SPECIAL REPORT

Capitalizing on
the New Wave
of Hybrid ORs
Published by OR Manager and Access Intelligence
 Introduction www.ormanager.com
SENIOR VP/GROUP PUBLISHER

An increasing number of hospitals nationwide now have hybrid

Jennifer Schwartz • 301-354-1702
jschwartz@accessintel.com

operating rooms. Building a new hybrid OR takes careful planning, PUBLISHER, DEFENSE AND HEALTHCARE
Thomas A. Sloma-Williams • 301-354-1696
requires specialized and advanced audiovisual and imaging tawilliams@accessintel.com

EDITOR
equipment, and involves the collaboration of many decision Elizabeth Wood • 301-354-1786
ewood@accessintel.com
makers. And once a hybrid OR is in place, procedures often require CLINICAL EDITOR

teams from several disciplines to work together as one. This process

Judith M. Mathias, MA, RN

CONTRIBUTING WRITERS
may be daunting, but the results may leave you in a better position Paula DeJohn, Cynthia Saver, MS, RN

to offer a variety of surgical procedures, enhance patient safety, and

WEBINAR COORDINATOR
Ellen Lord, MS, RN, CNOR

achieve long-term cost savings with improved efficiencies. CONFERENCE DIRECTOR

Jess Tyler

Regardless of whether you’re building a new hybrid OR or ART DIRECTOR

Yelena Shamis

remodeling to accommodate the new room within existing space, yshamis@accessintel.com

SENIOR PRODUCTION MANAGER

you must commit considerable financial and human resources. Joann M. Fato • 301-354-1681
jfato@accessintel.com
This special report provides insights from professionals who have ADVERTISING
transitioned to a hybrid OR, offering tips and strategies to help National Advertising Manager
Jamila Zaidi
you through the process. As with any transition, getting input from Account Executive, OR Manager
jzaidi@accessintel.com
physicians, anesthesiologists, nurses, technical staff, and other 301-354-1678
Fax: 301-340-7136

members of your team is crucial to success. It is our hope that this REPRINTS

report lays the groundwork for a successful conversion. Wright’s Media

877-652-5295 • sales@wrightsmedia.com

OR Manager (ISSN 8756-8047) is published monthly by

Access Intelligence, LLC. Periodicals postage paid at Rock-
ville, MD and additional post offices. POSTMASTER: Send
address changes to OR Manager, 4 Choke Cherry Road,
2nd Floor, Rockville, MD 20850. Super subscription (in-
cludes electronic issue and weekly electronic bulletin) rates:
$219 (plus $10 shipping for domestic and Canadian; $20
shipping for foreign). Single issues: $39. For subscription
inquiries or change of address, contact Client Services,
clientservices@accessintel.com. Tel: 888-707-5814, Fax:
301-309-3847. Copyright © 2015 by Access Intelligence,
LLC. All rights reserved. No part of this publication may be
reproduced without written permission.
OR Manager is indexed in the Cumulative Index to Nursing
and Allied Health Literature and MEDLINE/PubMed.

Access Intelligence, LLC

President & CEO
Don Pazour
Chief Operating Officer
Heather Farley
Executive Vice President & Chief Financial Officer
Ed Pinedo
Exec. Vice President, Human Resources & Administration
Macy L. Fecto
Senior Vice President, Chief Information Officer
Rob Paciorek
Senior VP, Customer Acquisition and Retention
Sylvia Sierra
Senior Vice President, Digital Development
Alison Johns
VP, Production, Digital Media & Design
Michael Kraus
Vice President, Financial Planning and Internal Audit
Steve Barber
Vice President/Corporate Controller
Gerald Stasko

4 Choke Cherry Road, Second Floor

Rockville, MD 20850 • www.accessintel.com

2 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs

 Table of Contents
Clear vision critical to successful hybrid OR development......................... 4
Case Study: Operationalizing the hybrid OR............................................... 6
Lessons learned from hybrid OR installations.............................................. 8
Specialized equipment serves hybrid and standard ORs equally well...... 11
Endovascular hybrid ORs in community hospitals: Driving success........ 13
Include infection prevention in your hybrid OR design..............................17
Perceptive leadership fosters collaboration among hybrid OR staff........ 19
Building the business case for a hybrid OR................................................. 23

