Each year, the OR Manager Conference showcases the latest hybrid OR technology along with expert advice from clinicians and manufacturers. The 2017 conference (October 2-4 in Orlando, Florida) will feature an extensive exhibit and opportunities to interact with the Hybrid OR Steering Committee members (sidebar, p 15):
• Monday, 2 pm–breakout session, Understanding the Next Generation of Surgical Suites: The A to Z of Hybrid Operating Rooms, with Patricia Seifert, MSN, RN, CNOR, FAAN, an independent cardiac consultant in Falls Church, Virginia; Tracy Diffenderfer, MSN, RN, CNOR, administrative director of perioperative services at Vanderbilt University Medical Center in Nashville, Tennessee; and Susan Hodgin, manager of neurosurgery at Vanderbilt.
• Monday, 5 pm–Happy hour
• Tuesday, 9:30 am–Town hall session.
In a recent OR Manager survey, more than half of respondents said they think their facilities would benefit from having a hybrid OR, and the majority said a checklist or toolkit would be helpful.
Those with an existing hybrid OR said they wished they had known things like how long it would take, how much it would really cost, how it would actually be used, and how technology would change space and function requirements.
We recently asked committee members some "burning questions" about their experience in an effort to help others embarking on the hybrid OR journey.
Why have a hybrid OR?
The opportunity to increase revenue and enhance the facility "brand" makes hybrid ORs attractive, according to Patricia Seifert, MSN, RN, CNOR, FAAN. Seifert, an independent cardiac consultant, was formerly at the Inova Heart and Vascular Institute in Falls Church, Virginia, which has a hybrid room for cardiovascular procedures and more than four hybrid ORs in the cath labs. Two additional hybrid rooms are being built, Seifert says.
Interventional procedures in need of a home pushed both Memorial Hospital of South Bend (South Bend, Indiana) and Carson Tahoe Health (Carson City, Nevada) to build hybrid ORs. Interventional vascular procedures and TAVR/EVAR (transcatheter aortic valve and endovascular aneurysm repair) were the main procedural drivers at Memorial Hospital, says Debra Thompson, MSN, MBA, BSN, RN, executive director, surgery, trauma, pulmonary services. At Carson Tahoe Health, the hybrid OR project was championed by a vascular surgeon, says Cindy Kuperus, MBA, RN, CASC, director of perioperative services.
At the University of Colorado Hospital (UCH) Aurora, the growth of minimally invasive procedures and minimally invasive technology led to the need for a hybrid OR, says Tamara Mayne, BSN, RN, CNOR, cardiothoracic surgery service specialist.
Which procedures are performed?
UCH and Memorial Hospital both have two hybrid ORs where multiple types of procedures are performed. At UCH, numerous endovascular and cardiovascular procedures are performed as well as other procedures that "aren't necessarily hybrid procedures but we perform them in our hybrid ORs," says Mayne.
Hybrid OR procedures at Memorial Hospital include cardiothoracic, neurological, vascular, and general surgical procedures, says Thompson.
At Carson Tahoe Health, endo- vascular procedures are done in the hybrid OR, and interventional radiologists sometimes also use the room, Kuperus says.
What goes into implementation?
Regardless of whether the hybrid OR originates from a renovation or new construction, a great deal of planning and support from key stakeholders are paramount.
Seifert stresses involving numerous individuals in planning, including:
• executive suite and OR leaders
• anesthesia providers
• surgeons and their office staff
• staff from interventional cardiology, radiology, finance, and marketing
• educators
• staff from preoperative and postoperative areas, cardiac rehabilitation, and discharge planners
• vendors.
Among the many factors to consider, Seifert says, risks and relationships are key. Costs must be weighed against anticipated return on investment (ROI). It's hard to know what reimbursement rates are and how they might change, but some solid research will help leaders make more informed decisions.
Based on her experience, Seifert advises OR leaders to:
• Develop partnerships with stakeholders, eg, staff from the OR, interventional cardiology, radiology, and anesthesia.
• Become familiar with healthcare trends in the literature, including business and management; nursing, medical, and surgical; quality; and hybrid construction.
• Know the reimbursement rates for the procedures to be performed and how devices will be paid for.
• Find out who has the ear of administration.
• Collaborate with staff and trusted colleagues to identify potential problems and solutions before meeting with administration.
At UCH, one room was renovated, and an additional room was later put into a new space, Mayne says. "For the first hybrid OR, we collected data and information to help convince the hospital administration that this change was needed," she explains. Key stakeholders were hospital administrators, vascular and cardiothoracic surgeons, anesthesia providers, interventional radiologists, cardiology and OR nursing staff, IR/cath lab/EP (electrophysiology procedure) staff, and perfusionists.
"For our second hybrid OR, we used data and information that had been collected during our first 2 years of use of the current hybrid OR and showed that an additional hybrid was needed to accommodate the uncontrolled growth we were experiencing," she says.
Mayne believes it's important to seek answers to these questions:
• What are local market demands?
• What are the costs (vendors, education, ‘bricks & mortar,' training, new hires)?
• Is there a culture that supports new technology use between previously nonrelated groups (eg, interventional radiology and the OR)?
• Which leaders are responsible for melding the various teams?
• Is there a realistic business plan?
• What and who are your resources?
At Carson Tahoe, Kuperus says, the hybrid room was shelled from the original construction. "It was our standard size of approximately 800 square feet, so we had to also include the sub-sterile room during construction to create the control room," she explains. "It was a difficult design and construction with the limited space, but it turned out great. This was an added value and service for patients to have their vascular lab procedure done in the hybrid room and, if needed, to have an open procedure immediately."
