Endovascular hybrid ORs in community hospitals: Driving success

Endovascular hybrid operating rooms are no longer limited to university medical centers, as community hospitals expand their cardiovascular services. According to Dorothy Urschel, MS, MBA, RNFA, ACNP-C, NEA-BC, 3 main trends are stimulating the growth of hybrid ORs: “Cardiac surgery is becoming less invasive, interventional cardiology is becoming more invasive, and vascular surgery continues to be minimally invasive and use catheter techniques combined with radiology techniques.” Urschel is cardiac and vascular service line director at St Peter’s Health Partners, a system of 4 community hospitals in Albany, New York.

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

But a successful hybrid program requires careful analysis and planning by a multidisciplinary team. “Start with the patient, and work your way back to determine what you need,” says Thomas Skorup, MBA, FACHE, vice president of applied solutions for ECRI Institute. “Technology supports practice, it doesn’t drive it.”

New procedures

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

Skorup, who says that “advanced imaging” typically refers to an angiography system—as opposed to CT or MRI—points to approval of the Sapien (Edwards Lifesciences) transcatheter aortic valve in 2011 as a major stimulus for endovascular hybrid ORs. Transcatheter aortic valve replacement (TAVR) “exemplifies what a hybrid OR is all about,” he says. “It’s not a traditional vascular intervention. We’re not performing an open procedure or reinforcing a vessel with a stent; we’re replacing a surgical procedure by performing a procedure through a catheter.” Before TAVR, nearly a third of patients with severe aortic disease weren’t candidates for surgery, so adding this new procedure has expanded the market—and saved lives. “One randomized, controlled trial showed that TAVR significantly reduced mortality rates at 1 year and at 2 years,” Skorup says.

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

“It’s amazing what you can do,” says Urschel. “We have doubled the number of procedures we anticipated when we were in the planning stage.” Block time is 75% efficient. Although their hybrid room is not exclusively for endovascular procedures, most cases are vascular. Urschel notes a number of factors have contributed to the program’s success, starting with multidisciplinary planning.

A planning team

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

Becky Chalupa, MS, RN, CNOR, associate chief nursing officer at Methodist Sugar Land Hospital in Texas, adds that other needed players are anesthesia and facility managers. Methodist has 243 beds, 18 ORs, and 1 endovascular hybrid OR that opened in December 2012.

“Each hospital has a different case mix,” Skorup says. “You need to take a surgical time-out to define the case mix you expect and use that as a template for your planning efforts. You then have a greater likelihood of engaging the right people and having success.” He recommends considering all options. “If you plan for only 1 specialty, you have limited the future of the room and may not have the volume you need to be successful,” he says.

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

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

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

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

Equipment decisions

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

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

Supply management

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

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

Staffing and training

One of the biggest challenges for a hybrid OR is managing personnel. Depending on the procedure, those in the room might include the anesthesiologist and anesthesia technician, vascular and cardiothoracic surgeons, interventional cardiologist, physician assistant, scrub technician, circulator, interventional cardiology technician, and radiology technician. “It’s combining a cath lab and an OR team,” says Urschel, who notes she needed to add 4.2 full-time equivalent (FTE) employees to open the room.

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

To educate staff, Chalupa had a radiology technician attend training provided by the manufacturer, and both radiology technicians and nurses spent time in hybrid ORs in other hospitals within the Methodist system. Chalupa held 3 dry runs before the first case. The dry runs turned up problems: Neither the equipment needed to perform bolus chasing nor the intercom system had been installed as requested. The dry runs also helped determine the room setup, which Chalupa says varies according to type of case as well as physician and anesthesia preferences.

Competency

Skorup notes that data show a “strong correlation between a recommended number of procedures and maintaining competence” for surgical robotics teams, and he expects that to extend to transcatheter procedures such as TAVR. It’s important to have a plan for determining staff and physician competence in the procedures being performed. In some cases, guidelines are available. For example, the Centers for Medicare and Medicaid Services outlines requirements that must be met to obtain reimbursement for TAVR. These include specific volume guidelines for the cardiovascular surgeon and the interventional cardiologist.

On the horizon

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

In the future, the use of hybrid ORs is likely to continue expanding. Skorup expects to see more multiple interventions for individual patients. “Some centers are doing vessel verification after a CABG procedure,” he says. He adds that physicians in Europe are performing transcatheter mitral valve repair, and he expects the procedure to emerge in 2 to 3 years.

—Cynthia Saver, MS, RN

Cynthia Saver, a freelance writer, is president, CLS Development, Inc, Columbia, Maryland.

References

Centers for Medicare and Medicaid Services. Decision Memo for Transcatheter Aortic Valve Replacement (TAVR) (CAG-00430N). May 1, 2012. . Accessed June 25, 2013.

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

Where the money goes

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

SOURCE: ©2013 ECRI Institute

Examples of procedures done in endovascular hybrid ORs

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

Equipment needs

In addition to the usual OR equipment, the hybrid OR required the following:

• Radiologic C-arm device/angiography unit
• Hybrid operating table
• Video monitors
• Control room
• Contrast injector
• All this equipment means that hybrid ORs are typically about 500 sq. ft. larger than traditional ORs

Elements to include in a business plan for a hybrid OR

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

Source: Dorothy Urschel