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 3

 Clear vision critical to successful hybrid OR development
About 100 US hospitals now have a hybrid operat-
ing room, and a 15% increase is projected over the
next decade, according to experts who have man-
aged installations at numerous facilities.
Whether your hospital is considering converting a
conventional operating room into a hybrid OR or
building a brand new room, it’s important to know
where you want to end up before you take the first
step to get there.
“Knowing what you want to accomplish—having
a business plan—is the most critical part of plan-
ning. Just knowing that you want to have a hybrid
OR isn’t very helpful,” says Lynne Ingle, MHA,
BS, RN, CNOR. As a project manager with Gene
Burton & Associates, a health care technology con-
sulting company in Franklin, Tennessee, Ingle has
overseen several hybrid OR installations. As a for-
mer director of surgical services, she is well versed
in the kinds of improvements hospitals hope to
achieve with the new technology.
Planning
Key players in the planning process are hospital
administration, interventional cardiologists, open
heart and vascular physicians, neurosurgeons, an-
esthesia providers, department heads and staff from
the cardiac catheterization lab and the OR, a charge
nurse, a staff nurse, and information technology,
Ingle says. Participants from the nonclinical side
include architects, vendors, and engineers. And for
any remodeling project, it’s critical to consider in-
fection prevention, she emphasizes.
Start by determining just how your hospital defines
“hybrid.” Consider questions such as:
• What is the hospital’s goal?
• Who is driving the function of the space?
• What procedures are planned?
• What is the budget?
A traditional OR is about 700 square feet, whereas at
least 1,000 square feet is needed for a hybrid room,
and 1,200 square feet is preferable for accommo-
dating the imaging equipment within the room plus
the control room from which procedures are moni-
tored. Hybrid ORs must allow for the possibility of
4 OR Manager Special Report
converting to an open procedure, so they must be
large enough to accommodate staff and equipment
for two separate clinical teams, Ingle explains.
Procedures
The list of procedures that can be performed in a hy-
brid OR is growing. Among these are many cardiac
procedures that in the past have been done in the
cath lab, but Ingle notes that “hybrid ORs should not
be glorified cath labs.” Newer procedures include
transcatheter aortic valve replacement (TAVR) and
mitral valve clipping, endoscopic abdominal aortic
aneurysm, and aortic arch repair.
Some hospital leaders have mistakenly believed
that for a procedure such as an aortic valve replace-
ment, a cath lab can be turned into a hybrid room,
she says. However, some valve vendors won’t enter
into a contract with a hospital if these procedures
are to be performed outside the restricted area of
the surgical suite. “You need to have all the capa-
bilities for converting to an open procedure if need
be,” Ingle says.
Form and function
The most common configuration for a hybrid OR
includes a single-plane angiographic x-ray imag-
ing system and surgical equipment for open cardiac
surgery.
Lights for the hybrid OR must have a longer arm
reach, especially depending on who’s doing the
imaging, Ingle says. Whether a ceiling-mounted or
floor-mounted C-arm is the best choice depends on
which procedures will be done in the room. Place-
ment of lights and booms is important because
anesthesia staff must be able to have access to the
head of the table.
Knowing how the space will be used is especially
important for determining the type of table that’s
needed. If most procedures will be interventional,
the table selected should be one that communicates
with the imaging system, which is typically pur-
chased from the imaging vendor. If the room will
function primarily as an OR, however, the table
should be appropriate for surgical procedures and
thus it won’t be able to communicate with the imag-
Capitalizing on the New Wave of Hybrid ORs
 ing system. Some OR vendors offer a table with a
fixed base and two tabletops—one for surgical pro-
cedures and one for imaging procedures.
Well-funded facilities may have a dedicated wall
for imaging. But in general, facilities need to have
a “live” monitor and a reference monitor from the
imaging vendor, displays at the OR table for the
surgeon and assistant, and displays on the wall—
as few or as many as hospitals can afford or want,
Ingle says.
Knowing the visuals needed in the control room
is an important factor in deciding on vendors, she
notes, because the technician in the control room
must be able to see and understand what the sur-
geon needs.
As an example of the efficiency gain that’s achieved
with a hybrid OR, Ingle says, troubleshooting can
be done in one place instead of moving the patient
from room to room. “For cardiac surgery, some-
times a patient is taken from the cath lab directly
to the OR, and measurements are taken for vessels
behind the heart, which can’t be seen. If the patient
then moves to the ICU but isn’t doing well, the pa-
tient must go back to the cath lab for imaging and
then back to the OR,” she says. “If everything were
done in the hybrid OR, the surgeon would see the
vessels right there because imaging would be done.
That would cut down on morbidity, infection, and
cost, and the patient could be discharged in a more
timely manner.”
Hybrid ORs can also benefit patients in remote ar-
eas. Ingle was involved in a $3 million hybrid OR
installation at St. Rose Dominican Hospital Siena
Campus in Henderson, Nevada, in 2012.
“A multi-disciplinary ‘TAVR Heart Team,’ led by
cardiothoracic surgeons and interventional cardi-
ologists, has been through a comprehensive training
program that includes procedure and complication
management,” according to Rod Davis, president
and CEO of St. Rose Dominican Hospitals and se-
nior vice president of operations, Dignity Health Ne-
vada. TAVR allows cardiac specialists to deliver and
place a new aortic heart valve in the heart through
a noninvasive procedure that doesn’t require cutting
through the sternum or stopping the patient’s heart.
Capitalizing on the New Wave of Hybrid ORs
Previously, patients in that area of Nevada who
were too ill to undergo aortic valve replacement
with an open procedure usually had to go to south-
ern California, Ingle says. Installation of the hy-
brid OR allowed them to have TAVR without hav-
ing to travel.
The future
In 2013, the interventional trauma operating room
(ITOR)—a $6-million 1,600-square-foot hybrid
operating suite—opened at the Foothills Medical
Center in Calgary, Alberta, Canada. The facility is
“the first of its kind designed specifically for trauma
patients [and] is more than twice the size of a tradi-
tional OR,” according to Andrew Kirkpatrick, MD,
Alberta Health Services’ medical director of trauma
services. The angiography equipment, which al-
lows surgical and diagnostic imaging teams to work
on patients at the same time, makes it possible for
patients with severe bleeding to go directly to the
ITOR for treatment.
Whether future hybrid ORs in the US will be
built specifically for trauma patients remains to
be seen, but Ingle says it’s a good bet that more
spinal procedures will be done in hybrid ORs of
the future.
“A hybrid OR lends itself to spinal surgery because
it has real-time data with the C-arm and high-defini-
tion 3D pictures,” she explains. “You can’t see those
as well with a mobile C-arm that must be rolled into
the room. The hybrid room equipment allows the
surgeon to see on the screen where to place surgical
components like screws and plates.”
While most hybrid ORs initially were installed in
university hospitals, an increasing number of com-
