Is it in your future?

The shift from traditional open surgical modalities to percutaneous interventions requires a new type of practitioner, new technology, new teams of staff, and new surgical room designs.
By Janet A. Urbanowicz, PhD, RN, NEA-BC, CPHQ, and Gail Taylor, AAS, CCM
a aving the a availability o of a hybrid su suite crea ates new o opportunis oc end endovas ties to combine endovascular and open surgery into one operative episode. The patients recovery time is potentially shortened, having not been exposed to multiple anesthesia encounters and the physiologic stress related to multiple procedural events. Length of stay is minimized, as theres no staging of separate procedures and no intraprocedural medical management. Finally, the cost of the care is dramatically reduced. This new opportunity will allow many patients with complex disease processes to benefit from hybrid approaches that allow care to be delivered in one treatment setting, thus avoiding the issues related to multiple staged procedures.

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Hybrid OR: Is it in your future?

Whats a hybrid operating suite?

Room and equipment In medical terms, a hybrid could be defined as a mixture of therapies from different subspecialties. One example is a hybrid coronary artery bypass grafting procedure that combines surgical and catheter-based intervention to treat coronary artery disease (CAD).1 Hybrid operating suites combine the conventions of an OR with highly technical stateof-the-art endovascular imaging equipment.2 The size of these suites is significantly larger, with a typical room requiring 1,000 to 1,200 square feet, compared with a standard OR thats 600 to 700 square feet. Primary components of these suites include tables that have the capability to slide back and forth, rotate side-toside, and move into Trendelenburg and reverse Trendelenburg positions, intraoperative angiography, and fluoroscopy equipment.2 The introduction of endovascular procedures in the OR has changed the way surgeons perform their procedures. They no longer are looking at the patients anatomy directly, but at images on a video screen. This necessitates high-definition imaging screens, equivalent to large flatscreen TVs, which are fixed to ceilingmounted arms, or booms, and have the ability to move in every conceivable direction. Imaging technology can include 3D rotational angiography, computed tomography scanning capability, intravascular ultrasound, 3D transesophageal echocardiogram, magnetic resonance imaging, and large, up to 83-inch image intensifiers. All of this equipment is typically fixed in the suite and allows for ready utilization to produce very accurate high-resolution image quality. Procedural capability Patient and market forces continue to push for minimally invasive
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The ability to perform hybrid procedures creates efficiencies on many fronts.

approaches over more traditional open surgical approaches, with proven efficacy and long-term treatment benefit. These minimally invasive procedures have resulted in markedly decreased morbidity and mortality of elderly patients who would otherwise be exposed to major operative surgery.3 Although the majority of endovascular procedures are performed without major intraoperative complications, more challenging cases create an increased potential in the number of conversions, from closed to open procedures, that may arise. For instance, interventional cardiology is being used in simple and complex lesions of congenital heart disease, for which surgery remains the treatment of choice. Transcatheter therapies are currently being developed to treat valve diseases, such as mitral valve regurgitation, aortic stensosis, andin children pulmonary valve disease. For the repair of mitral regurgitation, more than 80 devices are currently under investigation and await FDA approval. In addition, CAD, for which surgical bypass grafting and percutaneous coronary artery revascularization are traditionally considered isolated options, could

benefit from a simultaneous hybrid approach, allowing opportunity to match the best strategy for a particular anatomic lesion. Having the ability to work in a suite thats designed for a fluid transition from percutaneous procedure to open surgery allows for safer conversion and/or a combined approach to treatment. Several procedures optimally performed in a hybrid suite include: Endovascular repair for abdominal aorta in chronic aneurysms, which has become a valid alternative to open repair with superior survival. The combination of the surgical epicardial approach with the interventional endocardial approach for treatment of rhythm disturbances, particularly in atrial fibrillation. Pacemakers and implantable cardioverter defibrillators, particularly biventricular systems. Lead extraction, the tenuous removal of cardiac device leads, which can now be safely removed percutaneously as an alternative to open removal. The need for hybrid operating theaters isnt restricted to cardiac surgery. Vascular surgeons and neurosurgeons alike have equally developed hybrid procedures necessitating higher caliber angiography systems in the OR.4 Planning Before planning a hybrid OR, a clear vision for the utilization should be established. Consideration for what procedures will be performed, how often, and by whom will help identify key stakeholders in the planning and design process. Whereas one specialty, such as cardiac surgery, may lead the design team, other specialties, such as trauma, orthopedic, urology, vascular, neurology, and gynecology, may also be interested and
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should be involved in the process of developing this suite. A multidisciplinary team is key to success and will require representatives from hospital administration, engineering, architects, nursing, anesthesia, surgeons of various disciplines, interventionalists, the radiology technologists who will be running the imaging equipment, and cardiac perfusionists.2 Careful planning may take up to 1 year and will include considerations for location, size, layout, equipment and technology, stock and supplies, access and scheduling, and staffing and training at a minimum. Cost will be of concern as the expense for a hybrid suite can vary between $3 and $9 million.2