Although initially the new room did not show ROI, over time case volume has increased and the hospital is seeing the benefits, she adds. Kuperus offers this step-by-step approach:
• Decide who will use the hybrid room.
• Decide which products are wanted. "We visited local hybrid rooms to talk with management to discuss pros and cons and what would they have done differently," she says.
• Identify stakeholders.
• Choose the construction company and architect.
• Create a construction team. At her facility, this consisted of the director and manager of perioperative services, vascular nurse team leader, cath lab manager, endovascular surgeon, infection control manager, facilities director, project manager, imaging manager, information technology manager, construction supervisor, and other construction company representatives.
"We converted a room," Kuperus says. "We opted to not have booms (only the anesthesia boom) and built-ins due to space constraints, to give us more flexibility. Our construction company provided the project manager, who kept us on track. We worked closely with the cath lab manager during the entire process, and we still do today."
Building a business plan to show how the new technology would grow revenue and surgical volume was key to getting the hybrid OR off the ground, Thompson says. Thompson, currently employed at Memorial Hospital, was part of the build team at Borgess Medical Center in Kalamazoo, Michigan. The use of Sg2 data analytics and other tools helped with strategic planning, she adds. Thompson says her key stakeholders were surgeons from the vascular, cardiac, and neurosurgery service lines; staff from anesthesiology, interventional radiology, cardiology, and finance; and executive leaders.
Healthcare providers at other facilities shared their "wins" vs "if I could do it over" experiences. That knowledge in combination with site visits greatly helped her own planning, she adds.
The 2017 hybrid OR exhibit will showcase technological advances in equipment.
How are staff educated?
"The OR team was already working with the vascular lab team doing endovascular procedures in the vascular lab," says Carson Tahoe's Kuperus. "So the education was for the vascular lab team to learn the OR standards. Then everyone learned the new process for the hybrid room. We have had a very good experience with the teamwork between the departments."
At UCH, Mayne says, all OR and interventional radiology staff had training for the hybrid OR. "We worked closely with the OR educators, IR/cath lab/EP, and vendors to create checklists to ensure proper education in the skills needed to function in the hybrid OR," she says. "Detailed information books created by the service specialists for cardiothoracic and vascular surgery are located in each hybrid room."
In addition, Mayne says, staff performed mock cases before the room opened so they could identify areas in need of improvement, and staff were shown where supplies were located by specialty hybrid cases.
At Borgess Medical Center, Thompson says, education included offsite observation, onsite vendor training, OR sterile technique, teambuilding, pre- and post- operative care protocols, biomedical training, and environmental cleaning.
Seifert offers the following questions to consider for planning hybrid OR education:
• Do the staff know what they don't know?
• Who's involved in the education: surgeon, vendor, nursing staff educator?
• Who selects the team?
• Is it a dedicated team, or can any OR staffer be involved?
• Do staff need to go off site, and if so, can they train the remaining team members?
• Do interventional and OR staff know one another and work well together?
• Are these staff familiar with patient care processes in their respective areas?
• How are vendor clinical educators used?
• Is there a clear distinction between a vendor's educational responsibilities and clinical role?
What did and did not go well?
"For the most part, all went well," Thompson says. Some equipment- and monitor-related changes were needed after the room "went live"–for example, the first hybrid OR lacked cardiac monitor/documentation software, which had to be added a year later when the TAVR program started.
An important lesson was learned about staff education, she notes. Initially, a core team was trained, but after the program was up and running, additional staff were needed. These staff members felt "second best" or "not part of the chosen," Thompson says. "They didn't have the same training or understanding of the program, and they felt as if they were set up to fail." Her advice is to train the entire team and explain that the initial go-live team will be limited, with staff added to the hybrid OR as the program grows.
"One task that I found to be extremely helpful was to measure footprints of all the equipment that the surgeons/anesthesia staff/nursing staff felt was needed, and make a mockup of the area to lay out placement of the equipment," Mayne says. "The more time these multidisciplinary groups work together in building the room, the more information is covered and the more likely it is that they will notice things that otherwise might be missed."
Things that went well included multidisciplinary group meetings, identifying which interventional supplies were needed, staff education, and the cases performed on opening day, Mayne says. However, for the second hybrid OR, they should have had more meetings, and some equipment was added at the last minute.
At Carson Tahoe, Kuperus says, construction went very well. "We have a great team approach and have had very few issues. Very rarely do we have to delay a procedure because the vascular lab staff are busy."
To correct a monitor that was partially obstructed, they switched a light and the monitor, but it was not an easy fix because of the amount of weight bearing each fixture could withstand, Kuperus says. "Be sure to budget for maintenance and upgrades," she adds.
At Inova, there was good collaboration between OR and cath lab staff, and patients did well, according to Seifert. However, she notes that–as an early hybrid room–the design did not easily accommodate procedures such as coronary artery bypass grafting, and there was too much down time before the room was fully utilized.
What are the biggest lessons learned?
Thompson offers this laundry list of "must do's" when adding a hybrid OR:
• Know how the room will be used.
• Build block times if there are multiple users, and prioritize case types to assist in scheduling when there are multiple requests for the same time or day.
• Hold multidisciplinary meetings with physicians and staff to assist with the build, and make decisions related to the vendors.
• Send staff on two or three different site visits.
• Make sure the room will be big enough; don't skimp on square footage.
Seifert says it's important to anticipate potential problems (and their possible resolution), attend meetings, and talk with those who will be using the room.
Both Mayne and Kuperus stress the importance of having a physician champion and stakeholders who are invested in the success of the room. "Encourage multidisciplinary harmony by being a leader staff want to follow and learn from," Mayne advises. ✥