munity hospitals have added or are planning to add
at least one hybrid OR, Ingle says.
—Elizabeth Wood
References
Calgary Herald. Specialized operating room for trauma patients
opens. March 28, 2013.
www.strosehospitals.org.
OR Manager Special Report 5
 Case Study: Operationalizing the hybrid OR
You’ve cleared the hurdle of installing a new hybrid
operating room, but now another hurdle looms: put-
ting it into operation.
The good news is you likely have already built a
collaborative relationship among key players. “Get-
ting 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 cardiotho-
racic surgery for the University of Colorado Hospi-
tal (UCH) in Aurora, which opened its hybrid OR
in April 2012. About 30 to 40 cases, mostly endo-
vascular, are done each month, with utilization be-
tween 66% to 80% during weekday business hours.
You’ll need to build on that collaboration in four
areas: education, staffing, supplies/billing, and co-
ordination. Here’s how UCH did it.
Ramping up
“We used multiple opportunities to educate staff,”
says Tamara Mayne, BSN, RN, cardiothoracic sur-
gery service specialist for the UCH OR. “The edu-
cators in interventional services and the OR part-
nered 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 train-
ing and learning about the equipment, which in-
cludes fluoroscopy imaging, a surgical table, equip-
ment 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 po-
sitioned,” she says. Mayne keeps the images on her
6 OR Manager Special Report
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 Ta-
mara provided made it work,” he says.
“We overcame anxiety through repetition in edu-
cation 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 pro-
cess 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 ob-
stetrics and perioperative series at UHC. Staffing is
based on case type. Staff from the cardiovascular
(CV) center and the OR handle combined cardiol-
ogy 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 radi-
ology 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 interven-
tional 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-vol-
ume 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 in-
terventional radiology or the CV center, billing is
done by procedure.
Capitalizing on the New Wave of Hybrid ORs
 Coordination
“The greatest challenge of a hybrid OR is the co-
ordination,” 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 per-
form 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 vol-
ume 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 four 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 plan-
ning process. The meeting focused on the princi-
ples of collaboration and included key stakehold-
ers, 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. “Estab-
Capitalizing on the New Wave of Hybrid ORs
lishing the framework clarified our mutual goals
and purpose,” Halverson-Carpenter says. “It be-
came an expectation that people would collabo-
rate.” The group met with the vendors, conducted
site visits, and worked with designers during the
process.
That spirit of collaboration carried over into opera-
tions meetings among centers, where details were
hammered out. The team had to consider current
practices while determining how to best work to-
gether, something they continue to do. “We respect
the practices and philosophies of each of the indi-
vidual 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 pa-
tients with complex anatomy and percutaneous car-
diac 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
OR Manager Special Report 7
 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 ex-
periences 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 Univer-
sity of Maryland Medical Center (UMMC) in Bal-
timore, which has 4 hybrid ORs. Procedures per-
formed in these ORs range from standard coronary
artery bypass grafting and valve cases to endovas-
cular 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 Mc-
Gowan. 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 technolo-
gists,” 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 utiliza-
tion is for hybrid cases, he notes.
Honing skills
Most hybrid procedures involve teams from sev-
eral disciplines working together in the same room.
More staff members are required in the hybrid
room, and everyone must be aware of the equip-
ment setup and roles of their team members. Ad-
ditionally, the procedures performed in the hybrid
OR often require techniques that are unique to the
minimally invasive nature of the procedure—tech-
niques 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.
8 OR Manager Special Report
“As our program has matured and we’re doing high-
er acuity, more sophisticated cases, we are discov-
ering 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 technol-
ogy 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 accom-
plish their tasks within the operating room environ-
ment. McGowan points to someone who is “very
well trained and understands interventional radiol-
ogy and a cath lab environment from a radiology
technologist perspective” as an example of the skill
set required of staff focused on operating the tech-
nology in this type of environment.
OR staff no longer perceive the hybrid room as dif-
ferent from any other room, McGowan says. When
it was new, some people took a dim view of the hy-
brid 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 collabo-
ration 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 Massachu-
setts General Hospital. MGH has two 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
Capitalizing on the New Wave of Hybrid ORs
 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 natu-
rally took ownership as a team, not as individuals.”
The original core group helped integrate new mem-
bers of the team, providing education, training, and
support to get everyone up to speed, notes Scott Far-
ren, nurse manager of vascular and neuro services.
“I think because of the team building that had hap-
pened ahead of time and the lessons learned during
the simulations [we had a good start],” agrees Fer-
guson. “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 equip-
ment 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 pro-
cedures. At MGH, a limiting factor in the original
hybrid OR was the OR table. “When we designed
our two new vascular hybrid ORs, we had the op-
portunity 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 vascu-
lar hybrid ORs has made planning for and design-
ing a new cardiac hybrid OR a very positive experi-
ence for all.”
McGowan likewise sees hybrid ORs in a positive
light: “The newer rooms have a lot of capabilities
Capitalizing on the New Wave of Hybrid ORs
with the beds and the C-arm—you can actually do
other cases in the room, so it does allow you to [ar-
gue] the business case pretty quickly.”
Farren estimates that the MGH hybrid ORs accom-
modate 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 lim-
ited 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 sur-
gery suite. However, with the benefit of hindsight,
Schatz says, he would approach planning differ-
ently 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. Technol-
ogy 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.
OR Manager Special Report 9
 “We did this for the new building to engage the clin-
ical staff at the very beginning of the design pro-
cess,” 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
10 OR Manager Special Report
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
Capitalizing on the New Wave of Hybrid ORs
 Specialized equipment serves hybrid and standard ORs equally well
The advanced audiovisual and imaging equipment
used in hybrid operating rooms allows clinicians
to complete minimally invasive and interventional
