most projects take a total of 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 TeamSite Visits Financial Analysis References: Belkin 2009, Kpodonu 2010, Deshchenko 2011

15 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 Business 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 TeamSite Visits Financial Analysis AdministrationMedical Staff Design/Engineer/ Construction References: Hirsch 2008, Odle 2011

16 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 core 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 TeamSite Visits Financial Analysis Reference: Hirsch 2008

17 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 Visits 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 TeamSite Visits Financial Analysis Reference: Belkin 2009

18 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

19 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 IPhase III Key Steps in Building & Operating a Hybrid OR

20 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 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 SystemImagingTable References: Kpodonu 2009, Bashore 2012 Room Design

21 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 SystemImagingRoom DesignTable

22 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 SystemImagingTable Reference: Kpodonu 2009 Getty Images Room Design

23 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 SystemImagingTable References: Belkin 2009, Bashore 2012 Image courtesy of Maquet Room Design

24 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 SystemImagingTable References: Kpodonu 2009, Nollert 2010 Image courtesy of Maquet Room Design

25 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 SystemImagingTable References: Hirsch 2008, Belkin 2009 Room Design

26 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 SystemImagingRoom DesignTable IT System Reference: Hirsch 2008

27 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

28 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 IPhase III Key Steps in Building & Operating a Hybrid OR

29 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 SchedulingTrainingStaffingProtocols 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

30 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 SchedulingTrainingStaffingProtocols Inventory Management Hybrid OR Committee

31 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 SchedulingTrainingStaffingProtocols Inventory Management Hybrid OR Committee

32 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 SchedulingTrainingStaffingProtocols Inventory Management Hybrid OR Committee

33 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 SchedulingTrainingStaffingProtocols Inventory Management Hybrid OR Committee

34 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 SchedulingTrainingStaffingProtocols Inventory Management Hybrid OR Committee

35 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

36 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

37 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:

38 The Cardiac Hybrid OR References & Resources

39 Published References Bashore TM, Balter S, Barac A, et al 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: Byrne JG et al. Hybrid cardiovascular procedures. JACC Cardiol Interv 2008;1: Hirsch R. The Hybrid Cardiac Catheterization Laboratory for Congenital Heart Disease: From Conception to Completion. Cath Cardiovasc Interven 2008;71: 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: Maisano F et al. Hybrid rooms for transcatheter valve interventions: rationale, vision and technical requirements. Intervent Cardiol 2010;2(10): Kpodonu J. Hybrid Cardiovascular Suite: The Operating Room of the Future. J Card Surg 2010;25: 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: Odle TG. Managing transition to a Hybrid Operating Room. Radiol Technol 2011;83(2): 165CI-181CI.

40 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/ /transcript.pdf) Miller R. Hybrid revascularization strategy driven by new technology, and soon, new data. January 31, (www.theheart.org/article/ 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).

41 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).

42 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 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: 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: 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):

43 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: 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 Cardiac Catheterization Laboratory Standards Bashore TM, Balter S, Barac A, et al 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:

44 Additional Resources For Hybrid OR case studies, visit 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 institutionswww.advisory.com * 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. UC EN © 2012 Medtronic, Inc.


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