Hybrid OR: Planning for the Metamorphosis

In this article, the author discusses the development of a hybrid OR at the University of Michigan, which has three hybrid rooms and plans to add two more: one for the new children’s and women’s hospitals, and another in the Cardiovascular Center.

We have seen it happen before in healthcare as well as in other industries: new technologies that force changes to structure, function and personnel. However, the next technology move facing healthcare pushes even deeper into our comfort zones, demanding the melding of technologies and personnel that have traditionally lived in very different worlds — surgery- and catheter-based labs.

The evolution at the University of Michigan began with multidisciplinary clinics that put cardiologists, surgeons and radiologists in the same environment to care for the same population of patients cooperatively instead of competitively. This collegial relationship brought staff and physicians into common circles working side by side, problem solving and delivering excellent patient care. When it came time for the procedure, it was done in an environment in which the primary operator felt most comfortable, either an OR with fluoro capabilities or a catheter-based lab. This work laid the foundation for the next discussion: where to perform transcatheter structural heart procedures.

When considering all of the aspects of what is needed for a procedure of this nature, it requires a blending of the OR environment, preferred for its high sterility and preparedness for emergencies, and the catheter-based labs, which are preferred for their hemodynamic monitoring and fluoro equipment. Here at the University of Michigan, some rooms existed that had some of the desired technologies already blended into a single room, but no room had them all.

As work continued preparing for these complex cases, it became clear that the personnel is what would make the difference! No single staff had all of the needed skills — it would take them all. Staff from the OR and catheter-based labs were brought together into a common environment. Skills were identified that staff needed to cross train, including reviewing the definition of a sterile environment. OR staff and lab staff identified the roles that each would fulfill during the cases, and simulated cases were performed with all staff present (sometimes with 25–28 people in the room) to practice movement of equipment, skills, and communication between the team. Following each of the three simulated cases, a debriefing session was held in a round robin format so every team member, regardless of title, could address what they felt went well and what needed to change to help them fulfill their role better.

The two current hybrid ORs are in the Cardiovascular Center (CVC) in the OR suite. A cath lab functions as a third hybrid room (not a licensed OR) for structural heart procedures. The rooms range from 680–900 square feet. The CVC opened with one hybrid room five years ago. As demand for this type of room increased, a second room opened nearly two years ago. Minor modifications to the air flow delivery took place in this room to convert what was an interventional radiology suite into a hybrid OR. These two rooms are utilized by vascular surgeons and interventional radiologists for cases ranging from endografts to peripheral interventional cases.

As cases began in April 2011, the hard work and preparation paid off in great dividends as the staff moved in and out of procedures in a well-choreographed event. We now have two separate staff working as one to deliver superior clinical care. To date, we have performed over 20 procedures using this model of care delivery.  We initially continued with the debriefing sessions right after the cases to ensure all staff were comfortable and to discuss changes as well as improvements. 

Future Considerations

Planning teams are in place for two additional hybrid rooms — one for the new C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, and a second in the CVC. These rooms are being planned for 1500 square feet plus a control room, equipment room and storage space. The team is diverse, including facility planners, architects, surgeons (cardiothoracic and vascular), interventional cardiologists and radiologists, and anesthesiologists, along with nurses, technologists, and administrators from the OR, cath lab and radiology. To date, the team has made three site visits looking at x-ray equipment, floor plans and flow into hybrid rooms. These visits have served to build relationships among team members as well as to gain ideas from other institutions’ experiences. In addition, the team has found a comparatively sized space to walk around in to discuss door and equipment placement. The building of the room is 6–12 months into the future, and the team is confident that the end product will be a space that will be a melding of the best all areas have to offer. 

Summary

The future direction of transcatheter structural heart procedures will push healthcare facilities to critically examine their procedural spaces to be more flexible, dynamic and nimble for yet unseen technologies. There will also be the challenge of training staff to work in these highly technical and clinically intense environments.