procedures in less time, leading to improved patient
safety and outcomes.
But this equipment is not just for hybrid rooms. It
can also enhance efficiency and increase physician
satisfaction when placed in regular ORs.
While awaiting completion of 10 new ORs, Sarato-
ga Hospital in Saratoga Springs, New York, needed
to upgrade an existing OR for minimally invasive
and robotic procedures.
The 170-bed facility had a steel building struc-
ture that didn’t allow for monitors and equipment
booms to be suspended from the ceiling. The small
OR also lacked space for an audiovisual equipment
closet where the hardware for a visualization sys-
tem would normally be located.
A multidisciplinary team responsible for choos-
ing equipment for the 10 new ORs began evalu-
ating different options for the existing OR. They
decided on a floor-mounted boom that could be
easily installed with only a couple of days’ down-
time.
The boom has four high-definition monitors with
touchscreen-controlled visualization that routes and
displays signals from cameras, endoscopes, naviga-
tion systems, ultrasound, C-arms, PACS (picture
achieving and communication) systems, and other
input sources. It also has visualization system hard-
ware enclosed, so a separate equipment closet isn’t
needed.
“These booms are not just for hybrid ORs, they
benefit any room,” according to Sharman Lisieski,
BS, RN, CNOR. “Your nurses will no longer be
‘hunters and gatherers’ because all of the equipment
that used to be on separate towers is consolidated on
shelves on the boom,” says Lisieski, director of the
OR and PACU (postanesthesia care unit) at Sara-
toga Hospital.
Because nurses are not moving towers full of equip-
ment in and out of the room, turnover times have
decreased and on-time starts have increased, she
says. In addition, she says, “the images the boom
Capitalizing on the New Wave of Hybrid ORs
provides are phenomenal. It is a complete satisfier
for both nurses and surgeons.”
Outfitting older rooms
The floor-mounted boom is a good way to outfit an
older or smaller room with advanced imaging tech-
nology in a cost-effective manner, says Lisieski.
For ceiling-mounted booms, all of the wiring has to
go into the ceiling. Those booms may be impossible
or difficult to install because of lack of space.
With the floor-mounted booms, all of the wiring is
easily accessible in the back of the unit. The visu-
alization hardware also is in the back of the unit
rather than having to be housed in a closet outside
the OR.
“Our experience with the floor-mounted boom is
that it has the same amount of flexibility as ceiling-
mounted systems,” notes Lisieski. The relationship
between the patient and equipment shelves is the
same because of the cord length of the cameras.
“As long as the monitor booms can reach where the
surgeon needs them, either boom style works,” she
says.
The vendors came into the hospital and were avail-
able to the staff until everyone was trained on the
boom.
Adding new rooms
The boom eventually will be moved to one of the
new ORs, and then another four rooms will also be
video-integrated rooms for minimally invasive sur-
gery. Eventually two interventional rooms will be
added.
“Even though we are not to that interventional
stage, there are many advantages to this boom,”
says Lisieski.
For example, “when we do a laser lithotripsy we
have the four monitors around the OR table—we
put our PACS on number 1, the patient’s x-rays on
number 2, and then we can put the endoscope im-
age and C-arm image side by side on number 3 and
number 4,” she says. “It really is a sweet system.”
OR Manager Special Report 11
 Another example of its versatility is that at the end
of a case the surgeon can view x-ray images on one
of the monitors from a patient in the emergency de-
partment (ED) who may need urgent surgery and
have a telephone consultation with a radiologist or
ED physician. All x-rays are digital and can be seen
on any monitor.
12 OR Manager Special Report
“For OR managers, this equipment is worth look-
ing into, depending on what their needs are,” says
Lisieski. “If they are looking for a way to get video
integration into their ORs in a small, tight spot, it
could be the answer.”
—Judith M. Mathias, MA, RN
Capitalizing on the New Wave of Hybrid ORs
 Endovascular hybrid ORs in community hospitals: Driving success
Endovascular hybrid operating rooms are no longer for ECRI Institute. “Technology supports practice,
limited to university medical centers, as commu- it doesn’t drive it.”
nity hospitals expand their cardiovascular services.
According to Dorothy Urschel, MS, MBA, RNFA,
ACNP-C, NEA-BC, three main trends are stimulat-
New procedures
ing the growth of hybrid ORs: “Cardiac surgery is In its report “Hybrid Operating Rooms with a Focus
becoming less invasive, interventional cardiology on Endovascular Hybrid ORs,” ECRI Institute says
is becoming more invasive, and vascular surgery hybrid ORs are a good fit for high-risk, minimally
continues to be minimally invasive and use catheter invasive cardiovascular procedures that require ad-
techniques combined with radiology techniques.” vanced imaging and may require transition to open
Urschel is cardiac and vascular service line director surgery.
at St Peter’s Health Partners, a system of four com-
Skorup, who says that “advanced imaging” typically
munity hospitals in Albany, New York.
refers to an angiography system—as opposed to CT
ECRI Institute, which assists hospitals with strate- or MRI—points to approval of the Sapien (Edwards
gic planning and technology assessment, has seen Lifesciences) transcatheter aortic valve in 2011 as a
about a 10% annual growth in requests related to major stimulus for endovascular hybrid ORs. Trans-
hybrid ORs among its 3,500 hospital members. The catheter aortic valve replacement (TAVR) “exempli-
trend of more hybrid ORs—including those in com- fies what a hybrid OR is all about,” he says. “It’s not
munity hospitals—is likely to continue. a traditional vascular intervention. We’re not per-
forming an open procedure or reinforcing a vessel
But a successful hybrid program requires careful
with a stent; we’re replacing a surgical procedure by
analysis and planning by a multidisciplinary team.
performing a procedure through a catheter.” Before
“Start with the patient, and work your way back to
TAVR, nearly a third of patients with severe aortic
determine what you need,” says Thomas Skorup,
disease weren’t candidates for surgery, so adding this
MBA, FACHE, vice president of applied solutions
new procedure has expanded the mar-
ket—and saved lives. “One random-
Where the money goes ized, controlled trial showed that TAVR
Imaging equipment is the largest expense when building a hybrid significantly reduced mortality rates at
OR—typically at least half of the cost. 1 year and at 2 years,” Skorup says.
Other procedures typically performed
Where the Money Goes in an endovascular hybrid OR include
combination coronary artery bypass
Imaging Equipment: $2M graft (CABG)/percutaneous coronary
5% 3% Construction: $1M**
7% intervention (PCI) and endovascular
OR Equipment: $0.4M
Life Support Equipment: $0.3M aneurysm repair. At St Peter’s Health
Audio/Visual Equipment: $0.2M Partners, physicians perform a wide
10%
Surgical Equipment: $0.1M range of procedures, including stent
50% **Typical construction costs can graft placement and various types of
range from $0.5M to $2M.
aortic surgery.
Imaging equipment is the Biplane (9%)
25% largest expense when building “It’s amazingwhat you can do,” says
a hybrid OR—typically at least Urschel. “We have doubled the num-
half theSingle Plane, Ceiling (27%)
total cost.
ber of procedures we anticipated when
we were in the planning stage.” Block
Single Plane, Floor (64%)
time is 75% efficient. Although their
Source ©2013 ECRI Institute hybrid room is not exclusively for

