Lessons learned from hybrid OR installations

The cost investment, space and equipment needs, and learning curve involved in adding a hybrid OR can seem daunting, but the increased flexibility and efficiency that can be achieved suggest the effort is worthwhile. Staff at 3 East Coast hospitals who have been through the process reflect on their experiences and describe what a hybrid OR project entails.

Building the first hybrid OR was a “leap of faith,” says James E. McGowan, DHA, MBA, RRT, vice president of procedural care services at the University of Maryland Medical Center (UMMC) in Baltimore, which has 4 hybrid ORs. Procedures performed in these ORs range from standard coronary artery bypass grafting and valve cases to endovascular and minimally invasive valve procedures.

Initial interest in investing in a hybrid OR was sparked by a surgeon who often worked in robotic surgery and who had formed a partnership with a faculty interventionalist at that time, says McGowan. UMMC recognized the future potential of such an OR and played the odds.

“If I were to try to dial back time … I wouldn’t have even had on my radar the fact that we would be floating valves into people’s hearts in a room that has to have a team of OR nurses and a team of nurses from the cath lab plus radiologic technologists,” says McGowan. Two of the 4 hybrid ORs 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.

Honing skills

Most hybrid procedures involve teams from several disciplines working together in the same room. More staff members are required in the hybrid room, and everyone must be aware of the equipment setup and roles of their team members. Additionally, the procedures performed in the hybrid OR often require techniques that are unique to the minimally invasive nature of the procedure—techniques that may test the skill set of the average cath lab technician or radiology technologist.

UMMC initially trained radiology technologists in a standard equipment training program offered by the vendor.

“As our program has matured and we’re doing higher acuity, more sophisticated cases, we are discovering that [the old] skill set is not enough. We are going back to the drawing board to say ‘we need to collaborate with our radiology cath lab staff around a new staffing model to better support the technology and the interventionalist,’” says McGowan.

UMMC’s current goal is to create an environment that is seamless for physicians who are moving from a standard procedure outside of an operating room to a hybrid procedure within one. Regardless of whether they work in a traditional or a hybrid OR, nurses have similar responsibilities; however, other staff tend to require more training to accomplish their tasks within the operating room environment. McGowan points to someone who is “very well trained and understands interventional radiology and a cath lab environment from a radiology technologist perspective” as an example of the skill set required of staff focused on operating the technology in this type of environment.

OR staff no longer perceive the hybrid room as different from any other room, McGowan says. When it was new, some people took a dim view of the hybrid OR and the changes it demanded of OR staff, but over time they’ve come to accept it. “So much of cardiac surgery is becoming minimally invasive that [the proliferation and frequent use of the hybrid OR] is just a sign of the times,” he says.

Taking ownership

Strong group training, team leaders, and collaboration helped Massachusetts General Hospital (MGH) prepare for many of the challenges that come with adopting a new system, says Joanne Ferguson, RN, director of operational planning and EOC, perioperative services at Massachusetts General Hospital. MGH has 2 hybrid ORs containing single-plane C-arm units in the new Lunder Building. These hybrid ORs, which were planned and designed through the collaboration of surgery, radiology, and nursing staff, support a full range of open, interventional, and hybrid procedures.

Countless simulations were performed before these rooms were opened, allowing the interdisciplinary team to understand the workflows and processes in a hybrid OR well before the team cared for its first patient.

“Because this team of people had been together for close to 3 years during the design phase and many of us had traveled together to look at other sites, we had a very collaborative multidisciplinary team with a united focus that designed every inch of these ORs,” says Ferguson. “By the time the construction was nearing completion and we were preparing for the simulations in these new ORs, the team naturally took ownership as a team, not as individuals.”

The original core group helped integrate new members of the team, providing education, training, and support to get everyone up to speed, notes Scott Farren, nurse manager of vascular and neuro services.

“I think because of the team building that had happened ahead of time and the lessons learned during the simulations [we had a good start],” agrees Ferguson. “I would say that we now have such a strong core team that when someone new joins the team, it is typically a very smooth transition.”

Selecting and locating the various types of equipment in these spaces is important, Ferguson says, noting that the lessons learned with their first hybrid OR made it much easier to plan for a new cardiac hybrid OR. A key lesson was that the hybrid OR needed to be outfitted for both open and hybrid procedures. At MGH, a limiting factor in the original hybrid OR was the OR table. “When we designed our 2 new vascular hybrid ORs, we had the opportunity to select an OR table that worked for both open and hybrid procedures. The flexibility of our vascular hybrid ORs confirmed for us the viability of a cardiac hybrid OR,” says Ferguson.

“We are currently performing the cardiac hybrid procedures in our cardiac cath lab, a suboptimal setting for surgery. The team recognized the need to move these procedures to the OR setting, and we developed a plan to build the new cardiac hybrid OR. The 2 years’ experience we have in our vascular hybrid ORs has made planning for and designing a new cardiac hybrid OR a very positive experience for all.”

McGowan likewise sees hybrid ORs in a positive light: “The newer rooms have a lot of capabilities with the beds and the C-arm—you can actually do other cases in the room, so it does allow you to [argue] the business case pretty quickly.”

Farren estimates that the MGH hybrid ORs accommodate roughly 100 procedures each month, despite what official documentation shows. “Once staff get in there and see the utility of the room, almost every single one of our cases now turn into some sort of hybrid case for vascular,” Farren says.

Anticipating needs

Overall utilization of the hybrid OR at Inova Heart and Vascular Institute in Falls Church, Virginia, is currently lower than anticipated because of the limited equipment selection within the room, says Ed Schatz, RN, CRNFA. Inova opened a hybrid room in December 2010 as part of an 8-room cardiac surgery suite. However, with the benefit of hindsight, Schatz says, he would approach planning differently today.

“If we were to build another one, we would look at all the possible cases we could do in a hybrid room and then make our equipment choices based on that,” says Schatz. “The one we have here is good for cardiac procedures, but not for some things that we should be able to do in that room.”

Successfully building a hybrid OR requires a great deal of preplanning and some flexibility on the part of planners, according to Ferguson. Technology is constantly evolving, and a particular piece of equipment the hospital plans to use may not be available for purchase when it is time to actually construct the room. Equipment size may also pose unexpected problems; MGH had to scrap plans for a third hybrid OR when 1 piece of equipment took far more space than anticipated. “No matter how much you’ve preplanned, technology will change. Know that, and you can deal with it effectively,” advises Ferguson.

Ferguson also recommends going on site visits to facilities with existing hybrid ORs, as well as those in the process of building one. Finished rooms can give visiting teams ideas for potential room layouts and equipment setup for their own hospitals, and hybrid rooms under construction will help them learn how to plan.

“We did this for the new building to engage the clinical staff at the very beginning of the design process,” notes Ferguson. “Once you’re into the design development and past the schematic design, that’s when you have to engage the team, because that’s when the team begins to come together. It was huge for our success here.”

Despite the challenges involved in establishing a hybrid OR, some see the future demands of health care as a reason to start investing now. “This is not about an optional exercise,” says McGowan. “You’re just going to have to do it because that’s where health care is going. Have an organized approach for when to build them and how to build them, manage that process, and come out on the other side with something that actually works.”

—Steven Dashiell