Framing the issue:

  • Interest in hybrid ORs is driven by the demand for minimally invasive surgery.
  • The complexities of interventional imaging also are sparking interest.
  • 75% of cardiovascular surgeons are expecting to be working in a hybrid OR by 2018.
  • The investment to create a hybrid OR is high, but it can pay off by allowing a variety of surgeries and attracting top physicians.
  • These ORs allow patients to undergo both surgical and interventional procedures at the same time.

The electrophysiology team at University of Virginia Health System recently was extracting a patient's pacemaker lead, a complicated procedure because the wire was bound to its vein with scar tissue. Tugging the wire out without completely detaching it could pull a hole in the heart. The team reached a spot that their catheter-guided laser couldn't cut through.

They faced the prospect of stopping the minimally invasive procedure and calling the standby thoracic surgery team into the room to perform open surgery to remove the lead. Instead, the electrophysiology team called the interventional radiology department on the floor below, explains Gregory Wozneak, administrative director of invasive cardiology. The interventional radiology team was able to enter the patient's vasculature from another location and snare the catheter.

"They were able to work it loose by the interventional radiology and electrophysiology teams pulling back and forth, and they finally broke the lead free without any complication," Wozneak says. "It was an incredibly elegant level of teamwork."

Their success spared the patient open surgery and its accompanying increased recovery time, length of stay, infection risk, anesthesia levels and scarring. The two-team effort was made possible by UVA Medical Center's hybrid operating room for heart patients.

Like interventional labs, hybrid ORs have sophisticated imaging systems for catheter-based procedures, but also meet the sterility standards and have the equipment of a traditional operating room. This enables providers to perform high-risk minimally invasive procedures and to switch to open surgery without moving the patient if a dire complication arises. Hybrid ORs also make it possible to conduct catheter-based and open procedures on a patient at the same time.

Interest in hybrid ORs has grown in recent years fueled by the rising demand for minimally invasive surgery and the ever more complex nature of interventional imaging, says Rohit Inamdar, senior associate in the Applied Solutions Group at the ECRI Institute, a health care safety research organization. The aging population and the increase in such chronic conditions as heart disease and diabetes mean the need for services provided in hybrid ORs is increasing. These procedures include catheter-based heart valve repair and implantation, stent placement to repair aneurysms, and treatment of blocked peripheral arteries, especially in the legs.

Academic medical centers led the way in building hybrid ORs, but they can't meet all the patient demand. So, community hospitals have a big role to play, especially in the cardiovascular realm, Inamdar says. "All facilities that do cardiovascular care should be planning for a hybrid OR if they do not have one already," he says. "This is where the market is. You can't be left behind." By 2018, 75 percent of cardiovascular surgeons will be working in a hybrid operating suite, ECRI projects.

However, because a hybrid OR costs $2 million to $4 million, hospitals must make sure it makes strategic and financial sense, Inamdar cautions. Even then, return on investment can take years.

Making the ROI case

At Susquehanna Health, a four-hospital system in Pennsylvania, the vascular surgery department pushed for the investment in a hybrid OR for endovascular grafts to treat aneurysms. "With so many advances in that particular procedure alone, it's vital for anyone who wants to offer modern-day therapy," says vascular surgeon Karla Anderson, M.D.

Anderson was successful in securing support from hospital administration, which initially was worried the room would not earn a return on investment with only vascular cases, says Lori Beucler, Susquehanna executive director of perioperative services. But hospital officials realized a hybrid OR would enable growth in both vascular and cardiology cases.

The room, which went live at Susquehanna's Williamsport Regional Medical Center in June 2012, helped the hospital to recruit a cardiac surgeon trained in complex minimally invasive techniques and to retain its vascular surgeons, Beucler says. Now, six proceduralists use the hybrid OR to perform a full range of endovascular services, including abdominal aortic aneurysm repair and carotid artery stenting, as well as electrophysiology services. The system is working toward meeting federal requirements to offer transcatheter aortic valve implant, known as TAVI.

The hybrid OR enables the system to offer minimally invasive surgery to older patients with multiple comorbidities who would face difficult recovery with open surgery or aren't even candidates for it, Beucler says. This includes patients with widespread arteriosclerosis, not just in the aorta but in other vessels in the pelvis and legs.

"We like to think of ourselves as a limb salvage center," Anderson says. "[The hybrid OR] allows us to improve the blood flow all the way down to the foot."