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 13

 A Siemens Artis Zeego imaging system with a Maquet A hybrid OR at St. Peter’s Health Partners in Albany,
table at Methodist Sugar Land Hospital in Texas. New York.

endovascular procedures, most cases are vascular.
Urschel notes a number of factors have contributed
to the program’s success, starting with multidisci-
plinary 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 one 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 one 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.

Examples of procedures done in endovascular hybrid ORs

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

14 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs

 Equipment needs
In addition to the usual OR equipment, the hybrid
OR required the following:
nn Radiologic C-arm device/angiography unit
nn Hybrid operating table
nn Video monitors
nn Control room
nn Contrast injector
All this equipment means that hybrid ORs are typ-
ically about 500 sq. ft. larger than traditional ORs.
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 environ-
ment,” he says. “You have to determine how the
procedure will flow.” Of course, building manage-
ment 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 pro-
tection. 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 busi-
ness 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 ven-
dor to have early discussions with a single person
who then becomes an advocate for a particular sys-
tem and is not open to other options. Urschel adds
that visiting other facilities with hybrid ORs helps
identify what works and what doesn’t.
Capitalizing on the New Wave of Hybrid ORs
Elements to include in a business
plan for a hybrid OR
nn Executive summary
nn Strategic objective/planning
nn Program development overview (timeline)
nn Marketing
nn Technology review
nn Forecast of expected volume
nn Case mix (type and number of expected cases)
nn Planning considerations (eg, construction needs)
nn Equipment needed
nn Supplies
nn Financial impact
Source: Dorothy Urschel
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 sup-
ply 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 car-
diology 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 anesthesiolo-
gist and anesthesia technician, vascular and car-
diothoracic surgeons, interventional cardiologist,
OR Manager Special Report 15
 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 interven-
tional 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 hy-
brid OR. The technicians take call.
To educate staff, Chalupa had a radiology techni-
cian 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 three dry runs
before the first case. The dry runs turned up prob-
lems: 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 physi-
cian and anesthesia preferences.
Competency
Skorup notes that data show a “strong correlation
between a recommended number of procedures
16 OR Manager Special Report
and maintaining competence” for surgical robot-
ics teams, and he expects that to extend to trans-
catheter 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 re-
imbursement for TAVR. These include specific vol-
ume guidelines for the cardiovascular surgeon and
the interventional cardiologist.
On the horizon
Before looking ahead, Urschel recommends look-
ing 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 con-
tinue expanding. Skorup expects to see more mul-
tiple interventions for individual patients. “Some
centers are doing vessel verification after a CABG
procedure,” he says. He adds that physicians in Eu-
rope are performing transcatheter mitral valve re-
pair, and he expects the procedure to emerge in 2
to 3 years.
—Cynthia Saver, MS, RN
References
Centers for Medicare and Medicaid Services. Decision Memo
for Transcatheter Aortic Valve Replacement (TAVR) (CAG-
00430N). May 1, 2012.
ECRI Institute. Hybrid Operating Rooms with a Focus on
Endovascular Hybrid ORs. 2013.
Capitalizing on the New Wave of Hybrid ORs
 Include infection prevention in your hybrid OR design
If a hybrid operating room is likely to be part of your
hospital’s future, a critical part of the planning is to
decide where it will be located. Variables such as
available space, funding, and type of procedures to
be performed will drive the decision, but a common
component of all hybrid OR projects—whether new
constructions or renovations—is infection prevention.
“Infection prevention needs to be a part of the de-
sign process, not just the department that you con-
tact when you need to have an ICRA [infection con-
trol risk assessment] form completed,” says Heather
Hohenberger, BSN, RN, CIC, CNOR. As the qual-
ity improvement coordinator, perioperative services
at Indiana University (IU) Health, Hohenberger is
trying to raise awareness about the importance of
infection prevention when designing hybrid ORs.
In January 2012, she was involved in assessing the
hybrid room that opened in 2010 within the cardiac
catheter lab space at Riley Hospital for Children, a
freestanding pediatric academic center that is part
of the IU Health system. Her observations and rec-
ommendations led to elimination of surgical site
infections (SSIs) among hybrid patients as well as
changes in workflow and staff training.
“Infection prevention provides the guiding principle
for what barriers need to be in place for a demoli-
tion, renovation, or any type of construction process
to decrease the risk of infection from the dust and
debris,” she explains.
These efforts protect not only existing patients but
also future patients. “If infection prevention staff
aren’t involved from the onset, the potential for re-
work increases,” she notes.
Cath lab conversion
Riley Hospital has 14 ORs located in a section of
the hospital that was built in the mid-1980s, where
pediatric neurosurgery, cardiovascular, orthopedic,
general, gastrointestinal, genitourinary, and ENT
procedures are performed. Little space and block
time were available among those ORs and the cath
lab equipment was becoming outdated, so the deci-
sion was made to open a hybrid room within the
cath lab space.
Capitalizing on the New Wave of Hybrid ORs
Cardiologists approached hospital leaders, and once
approval was granted, a biplane was purchased for
fixed angiography and a control room and equip-
ment room were built. Monitors for fluoroscopy,
patient data monitors, an injector, a sterile back
table, a Mayo stand, anesthesia equipment, and me-
chanical ventilation equipment were needed along
with diagnostic tools for cardiac procedures.
A new exterior wall was built to allow space for the
additional equipment, Hohenberger says.
Design and construction teams met weekly with the
end users, equipment manufacturers, and contrac-
tors. Infection prevention staff, however, weren’t
consulted as a part of the design process until af-
ter initial demolition, when questions about air ex-
changes and room ventilation raised concerns about
converting to open procedures.
A hybrid room, especially if it’s built in an interven-
tional radiology (IR) or cardiac cath lab space, must
have a minimum of 15 air exchanges per hour, Ho-
henberger says. A Class A operating room has 15 air
exchanges per hour, and class B and C rooms must
have a minimum of 20 per hour. The architect—and
likewise the end users (nurses, cardiologists, and
hospital leadership)—may be unaware of the differ-
ences in infection prevention requirements between
diagnostic and open surgical procedures.
“If conversion to an open procedure is needed, the
room must be designed to provide the required
number of air exchanges for that procedure,” Ho-
henberger emphasizes. “If you’re renovating an
old cardiac cath lab space, you need to know how
many air exchanges exist because you may need to
increase that number.”
Staff training
When a hybrid OR is located in a cath lab or IR
area, staff must be trained in the infection preven-
tion measures that are second nature to OR staff.
“Infection prevention efforts start when a patient
comes into the room, not when a diagnostic proce-
dure changes to a surgical procedure,” Hohenberger
says. This mindset reflects a fundamental difference
OR Manager Special Report 17
 between OR staff and those who work in other de-
partments.
“If you’re in a cath lab space, make sure staff know
it’s not just a diagnostic procedure, it’s a surgical
intervention. Little things like wearing a surgical
mask while walking from the control room to the
procedural space and thinking about sterility in the
entire environment—not just the table but the whole
field—are important,” she notes. “We shouldn’t just
assume that people know this.”
Among the topics that should be covered during
training are:
• operative attire
• hand antisepsis
• setting up the sterile field
• patient skin prep
• draping techniques
• traffic patterns
• surgical conscience.
At Riley, there wasn’t a designated educator for
the cath lab/hybrid room staff when the new room
opened in 2010. Later on, concern about the occur-
rence of SSIs among patients treated in the hybrid
room prompted cardiology and the medical director
of infection prevention to request observation of the
procedures performed within the space. In January
2012, Hohenberger observed the hybrid staff and
recommended some changes. Since then, there have
been no SSIs from that area.
What changed? Hohenberger says they needed to
“go back to the basics” of infection prevention. An
OR educator was brought in to provide orientation
checklists such as how to perform a proper hand
scrub.
18 OR Manager Special Report
Because the room location and nature of the proce-
dures differ among hospitals, there is neither a con-
sistent staffing matrix nor workflow, Hohenberger
points out. Workflow is specific to each facility, and
the location and surgical specialty utilizing the hy-
brid room dictate the staffing needs.
“If the hybrid room is in the OR space, there will
be a circulator and a scrub nurse trained specifically
for that room, but in a cardiac cath lab space, there
may be a team that’s available by page to come as
needed—for example, a cardiac cath RN acting in a
circulator role, or another RN scrub helping to pass
instruments to the operating or diagnostic team,”
she explains. Anesthesiologists and physicians are
the only consistent staff.
Lessons learned
Efforts to raise awareness about infection preven-
tion efforts among hybrid room staff fostered a
sense of collaboration and understanding between
the hybrid and OR teams. “By building a relation-
ship with the OR staff, hybrid staff were able to see
that they weren’t alone—there’s a larger group of
people who understand the kinds of issues they have
while providing patient care,” Hohenberger says.
“If you’re looking to open a hybrid room, opening
it within the OR is the best option because it elimi-
nates so many factors that could eventually cause
problems,” she adds. “Each facility is different, and
for some it may be necessary to open the hybrid
room within a cath lab or IR space, so it’s impor-
tant to understand the infection prevention practices
that need to be in play at the very beginning of the
process.”
—Elizabeth Wood
Capitalizing on the New Wave of Hybrid ORs
 Perceptive leadership fosters collaboration among hybrid OR staff
The expanded volume of interventional cardiology
in recent years has played a major role in the growing
prevalence of hybrid ORs. As a result, many periop-
erative services leaders have had to develop systems
for managing hybrid ORs along with traditional ORs.
“Management of hybrid ORs is really a collision
of traditional hospital management and service line
management,” says David Wyatt, MA, MPH, BSN,
RN, CNOR.
“We are starting to talk seriously about the business
case for hybrid ORs, along with interprofessional
standards and how we are staffing these rooms,”
says Wyatt, administrative director of perioperative
services at Vanderbilt University Medical Center
(VUMC), Nashville, Tennessee.
Cardiovascular services has been at the forefront
of service line development, with the focus primar-
ily on getting cardiac surgeons and cardiologists to
work together to refer patients to the hospital. “For
many years, that did the trick,” says Wyatt.
But now more procedures are being performed in
the cath lab than in the OR, and cardiac surgeons
and interventional cardiologists are credentialed
to do some of the same procedures. These changes
have created tension between surgeons and cardiol-
ogists, and turf wars have cropped up not only in the
cardiovascular world but also in neuro intervention,
which is performed by neurologists, neurosurgeons,
and neuroradiologists.
“The neuro intervention specialties are even more
complicated to deal with than cardiac,” notes Wy-
att, “because they don’t have the background in col-
laboration that cardiac has had over the years.”
Collaboration between service lines
Successful management of hybrid ORs and their
utilization begins with collaboration between the
service line and operations administrators, notes
Wyatt.
A cardiology (service line) nurse administrator and
Wyatt, the perioperative (operations) administrator
share the top spot on the management structure for
cardiac hybrid ORs at VUMC (sidebar, p 20).
The director of the cath lab, electrophysiology (EP)
lab, and cardiac surgery reports to both Wyatt and the
cardiology administrator, and a matrix report goes to
both service line and operational management.
This management structure also holds true for the
neuro and vascular hybrid ORs, with Wyatt as the
operations administrator over all 3.
The service line approach is very provider- and
patient-centric, notes Wyatt. Though service line
administrators may not fully understand operations,
they do understand how to promote the flow of re-
ferrals between physicians and the hospital, how to
bolster collaboration among physicians, and how to
ensure optimal patient flow through the system, he

Key Stakeholders
Ownership
§ Determine primary room use
§ Determine the project owners as soon as possible!

