Case Study: Operationalizing the hybrid OR

You’ve cleared the hurdle of installing a new hybrid operating room, but now another hurdle looms: putting it into operation.

The good news is you likely have already built a collaborative relationship among key players. “Getting everyone on the same page to justify the OR sets the team up for success,” says T. Brett Reece, MD, a faculty member in the division of cardiothoracic surgery for the University of Colorado Hospital (UCH) in Aurora, which opened its hybrid OR in April 2012. About 30 to 40 cases, mostly endovascular, are done each month, with utilization between 66% to 80% during weekday business hours.

You’ll need to build on that collaboration in 4 areas: education, staffing, supplies/billing, and coordination. Here’s how UCH did it.

Ramping up

“We used multiple opportunities to educate staff,” says Tamara Mayne, BSN, RN, cardiothoracic surgery service specialist for the UCH OR. “The educators in interventional services and the OR partnered because they had the knowledge of how it would function and what information staff needed.”

The hybrid OR was open for a full week before the first case, giving staff and physicians time for training and learning about the equipment, which includes fluoroscopy imaging, a surgical table, equipment booms, and general imaging. Everyone on the OR staff was oriented to the hybrid OR to provide flexibility, although the vascular team members work there most frequently.

Education included how to set up the room. “We adapted current space to the hybrid OR, so we had to fit everything in so that it would work,” Mayne says. That attention to detail is important for a successful case. For example, she adds, “If you don’t move the C-arm correctly, you can’t move the lights.”

Physician preference added to the complexity. “You have to have a way to set up every room for every case for every physician,” says Dr Reece. Mayne turned to the traditional preference card as a tool, but with a twist. “We have lots of pictures and 3-D drawings showing how everything needs to be positioned,” she says. Mayne keeps the images on her office computer.

Education helped ease what Dr Reece feels was the most challenging part of the startup—anxiety among those in the room. “The consistency that Tamara provided made it work,” he says.

“We overcame anxiety through repetition in education and leading by example,” Mayne adds. “Now anxiety is low. People have a good idea of how to fit everything in the room and how the process works.”

A blended staff

“We use a blended staffing model for the hybrid OR,” says Katherine Halverson-Carpenter, MBA, RN, CNOR, patient care services director for obstetrics and perioperative series at UHC. Staffing is based on case type. Staff from the cardiovascular (CV) center and the OR handle combined cardiology and surgical procedures, with the CV center nurses supporting the cardiologists with imaging and documentation. A radiology technician from the interventional radiology (IR) department fills that role for IR procedures done in the hybrid OR. One challenge has been the finite number of radiology technicians with the skill set to work in the hybrid OR, Halverson-Carpenter says.

Supply and billing needs

“Managing supplies is a challenge,” says Mayne. Vascular surgeons (some of whom were new to UCH), interventional radiologists, and interventional cardiologists had to feel confident that the supplies they needed would be available, while OR leaders needed to reduce redundancy as much as possible. The OR is working on obtaining high-volume supplies on consignment to avoid replicating supplies in the IR and CV center suites.

Billing processes also had to be established. The IR department and CV center bill by the procedure, but the OR bills by time. “We got the finance team together and decided we would bill by the minute because the procedure was done in the OR,” says Halverson-Carpenter. If the procedure is done in interventional radiology or the CV center, billing is done by procedure.

Coordination

“The greatest challenge of a hybrid OR is the coordination,” says Halverson-Carpenter. At UCH a hybrid steering committee provides oversight and helps work through problems. Halverson-Carpenter and Dr Reece, who allocate the block time, cochair the committee. Among members are those who perform procedures in the room, nursing staff, nurse managers, and perioperative business managers from the IR department, OR, and CV center.

Halverson-Carpenter says the committee reviews utilization of the room both during regular business hours and after hours, which cases are being done 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 your block time allocation,” she notes.

One discussion centered on the use of the hybrid OR for traditional surgical procedures. Recently UCH opened 4 new ORs; once they are fully staffed, the hybrid OR will be dedicated to hybrid cases.

Halverson-Carpenter credits the success of the committee and the hybrid OR to a meeting she and the chair of surgery cochaired early in the planning process. The meeting focused on the principles of collaboration and included key stakeholders, such as the medical director of IR, section head of vascular surgery, chair of cardiothoracic surgery, chair of cardiology, all physicians and surgeons who would be working in the room, and administrators for the OR and CV center. “Establishing the framework clarified our mutual goals and purpose,” Halverson-Carpenter says. “It became an expectation that people would collaborate.” The group met with the vendors, conducted site visits, and worked with designers during the process.

That spirit of collaboration carried over into operations meetings among centers, where details were hammered out. The team had to consider current practices while determining how to best work together, something they continue to do. “We respect the practices and philosophies of each of the individual units,” Halverson-Carpenter says. “That’s helped us come together as a team.”

Satisfaction and future direction

Staff, physicians, and patients are satisfied with the hybrid OR at UCH. “We are able to do cases now that we weren’t able to do safely previously,” says Dr Reece. Those include fenestrated grafts for patients with complex anatomy and percutaneous cardiac valves. “We can reinvent what we provide to patients.”

“Everyone working together has made the program successful,” adds Mayne. “We’ve been a tight-knit group.” That success is expected to pay off; the UCH team is in the process of justifying a second hybrid OR.

—Cynthia Saver, MS, RN

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