Opening a Hybrid OR: Experience at St. Rita’s Medical Center

St. Rita’s is a large regional medical center that serves a 70-mile radius in the west central part of the state. It is a member of Mercy Health Partners, which includes 23 hospitals in Ohio and Kentucky. St. Rita’s and Mercy Health Partners have always been committed to bring state-of-the-art technology to the communities it serves. 

For the past 10 years, St. Rita’s has partnered with a major academic institution to provide electrophysiology services. However, this arrangement had several limitations. For example, the electrophysiologist could only be present once a week to do procedures. The distance between their main practice location and St. Rita’s also prevented the opportunity to have a continuous arrhythmia clinic in Lima. In addition, although St. Rita’s has three catheterization labs, one of which was used for device implants, simple diagnostic EP studies, and ablations, there was only a Bloom manual stimulator and simple recording system. Therefore, the majority of electrophysiology studies required treatment at the academic center. This arrangement has worked for many years, but the growth in electrophysiology cases treated at St. Rita’s or off campus is currently 400-500 per year. The hospital administration and physician leaders, recognizing the need to serve the local community and provide comprehensive electrophysiology services, made the decision to build a hybrid OR.

The hospital was faced with the decision to update one of the catheterization labs to serve as a dedicated electrophysiology lab. However, this would not meet the advances in both electrophysiology and interventional cardiology procedures. The solution for this need was to construct a new hybrid OR. 

Planning and development for the hybrid OR began two years ago. After careful analysis, the decision was made to use the Artis zeego (Siemens) imaging technology, WorkMate Claris Recording System (St. Jude Medical), and EnSite mapping system (St. Jude Medical). We also utilize the Digital O.R. (Brainlab). Careful planning was required to coordinate the integration of all these technologies. Extra steps were taken to install shielding by Siemens to reduce electrical noise. Although this was an extra cost, it eliminated the presence of electrical noise on the recording system, which is often a challenge to eliminate with new labs. 

The hybrid OR opened on October 17, 2016. All electrophysiology procedures are now performed in the hybrid OR. It is utilized for implantation of most CIEDs — we implant both MR conditional and traditional devices, as well as subcutaneous ICDs. In addition, we treat a wide range of arrhythmias, including complex ventricular tachycardia/PVC and atrial fibrillation (AF) ablations. Currently we perform most ablations with radiofrequency, although the majority of pulmonary vein isolation ablations for AF are performed with Arctic Front cryoablation (Medtronic). The ViewMate Intracardiac Ultrasound (St. Jude Medical) and NRG RF Transseptal Needle (Baylis Medical) are also used. 

We will also be utilizing the hybrid OR to perform the Convergent procedure for atrial fibrillation. I previously performed this procedure at another institution prior to the availability of this hybrid OR. There were definite challenges in performing the epicardial ablation in the OR and then transferring the patient to the EP lab for endocardial ablation. The ability to perform this procedure in a hybrid OR will be a definite advancement in care. We will also begin performing LAA occlusion with the WATCHMAN device (Boston Scientific). 

Staffing Considerations

We have 11 full-time RNs and 5 full-time radiologic technologists. All the staff had previously worked in the catheterization labs for several years. One of our radiologic technologists underwent dedicated training on the Artis Zeego (Siemens), and has been instrumental in training the other staff on the imaging equipment. Two other staff members have some basic experience with intracardiac recording and stimulation, and had on-site training from St. Jude Medical prior to starting live cases. They are actively involved with using the new equipment during cases with a clinical support technician from St. Jude Medical present for support. They are not using the EnSite mapping system at this time, but the goal is to become independent with all aspects of the WorkMate Claris and EnSite systems. The technical support personnel have also been very helpful during cases; we encourage their input and actively engage them during cases to understand the clinical reasons for performing the procedure. 

Patients arrive at the Heart and Vascular preparation and holding area at 6:00 AM. The first case usually begins at 8:00 AM. The day ends when the last scheduled case is completed or if there is an add-on case that cannot wait until the next day. Patients undergoing EP procedures, including new device implants or lead insertions, are observed overnight. 

The Cardiovascular QI manager is responsible for collecting the information and entering the data into the ICD Registry v2.2 Form. Prior to the procedure, she completes the demographics, episode of care information, history and risk factors, along with other NCD information. The form is then sent to the lab staff, and they complete any additional information not available in the EMR. All other sections of the form are completed within 1-2 days of the procedure. The data is entered into the ACC-NCDR ICD Registry online. The data collection form is then scanned into the patient’s medical record. 

Future Plans

The future goal for our new EP program is to develop independently and eventually have dedicated EP staff. Once procedure volume and scheduling constraints reach a level that cannot be accommodated by the hybrid OR alone, the plan is to convert one of the catheterization labs into a dedicated EP lab. The Convergent and LAA occlusion procedures would continue to be performed in the hybrid OR. 

Developing a dedicated electrophysiology program is a major commitment for any hospital. It is a very expensive task to undertake. Planning and execution require collaboration between physicians, administrators, engineers, and multiple vendors. In addition, it requires significant education both inside and outside the cardiovascular department. Despite the challenges a new EP program presents, it is a service that is necessary to provide comprehensive cardiac care for the community.

Disclosure: Dr. Hynes has no conflicts of interest to report regarding the content herein. Outside the submitted work, he reports being a consultant for St. Jude Medical.