Specialist EP Cardiothoracic Interventional Interventional Vascular Neurosurgeon

Surgeon Cardiologist Radiologist Surgeon
• Common •Diagnostic § CABG • Diagnostic § Balloon § AAA § Aneurysm
Procedures Studies § Aortic valve caths Angioplasty § TAA coiling
•PCA replacement • PTCA, PCI § Aortic § CAS § Intracranial
Pacemaker § Mitral valve • Peripheral Aneurysm § Peripheral stenting
Implants repair angioplasty, § Stenting angioplasty, § CAS
•ICD Implants § VAD stenting § Carotid stenting § Intra-arterial
•Arrhythmia implants Atherectomy Stenting § Peripheral TPA
•Ablations § Transplants § Biliary bypass
Drainage
§ Line
Placement
§ Vertebroplasty

Capitalizing on the New Wave of Hybrid ORs OR Manager Special Report 19

 says. On the other hand,
the service line ap- Cardiac Hybrid Suite Management Structure
proach can become too
costly for the system. Cardiology Perioperative
Administrator Administrator
“We have had to bal-
ance moving forward
with new technology
and services for our
patients without drain- Director
Cath & EP Lab, Cardiac
ing our resources,” says
Surgery
Wyatt.
Each new request for
hybrid technology has
Cath Lab Cath Lab Cardiac
brought forth change in
Assistant Assistant Surgery
how business is done in
manager manager Manager
the OR and the need for
a more systematic ap-
Change Change Change Change Change
proach to collaborating Nurse Nurse
Nurse Nurse Nurse
with services perform-
ing image-based proce-
dures. Source: Vanderbilt University Medical Center, Nashville, Tennessee.

“For example,” he says,
“biplane imaging technology is tremendously ex-
pensive, and you really have to think systematically
about who will be using it or there may not be a
return on investment.” VUMC has a stroke program
that is highly dependent on hybrid ORs because of
the need for biplane imaging by the neuro special-
ists. Cardiac and vascular specialists may also use
biplane or single plane imaging.
Before building new hybrid rooms, Wyatt says, they
look at which specialists would potentially use the
rooms, the like procedures they perform, the like
equipment they use, and the best placement for each
room (sidebar).
Placement of hybrid rooms, equipment is key
Several years ago, VUMC built its first hybrid room
adjacent to the cath lab on the first floor. The main
OR suite (with 35 rooms) is on the third floor.
“When the cardiac nurses and anesthesiologists had
to venture off the third floor, they were out of their
comfort zone,” says Wyatt. “It took them a while
to get comfortable doing coronary bypass surgery
on the first floor because they knew if they ran into
an emergency situation, the cath lab staff weren’t
much help, and they couldn’t go next door to get
help.”
In early 2014, VUMC opened 4 new hybrid rooms
on the fifth floor of the hospital—2 are used primar-
ily for EP cases and 2 primarily for interventional
cardiology cases, and the surgeons are able to use
any of them for open cases if necessary.
The third floor main OR suite has a neuro interven-
tional hybrid room and a vascular hybrid room. An-
other neuro interventional and potentially a cardiac
surgery hybrid room will be built on the third floor
this year, and the urologists also want a room, says
Wyatt.
The rationale for building the cardiac hybrid room
on the third floor is that it will allow cases that are
primarily surgical with some imaging rather than
cases that are primarily imaging with the potential
for open to be performed close to the rest of the
cardiac surgery and anesthesia teams.
“When we built our first hybrid OR on the first
floor, we learned a lot about space and placement of
equipment,” notes Wyatt. Cardiologists were more
involved in the initial design than was the surgical