The room recently generated the caseload necessary to create a return on investment after nearly two years of operation, which was the time frame expected by planners, Beucler says. She anticipates a real return on investment at five years, sooner if the hospital starts offering TAVI.

Mercy Hospital of Buffalo's interest in hybrid ORs began years ago with the need to expand its stroke treatment capabilities. "Buffalo is known for chicken wings and beef on weck [sandwiches], so western New York has some of the highest incidence of stroke and vascular disease in the nation," says Chief Operating Officer John Herman. When Catholic Health decided to create a comprehensive stroke center, now certified by the Joint Commission, it identified Mercy Hospital, its main tertiary hospital, as the site.

Part of that vision was to enhance interventional stroke treatment, and Mercy leadership recognized that a hybrid OR with a biplane imaging system, which provides detailed, real-time, 3-D images, would allow Mercy to offer that high level of image-guided care with the added safety of an OR environment, Herman says.

Mercy already needed to renovate four interventional rooms and to add a fifth because of growing demand for peripheral vascular services. Leadership decided to make all five rooms into hybrid ORs, one with biplane imaging and four with single-plane imaging systems.

"It was a premium, but recognizing the benefit that we were going to receive in the future, we made that investment," Herman says. The neurovascular, peripheral vascular, interventional radiology, electrophysiology and cardiac teams use the hybrid ORs.

The expanded service capability has helped to increase volume, Herman says. Comparing 2013 with 2009, neurodiagnostic and peripheral vascular diagnostic procedures each are up 47 percent, and neurointerventional procedures have risen 7 percent. Peripheral interventional services have seen the most growth at 300 percent. Still, the high-level cases in the hybrid ORs represent a small portion of the patient population, Herman notes. "If each hospital provided that capability, you could easily create financial hardship. But it works well for Catholic Health because we chose to consolidate that care for the community in one location at Mercy."

'Operational dream come true'

After a hospital determines that a hybrid OR makes strategic and financial sense, an extensive planning process follows. Questions that need to be answered include how big the space needs to be, where it should go, which specialties will use it and how, what equipment those providers will need and where to put it.

Hybrid ORs are nearly double the size of typical operating rooms, use more utilities, require shielding for the radiology equipment and need structural support for the large equipment booms. Finding the right location saves money and fosters collaboration.

Susquehanna Health built its hybrid OR in empty space next to the cardiovascular OR in a newly erected operating suite. The plan is to continue to build out more land so all of Williamsport Regional's heart and vascular services are in the same core area. "That way we can maximize utilization of our supplies, our staff and all of our resources," Beucler says. "It's an operational dream come true because these catheters are so expensive. This way, we can cut back on the amount of stock that we carry, and the team is much more versatile in being able to move from one room to the next."

Mercy Hospital of Buffalo, without the land or resources to build new, opted to renovate former imaging space into its hybrid ORs. That saved money because some of the required infrastructure, such as shielding for the radiology equipment and electrical service, already was in place, Herman notes. The hybrid rooms were built as close to identical as possible and located next to the ORs to promote flexibility and create economies of scale for staffing, especially as the line between interventional imaging and traditional surgery continues to blur.

For its hybrid OR, opened in 2010, UVA Health System renovated existing space that became available when interventional radiology moved down a floor to a new department. "Cost-wise it's more, but not dramatically more than renovating a new cath lab," Wozneak says. The medical center plans to have two more hybrid ORs, one specifically for electrophysiology, operating by late spring 2014.

UVA's hybrid cardiology OR doesn't sit idle when cases that require a high level of care aren't on the schedule. "Much of the use is routine, bread-and-butter interventional cardiology cases," Wozneak says. "Anybody who installed one of these would build it to be as versatile as possible, so if it's not being used for transcatheter valve cases, it can be used for diagnostic cardiac catheterization."

To avoid added expenses, physicians must be involved at every step of hybrid OR planning. Planners should get input not just from the providers who will use the room immediately, but those likely to use it down the road. "Depending on what kinds of procedures you do, you may need different kinds of equipment in the hybrid OR," Inamdar says. "If you're spending $3 million, it better be good for the next five to 10 years. You really have to look way ahead and ask, 'Is it possible that neurosurgeons may be using it, and do I need to buy that component now? Or do I buy it later but create the space for it now?' "

The needs of all of the professionals who will use the hybrid OR — including physicians of various specialties, nurses, imaging technicians and perfusionists — should be considered in room layout. At UVA, design on the third hybrid lab was well under way when planners discovered the anesthesia staff's equipment needs meant their hardware would be too close to the door. "We had to go back, reverse the entire room and anchor the X-ray system in the opposite corner from what we originally planned," Wozneak says. It's better to notice such problems in the design phase, he says. If not, the hybrid OR could "be named after you as the boondoggle of the century, and you really don't want that."