Other considerations
Efficiencies The ability to perform hybrid procedures within the hospital setting creates efficiencies on many fronts. Physicians and nurses alike gain efficiencies when involved in hybrid patient-care management. Physicians from different specialties must work together when performing hybrid procedures. This breaks down barriers related to territoriality among practitioners. Rather than providing medical management in silos, practitioners must more closely collaborate when providing medical management for the patient. Nurses working in the hybrid room will have colleagues from areas of expertise outside of their own to collaborate with during the procedure. This multidisciplinary care approach not only benefits the patient by having access to nursing experts who collectively focus on the patients needs, but also allows these nurses to share their expertise and skill sets with one another. Working as a team, each nurse expert can rely on the others strengths to more safely manage
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the patient during the procedure. Benefits for nurses caring for these patients during the postprocedure phase include fewer practitioners to interact with. With fewer practitioners involved in the medical management of the patients care, there will be fewer episodes of multidisciplinary communication and fewer opportunities for miscommunication, which can only enhance patient safety. The Joint Commission and the Institute for Healthcare Improvement have, for years, touted the benefits of fewer hand-offs when communicating information regarding the patients care. Length of stay will be shorter, allowing care planning to be streamlined. By reducing or eliminating the risks related to wound-care management, invasive line management, infection, episodes of bleeding, and hemodynamic or respiratory instability, a reduction in the patients acuity will lead to less intensive nursing care. The organization gains efficiencies through combined utilization of one operative suite. When hybrid procedures are performed, other operative labs arent utilized. This opens the possibility for scheduling additional work in areas such as interventional radiology or the cardiac catheterization or electrophysiology labs. In addition, the hybrid suite should become the one stop shop where patients receive care utilizing fewer resources during their hospital encounter and, in some cases, leave the next day.5 Marketing and advertising will also promote growth through patient and physician interest in this new option, which can lead to an increase in patient volume. Quality of care By having one operative encounter with less invasive treatment,

Hybrid OR sites
Youll find hybrid ORs at the following healthcare facilities, to name a few: Brigham and Womens Hospital, Boston, MA Chester County Hospital, Westchester, NY Cooper University Hospital, Camden, NJ Jersey Shore University Medical Center, Neptune, NJ Levinson Heart Hospital, Richmond, VA Nationwide Childrens Main Campus, Columbus, OH Penn Presbyterian Medical Center, Philadelphia, PA Riverside Hospital, Columbus, OH The Hospital of the University of Pennsylvania, Philadelphia, PA The St. Joseph Hospital, Orange, CA

the patients risks are immediately minimized. This allows patients to experience a dramatic improvement in their quality of care and recovery. Several factors that contribute to a decrease in the quality of the patients outcome can be mitigated or reduced. These quality issues include extended exposure to anesthesia, which potentiates fluid imbalance, that can lead to third spacing and overload; respiratory complications, such as pneumonia; integumentary breakdown, including pressure ulcers; healthcareassociated infection; and gastrointestinal setback, such as ileus. All of these risks can be minimized when hybrid procedures are employed. Length of stay is shortened because the need to have multiple-stage procedures is eliminated. Recovery time can be diminished, particularly if an endovascular approach is successful. Risk factors related to an open procedural approach and longer lengths of stay, such as bleeding and infection, are minimized.
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Hybrid OR: Is it in your future?

Interdisciplinary collaboration between practitioners improves communication regarding the patients treatment course. Finally, having the ability to return to their previous quality of life can markedly enhance the patient experience.

Conclusions
As the newer technology and techniques make their way into the publics awareness, patients will want to take advantage of these futuristic treatment options. Hospital demand for hybrid ORs has been growing, despite the recession. The imaging component of the rooms has grown at about 17% per year compared with about 1% for traditional imaging rooms.6 Many well-recognized hospitals across the United States have already made this commitment and have been marketing to the world. (See Hybrid OR sites.) The cost of heart-bypass payment ranges from $18,408 to $40,943 on average. The newest stent pro-

cedures cost between $8,912 and $15,795. Those costs dont include payments to surgeons or adjustments that hospitals make for serving underinsured patients or training young doctors. Currently, for one hospital stay, Medicare and private insurers will pay a single rate equaling the single most expensive procedure, not for two separate procedures.7 This is strong evidence that the hybrid solution makes financial sense. Hybrid ORs are the product of two needs for most hospitals: better quality of care and better cost-efficiency. N M

REFERENCES 1. Sutton SW. Team approach to the hybrid operating room. The 28th annual seminar of the American Academy of Cardiovascular Perfusion. Hilton San Diego ResortMission Bay, San Diego, Calif., January 26-29, 2007. 2. Michael BM. The design and implementation of hybrid operating rooms. http:// www.veithsymposium.org/pdf/vei/2761.pdf.