20 OR Manager Special Report Capitalizing on the New Wave of Hybrid ORs


In the Cardiac Hybrid Suite,
Collaboration is Key
Combining the tools of the Operating Room and the Cath Lab to
provide care to an increasingly complex patient population
Source: Vanderbilt University Medical Center, Nashville, Tennessee.
team, and the perfusionists had limited space for the
pump and their equipment. “The perfusionists had a
lot more input in our design of the fifth-floor hybrid
rooms,” he says.
Input from the anesthesiologists is also important,
he adds. “Placement of anesthesiology equipment
can make or break you.”
Wyatt recommends having a construction crew
build a mock room. Then move as much equipment
as possible into the mock-up to see how everything
fits.
“Your construction manager may not understand
that a column that juts out of the wall only 12 small
inches can [radically affect] placement of your ster-
ile field and the anesthesiologists’ equipment,” he
says.
VUMC hybrid rooms are typically larger than non-
hybrid rooms. Wyatt recommends targeting a space
that is 1,000 sq ft in order to accommodate the
equipment and staff required to do these complex
cases.
Capitalizing on the New Wave of Hybrid ORs
“The room will look as big as a
football field when it is empty, but
when all of the equipment is in, it
looks so crowded it is amazing,”
he says (photo).
Cross-training teams is
challenging
Historically, when an interven-
tional team and an OR team are
both working in the same room
for a hybrid case, 1 team is doing
nothing while the other team is
working.
“This made us start thinking
about how to have more versatile
teams and cross-training staff,”
says Wyatt. A new interventional
hybrid team model was designed
that included staff competencies
and standards of practice.
The difference in standards of
practice between specialties
caused problems early on. For
example, in cases that are primar-
ily image-based, radiation exposure is a concern.
Radiation detection devices need to be placed at
the point where the team members are at the high-
est risk—their hands—so they wear radiation de-
tection rings under their gloves.
Because AORN recommends against wearing rings
under sterile gloves, this practice made OR staff un-
comfortable. “We had to educate the OR staff on
the balance between putting staff and physicians at
a higher risk by not allowing them to wear the de-
tection rings or going against the standards,” says
Wyatt.
On the other hand, staff from the interventional set-
tings sometimes found themselves involved in pro-
cedures that changed from percutaneous to open,
and they did not have the skill sets to assist in these
procedures. “They had to learn the supplies and
equipment and sterile technique needed to transi-
tion from a percutaneous to an open procedure.”
Cross-training began with staff from the cath lab;
however, they found working in the OR challeng-
OR Manager Special Report 21
 ing and they had low competency scores. “What
we failed to take into consideration was that people
work in the cath lab because they like to do cath
lab procedures, and people work in the OR because
they like to work in open procedures,” says Wyatt.
Forcing OR staff to work in an environment where
they are limited to handling wires and balloons all
day is not satisfying for them. Taking nurses out of
the cath lab or interventional suite where they were
used to doing a variety of things, such as providing
sedation and monitoring patients, was too big of a
shift for them.
22 OR Manager Special Report
Instead of cross-training all staff, Wyatt says, they
had to change their strategy and be more selective
of the people they cross-trained.
“I have had to realize, the hybrid arena is a dif-
ferent world,” says Wyatt. “People are working in
new practice settings and with standards of practice
that are new to them. We have to think very clearly
about that and be sensitive to those differences to
foster the collaboration needed to manage hybrid
rooms successfully.”
—Judith M. Mathias, MA, RN
Capitalizing on the New Wave of Hybrid ORs
 Building the business case for a hybrid OR
Hybrid ORs are proliferating in response to mar-
ket, surgeon, and even patient demands, but build-
ing the business case for this technology can be
challenging.
“It’s a very expensive proposition,” says Lynne
Ingle, MHA, BS, RN, CNOR, project manager for
Gene Burton & Associates, a healthcare technol-
ogy consulting company in Franklin, Tennessee,
and a former director of surgical services. Costs
can average from $3 million to $6 million, accord-
ing to data from ECRI Institute and The Advisory
Board Company.
With that much money at stake, the natural first
question is, “Does our hospital need a hybrid OR?”
When answering this question, OR managers should
keep in mind that a hybrid OR is a long-term invest-
ment; short-term profits are unlikely.
Staying competitive
“I think we’re at the point that you need a hybrid
OR to be competitive,” says Deborah Rideout,
BSN, RN, CNOR, director of perioperative servic-
es at Southcoast Hospitals Group in New Bedford,
Massachusetts. The first hybrid OR in this four-fa-
cility system opened in New Bedford in 2008, and
another one is being built at their Fall River site.
About 230 cases per year on average are performed
at the New Bedford site.
Rohit Inamdar, senior medical physicist at ECRI
Institute, agrees with Rideout. “Even if you are a
small facility, minimally invasive surgery is here to
stay, so if you don’t get on board with a hybrid OR
or cath lab, you will be left behind,” says Inamdar,
who has consulted with many hospitals developing
hybrid rooms. “You need a hybrid OR to keep your
cardiac surgery program.”
Although academic medical centers remain the
most common site, Inamdar has seen a growing
number of hybrid ORs being installed in commu-
nity hospitals.
If hybrid ORs are a growing trend, how can OR
managers build a business case that provides a rea-
sonable return on investment? Inamdar says pro-
gram, staffing, and patients form a three-legged
Capitalizing on the New Wave of Hybrid ORs
This hybrid OR opened at Southcoast Hospitals Group in
New Bedford, Massachusetts, in 2008.
(Photo courtesy of Helio Rosa, Southcoast Hospitals Group.)
stool that supports the business case for a hybrid
OR (sidebar).
Ensuring a robust program
Inamdar recommends that anyone considering a
hybrid OR first determine if the facility has a ro-
bust open-heart surgery program for valve replace-
ment, given that currently the primary procedures
performed in the hybrid OR are transcatheter aortic
and mitral valve replacement (TAVR, TMVR).
OR managers should also consider other potential
future uses of the hybrid OR. At Inova Fairfax in
Falls Church, Virginia, for example, the endovascu-
lar hybrid OR began as a location for TAVR, but has
since expanded to include endovascular aneurysm
repair, says Anne Cochrane, MSN, RN, CNOR, in-
terim director of the cardiovascular OR. “You want
to set up the room so it can be used for anticipated
future procedures,” she says.
Planned future use also affects design and equip-
ment needs. For instance, Ingle says, “Some neuro-
surgeons want a biplane [angiograph imaging sys-
tem], but endovascular surgeons use a single plane,
and some neurosurgeons are OK with a single plane
and don’t need a biplane.” These decisions will af-
fect costs.
The geographic location of the hybrid room affects
the bottom line. “CMS [Centers for Medicare &
Medicaid Services] says you have to do TAVR in
OR Manager Special Report 23
 Creating the business plan
Writing a business plan isn’t done in isolation, says
Deborah Rideout, BSN, RN, CNOR, director of
perioperative services at Southcoast Hospitals Group
in New Bedford, Massachusetts. “It takes a team to
collect the information you need and put it into one
packet.”
The team should include surgeons, and staff from
business, finance, engineering, imaging, and biomedi-
cal, among others. Typically the plan projects break-
ing even at 5 years.
“Sales reps can be helpful in identifying break-even
points,” says Anne Cochrane, MSN, RN, CNOR,
interim director of the cardiovascular OR at Inova
Fairfax in Falls Church, Virginia.
Elements to consider when writing the plan include:
nnMarket intelligence. Rideout suggests answering
questions like, Who else in the region has a hybrid
OR? Where are they drawing the patients from?
nnMarket share. Estimate what market share the hos-
pital is losing because of not having a hybrid OR
and whether the hospital has strong enough refer-
ral relationships.
nnPatient-related data. This includes payer mix and
expected volume, including what percent of current
cases will be converted into hybrid cases. Forecast
predicted reimbursement based on payer mix and
note savings from reduced length of stay.
nnConstruction. Consider if you can upgrade an exist-
ing OR or if you need to create a new one, keeping
in mind that a hybrid OR averages 1,100 square feet,
compared to 600 square feet for a standard OR.
nnEquipment. To avoid missing something, meet with