Wozneak recommends hiring a seasoned architect. "If the architect is learning along with the program, that's going to cause a lot more effort to get to the same point than if you engaged an architect that has experience building cath labs and hybrid labs."

Planners also should run exercises with staff in the empty space with the floors marked and mock equipment in place. Inamdar says he's been to a facility where the hybrid OR's surgical lights were in the wrong place. "You have equipment, you have people, you have the patient, you have the imaging system, and all of these things are moving in real time in the OR," Inamdar says. "It's like choreographing a ballet. All of these things are flying, and the risk of collision or running into the table are very high, so all this is part of the planning."

Susquehanna Health ran such mock exercises. "We knew the mainstay was going to be vascular cases, but what if we were going to do a heart in there? Where would we put the perfusion machine and the anesthesia boom? And if we moved the table or we moved anything, would the anesthesia machine still be able to reach?" Beucler asks. "You really have to play out all of your scenarios."

So specialists don't clash

Another reason for early and continued stakeholder involvement is to prevent turf battles and promote collaboration. "Hybrid ORs are disruptive technology," Herman says. "You're breaking silos down because now you have different clinical specialties working together and assisting each other within a single space. You absolutely have to set the expectation that things are going to have to be different. You have to have your physician leaders and the physicians who are going to be working in the rooms accepting that very early in the process or it's going to be very difficult."

Strong physician leadership, a desire among physicians to do hybrid procedures, regular meetings about the project, and a "laser focus on what's best for the patient" helped Mercy Hospital to successfully navigate any conflicts, Herman says.

To avoid a scenario in which specialists — for example, interventional radiologists and cardiac surgeons — are fighting over the same procedures and patients, hospitals should make sure the hybrid OR creates new business, Inamdar says, otherwise, "you're simply shifting revenue from one part of the hospital to another."

Wozneak has been pleasantly surprised at the lack of conflict between the surgical and interventional teams at UVA Medical Center. "It's kind of a synergistic and codependent relationship because we need [the surgeons] to do what they do for a living, and they need [interventional cardiologists] for what we do for a living," he says. "The patient benefits from having all that done in a hybrid manner."

That collaboration makes a higher level of care possible, he says. For example, in some cases a patient has needed both an aortic stent graft, normally performed in an interventional lab, and heart bypass surgery, normally performed in an OR. "What they've done is use the hybrid lab to do both procedures at the same time."

The added level of safety the hybrid OR provides during high-risk interventional procedures also benefits patients, Wozneak says. In the past, if interventional cardiology patients experienced complications that required emergency open heart surgery, the team "would have to pack the patients up, keep them alive and wheel them down the hall to get them to the OR," he says.

Now, high-risk cases are performed in the hybrid OR with surgery team members on hand or on standby so they immediately can step in if a complication arises. "For the cath lab team to step back and watch thoracic surgery and perfusion take over and do what they do for a living, that is a wonderful feeling."

Geri Aston is an H&HN contributing writer.

Executive Corner

Building a hybrid OR is "a complex and error-prone undertaking" in terms of funding, planning, design and implementation, notes an ECRI Institute report. "In the current environment of health care reform and cost-containment, health care executives are advised to assess carefully the technology marketplace and cost, the typical procedures, and space requirements before making procurement and installment decisions," the report states. It also recommends that hospital leaders take these steps for successful implementation:

Seek input
from clinical and nonclinical experts from all related specialty areas, including interventional cardiology and vascular and cardiac surgery.

Do on-site visits
to hospitals with hybrid ORs to help determine the best room placement, technology options and procedures.

Choose vendors early
for each major system and use their expertise in room design and planning.

Carefully consider transitions
from interventional to surgical procedures. Talk to all stakeholders, especially those in anesthesiology.

Get a final construction drawing
that shows the placement of imaging systems, the operating table, booms and all other equipment. Review it carefully with all anticipated users before signing off on the document.

Define which procedures
require a hybrid OR and which do not to ensure cost-effective care delivery and promote more accurate future growth planning.

Consider working with
equipment vendors who have an existing relationship with an imaging system vendor for maximum efficiency and compatibility.