3. Sikkink CJ, Reijnen MM, Zeebregts CJ. The creation of the optimal dedicated endovascular suite [published online ahead of print October 25, 2007]. Eur J Vasc Endovasc Surg. 2008;35(2):198-204. 4. Nollert G, Wich S. Planning a cardiovascular hybrid operating room: the technical point of view. Heart Surg Forum. 2009; 12(3):E125-E130. 5. Kpodonu J, Raney A. The cardiovascular hybrid room a key component for hybrid interventions and image guided surgery in the emerging specialty of cardiovascular hybrid surgery [published online ahead of print July 21, 2009]. Interact Cardiovasc Thorac Surg. 2009;9(4): 688-692. 6. Vanac, M. Hybrid operating rooms mean collaboration, growth for Steris Corp. MedCity News. May 21, 2009. http://www. medcitynews.com/index.php/2009/05/ hybrid-operating-rooms1. 7. Goldstein J. Hybrid procedures are gaining ground. The Philadelphia Inquirer. February 18, 2010. Janet Urbanowicz and Gail Taylor are nurse managers at Jersey Shore University Medical Center, Neptune, N.J. The authors have disclosed that they have no financial relationships to this article.

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GENERAL PURPOSE STATEMENT: To provide the professional registered nurse with information about the features and benefits of a hybrid OR. LEARNING OBJECTIVES: After reading this article and taking this test, the nurse will be able to: 1. Describe a hybrid OR. 2. Discuss the benefits of using a hybrid OR. 1. Hybrid operating suites combine the conventions of an OR with: a. invasive procedure rooms. b. endovascular imaging equipment. c. post-anesthesia care units. d. patient care units. 2. Compared to a conventional OR, a typical hybrid suite is about a. half the size. b. the same size. c. twice the size. d. 3 to 4 times larger. 3. Primary components of a hybrid suite include a. portable x-ray machines. b. fluoroscopy equipment. c. medical lasers. d. stationary tables. 4. Surgeons performing procedures in hybrid suites typically view a. the patients anatomy directly. b. the patients anatomy via microscopy. c. images through a laparoscope. d. images on a high definition imaging screen. 5. Minimally invasive procedures have resulted in markedly decreased morbidity and mortality in a. the very young. b. school-aged children. c. middle-aged adults. d. the elderly. 6. Which procedure can be optimally performed in a hybrid suite? a. appendectomy b. knee arthroplasty c. ICD insertion d. Cesarean delivery 7. Before planning a hybrid OR, which of the following should be established? a. a clear vision of use b. the financial costs c. staffing required d. the imaging technology to be used 8. Which is key to the success of a hybrid suite? a. surgeons as key stakeholders b. nurses as key stakeholders c. a medical architectural design team d. a multidisciplinary team 9. Hybrid suite planning may take up to a. 3 months. b. 6 months. c. 1 year. d. 2 years. 10. Which range best describes the cost of hybrid suites? a. less than 1 million dollars b. between 1 and 2 million dollars c. between 3 and 9 million dollars d. over 10 million dollars 11. Benefits for nurses caring for post-hybrid procedure patients include a. fewer practitioners to interact with. b. fewer patients to care for. c. increased patient care time. d. decreased patient care planning. 12. Hybrid procedures enhance patient safety through a. shorter hospital stays. b. reduced complications. c. increased time for nursing care. d. fewer opportunities for miscommunication. 13. The benefits of fewer hand-offs has been touted by the a. Joint Commission. b. World Health Organization. c. Centers for Disease Control and Prevention. d. Centers for Medicare and Medicaid Services. 14. Hybrid surgery is instrumental in all except a. reducing risks of hemodynamic instability. b. lessened intensity of nursing care required. c. reduced patient acuity. d. fewer staff needed in the OR. 15. When hybrid ORs are used, organizations can gain efficiencies by a. reducing operative suite bookings. b. reducing workloads. c. scheduling additional work in non-OR testing/ intervention areas. d. scheduling additional staff. 16. Risks that can be minimized when using hybrid procedures include all except a. hospital-acquired infection. b. stroke. c. pneumonia. d. pressure ulcers. 17. Hybrid ORs are the product of hospital needs for better quality of care and better a. patient satisfaction. b. staff satisfaction. c. staffing levels. d. cost-efficiency.

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Hybrid OR: Is it in your future?

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