a hybrid room to receive reimbursement,” Inamdar
says. CMS lists additional qualifications needed for
reimbursement, including volume requirements.
Third-party payers are also providing incremental
reimbursement for TAVR. In 2014, CMS approved
a technology add-on payment to cover TMVR.
To support the hybrid OR, the program must be
supported by a good relationship with primary care
physicians who will refer patients. “If you have
good vascular surgeons but don’t have any primary
care alliance, you could find yourself with an empty
24 OR Manager Special Report
hybrid team members, including surgeons and ra-
diology staff, as well as vendors. Ask vendors for
names of hospitals to call, and go on site visits. Use
a bidding process to obtain the best price.
nnUpgrades. “It’s best to plan for software and hard-
ware upgrades on a rolling basis 5 to 10 years out
so you have a good idea as to future capital ex-
penses,” Cochrane says. “It’s not just the expenses
up front.” The finance department can help with
depreciation estimates, and the sales representative
would be able to provide upgrade time frames.
nnSupplies. The cost of implants such as those used
in TAVR are significantly higher than the grafts
used in an open procedure, so the plan will need
to include expenditures for stock. “Until you are
doing the program for about a year, you have to
purchase the implants instead of buying on con-
signment,” Cochrane says. She adds that it’s key to
work with the finance department to ensure sup-
plies are billed; some hospitals have set up a line
item for a hybrid procedure.
nnTimeline. Lynne Ingle, MHA, BS, RN, CNOR,
recommends targeting no more than 6 months for
making the decision as to what system to select. “It
gives you time to make site visits and get people
in agreement, but not so much time that you lose
momentum,” says Ingle, project manager for Gene
Burton & Associates, a healthcare technology
consulting company in Franklin, Tennessee, and a
former director of surgical services.
Cochrane also recommends working with finance to
determine allocation of revenue and supply charges.
For example, if a cardiologist and a surgeon are doing
a case, who receives credit? Also, block scheduling is
necessary for efficient operation of the hybrid.
room,” Rideout says. “You have to have strong pri-
mary care alliances.”
Getting support from the experts
“You should have cardiac surgeons who have expe-
rience and expertise with TAVR because these pa-
tients are considered high risk,” Inamdar says.
For hospitals without TAVR experience, CMS re-
quires cardiovascular surgeons to have performed at
least 100 career aortic valve replacements (AVRs),
Capitalizing on the New Wave of Hybrid ORs
 including 10 high-risk patients, or at least 25 AVRs
in 1 year, or at least 50 AVRs in 2 years, which in-
clude at least 20 AVRs in the last year before TAVR
initiation. Hospitals may need to recruit cardiovas-
cular surgeons or interventional cardiologists to
meet these numbers.
Surgeons need to maintain volume to ensure con-
tinued reimbursement. CMS requires the surgeon
and hospital to complete at least 20 TAVR proce-
dures in a year, or at least 40 TAVR procedures in
2 years. The agency also has volume requirements
for interventional cardiologists and the hospital’s
cardiac catheterization lab. For example, the cath
lab must perform at least 1,000 catheterizations per
year, including at least 400 percutaneous coronary
interventions per year.
In addition to physicians, CMS lists other mem-
bers who must be part of the team, including echo-
cardiographers, imaging specialists, heart failure
specialists, cardiac anesthesiologists, intensivists,
nurses, and social workers.
Above all, says Ingle, “The most critical part is hav-
ing physician champion.”
Identifying eligible patients
To analyze potential patient volume, Rideout sug-
gests asking, “What is the market share that we
aren’t getting because we don’t have a hybrid OR?”
It’s helpful to list cases that will be done immedi-
ately in the hybrid OR and those that will be added
later.
“Look at the length of stay for those patients, and
work with your business partners in the organiza-
tion to calculate what the savings would be if those
patients could be discharged sooner,” she adds.
Cochrane, who has several years of OR experience
in a variety of OR settings, says the surgeons are
good predictors of volume. “They really know their
market and where their referral base is,” she says,
adding, “It’s better to underanticipate than overan-
ticipate the numbers.”
Because a limited number of procedures currently
require a hybrid OR, hospitals can run into financial
difficulties. “There can be a positive profit margin
with TAVR, but it’s very small,” Inamdar says, not-
ing that many facilities may struggle to break even.
Capitalizing on the New Wave of Hybrid ORs
Part of the difficulty is that only a small number
of patients are currently eligible for the procedure,
and those who are eligible are also high risk. “The
national TAVR pool is about 20,000 to 30,000 in the
entire US,” Inamdar notes.
Reimbursement for the procedure from CMS rang-
es from $27,000 to $56,000, depending on the pa-
tient’s severity and how he or she is treated. Consid-
ering that the TAVR valve costs just over $30,000
and that the procedure cost ranges from $50,000 to
$80,000, it’s clear that a hybrid OR “is not a money-
making machine,” Inamdar says.
“If you’re armed with talented physicians who are
aligned with you, have a solid cardiovascular pro-
gram, and a market share that is validated to be
leaving the area because you’re not offering certain
services—that’s a good case for a hybrid OR,” says
Rideout.
Making the numbers work
Because of the expense, it’s not easy to make the
numbers work for a hybrid OR. “But because it [a
hybrid OR] has become a standard, you have to find
ways of being fiscally prudent while you’re doing
it,” Rideout says.
One way of saving money is to choose vendors
wisely, Ingle says. If, for instance, the cath lab is
already using equipment from Toshiba, the OR
manager might be able to obtain a discount by pur-
chasing Toshiba equipment for the hybrid OR. “You
will have multiple vendors, so coordination is really
important,” she adds.
If your cardiac surgery program isn’t large enough
for a hybrid OR, Inamdar suggests considering a
hybrid cath lab or adding a hybrid interventional
radiology (IR) suite.
The downside is that these rooms still require the
staff, supplies, and sterility needed in the OR. “But
it’s doable and it’s a lower price option,” Inamdar
says.
Ingle adds, “My philosophy is that it should be
behind the red line of the OR in case you have to
open the patient, but I’ve seen it done both ways.
It’s something hospitals have to discuss.” She notes
that remodeling an existing OR is less expensive
than building a new one.
OR Manager Special Report 25
 To maximize the use of the hybrid OR, Inamdar
recommends OR managers work with other phy-
sicians such as vascular surgeons, neurosurgeons,
and electrophysiologists, who use angiography im-
aging systems. “You might be able to consolidate
so you need fewer labs, and improve your financial
equation a bit,” Inamdar says.
Keep in mind that when not in use for its hybrid
capabilities, the OR can be used for certain other
cases. At Inova, for instance, “the hybrid OR is built
so it can be used for any patient who requires a by-
pass pump,” Cochrane says.
Ingle reports that hybrid OR use is being expanded
at many hospitals to include spinal and total joint
replacement surgery, as well as other cardiovascular
procedures, as physicians increasingly tap into the
value of good imaging for a variety of procedures.
Another option for reducing costs is to choose a re-
furbished angiography imaging system. Facilities
that are downsizing or upgrading their systems may
be trading in systems that are less than 5 years old.
Inamdar says the typical life span of these systems
is 10 years, so facilities could save as much as $1
26 OR Manager Special Report
million by purchasing a refurbished model. “It will
still meet your needs but won’t have all the bells
and whistles,” he says. When exploring the refur-
bished option, be sure to work with a reputable
vendor.
Envisioning the future
Inamdar notes that currently only one mitral valve
contouring system is approved for use in the United
States, but expects others currently being used in
Europe to receive approval as well, further pushing
demand for hybrid ORs. “Transcatheter devices are
a growth area, and I don’t see it slowing down any-
time soon,” he says.
—Cynthia Saver, MS, RN
References
Centers for Medicare & Medicaid. Decision memo for trans-
catheter aortic valve replacement (TAVR) (CAG-00430N).
http://www.cms.gov/medicare-coverage-database/details/nca-
decision-memo.aspx?NCAId=257.
The Advisory Board Company. System strategies for hybrid
OR investment. http://www.advisory.com/Research/Service-
Line-Strategy-Advisor/Original-Inquiry/System-Strategies-
for-Hybrid-OR-Investment.
Capitalizing on the New Wave of Hybrid ORs