Is it in your future? aving the availability of a hybrid suite cre- ates new opportuni- ties to combine endovascular and open surgery into one operative episode. The patient’s recovery time is potentially shortened, having not been exposed to multiple anes- thesia encounters and the physi- ologic stress related to multiple procedural events. Length of stay is minimized, as there’s no staging of separate procedures and no intra- procedural medical management. Finally, the cost of the care is dra- matically reduced. This new oppor- tunity 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. 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 a a a o su su su a a a o o o ties to combine endovas oc s to combine end www.nursingmanagement.com 22 May 2010 Nursing Management
Transcript
Is it in yourfuture?
aving the
availability
of a hybrid
suite cre-
ates new
opportuni-
ties to combine endovascular and
open surgery into one operative
episode. The patient’s recovery time
is potentially shortened, having
not been exposed to multiple anes-
thesia encounters and the physi-
ologic stress related to multiple
procedural events. Length of stay is
minimized, as there’s no staging of
separate procedures and no intra-
procedural medical management.
Finally, the cost of the care is dra-
matically reduced. This new oppor-
tunity 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.
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
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ties to combine endovaso cs to combine end
www.nursingmanagement.com22 May 2010 Nursing Management
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1.6CONTACT HOURS
Nursing Management May 2010 23www.nursingmanagement.com
Hybrid OR: Is it in your future?
www.nursingmanagement.com24 May 2010 Nursing Management
What’s 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 com-
bines surgical and catheter-based
intervention to treat coronary artery
disease (CAD).1 Hybrid operating
suites combine the conventions of
an OR with highly technical state-
of-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
that’s 600 to 700 square feet. Primary
components of these suites include
tables that have the capability to
slide back and forth, rotate side-to-
side, and move into Trendelenburg
and reverse Trendelenburg posi-
tions, intraoperative angiography,
and fluoroscopy equipment.2
The introduction of endovascular
procedures in the OR has changed
the way surgeons perform their pro-
cedures. They no longer are looking
at the patient’s anatomy directly, but
at images on a video screen. This
necessitates high-definition imaging
screens, equivalent to large flat-
screen TVs, which are fixed to ceiling-
mounted arms, or booms, and have
the ability to move in every conceiv-
able direction. Imaging technology
can include 3D rotational angiogra-
phy, computed tomography scanning
capability, intravascular ultrasound,
3D transesophageal echocardiogram,
magnetic resonance imaging, and
large, up to 83-inch image intensifi-
ers. 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
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 endo-
vascular procedures are performed
without major intraoperative com-
plications, more challenging cases
create an increased potential in the
number of conversions, from closed
to open procedures, that may arise.
For instance, interventional cardi-
ology is being used in simple and
complex lesions of congenital heart
disease, for which surgery remains
the treatment of choice. Transcath-
eter therapies are currently being
developed to treat valve diseases,
such as mitral valve regurgitation,
aortic stensosis, and—in 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 par-
ticular anatomic lesion.
Having the ability to work in
a suite that’s designed for a fluid
transition from percutaneous pro-
cedure to open surgery allows for
safer conversion and/or a combined
approach to treatment. Several pro-
cedures optimally performed in a
hybrid suite include:
• Endovascular repair for abdomi-
nal aorta in chronic aneurysms,
which has become a valid alterna-
tive to open repair with superior
survival.
• The combination of the surgical
epicardial approach with the inter-
ventional endocardial approach for
treatment of rhythm disturbances,
particularly in atrial fibrillation.
• Pacemakers and implantable car-
dioverter 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 isn’t restricted to cardiac
surgery. Vascular surgeons and
neurosurgeons alike have equally
developed hybrid procedures neces-
sitating higher caliber angiography
systems in the OR.4
Planning
Before planning a hybrid OR,
a clear vision for the utilization
should be established. Consid-
eration for what procedures will
be performed, how often, and by
whom will help identify key stake-
holders in the planning and design
process. Whereas one specialty,
such as cardiac surgery, may lead
the design team, other specialties,
such as trauma, orthopedic, urol-
ogy, vascular, neurology, and gyne-
cology, may also be interested and
The ability to perform
hybrid procedures
creates efficiencies
on many fronts.
Nursing Management May 2010 25www.nursingmanagement.com
should be involved in the process of
developing this suite.
A multidisciplinary team is key
to success and will require repre-
sentatives from hospital administra-
tion, engineering, architects, nurs-
ing, 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 loca-
tion, 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 considerationsEfficiencies
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 perform-
ing hybrid procedures. This breaks
down barriers related to territorial-
ity 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 nurs-
ing experts who collectively focus
on the patient’s 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 other’s
strengths to more safely manage
the patient during the procedure.
Benefits for nurses caring for these
patients during the postprocedure
phase include fewer practitioners
to interact with. With fewer prac-
titioners involved in the medical
management of the patient’s care,
there will be fewer episodes of mul-
tidisciplinary communication and
fewer opportunities for miscommu-
nication, which can only enhance
patient safety.
The Joint Commission and the
Institute for Healthcare Improve-
ment have, for years, touted the
benefits of fewer hand-offs when
communicating information regard-
ing the patient’s care. Length of stay
will be shorter, allowing care plan-
ning to be streamlined. By reducing
or eliminating the risks related to
wound-care management, inva-
sive line management, infection,
episodes of bleeding, and hemo-
dynamic or respiratory instability,
a reduction in the patient‘s acuity
will lead to less intensive nursing
care.
The organization gains efficien-
cies through combined utilization
of one operative suite. When hybrid
procedures are performed, other
operative labs aren’t utilized. This
opens the possibility for scheduling
additional work in areas such as
interventional radiology or the car-
diac catheterization or electrophysi-
ology 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 encoun-
ter with less invasive treatment,
the patient’s 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 patient’s
outcome can be mitigated or reduced.
These quality issues include extended
exposure to anesthesia, which poten-
tiates fluid imbalance, that can lead
to third spacing and overload; respi-
ratory complications, such as pneu-
monia; integumentary breakdown,
including pressure ulcers; healthcare-
associated infection; and gastrointes-
tinal setback, such as ileus.
All of these risks can be mini-
mized when hybrid procedures are
employed. Length of stay is short-
ened because the need to have mul-
tiple-stage procedures is eliminated.
Recovery time can be diminished,
particularly if an endovascular
approach is successful. Risk fac-
tors related to an open procedural
approach and longer lengths of stay,
such as bleeding and infection, are
minimized.
Hybrid OR sites
You’ll find hybrid ORs at the following healthcare facilities, to name a few:• Brigham and Women‘s 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 Children’s 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
Hybrid OR: Is it in your future?
www.nursingmanagement.com26 May 2010 Nursing Management
Interdisciplinary collaboration
between practitioners improves
communication regarding the
patient’s treatment course. Finally,
having the ability to return to their
previous quality of life can mark-
edly enhance the patient experience.
ConclusionsAs the newer technology and tech-
niques make their way into the pub-
lic’s 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 imag-
ing rooms.6 Many well-recognized
hospitals across the United States
have already made this commit-
ment 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 don’t include
payments to surgeons or adjust-
ments 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 expen-
sive 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. NM
REFERENCES1. Sutton SW. Team approach to the hybrid
operating room. The 28th annual seminar of the American Academy of Cardiovas-cular Perfusion. Hilton San Diego Resort-Mission Bay, San Diego, Calif., January 26-29, 2007.
2. Michael BM. The design and implemen-tation 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 cardiovas-cular 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 cardiovas-cular 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 gain-ing ground. The Philadelphia Inquirer. February 18, 2010.
Janet Urbanowicz and Gail Taylor are nurse managers at Jersey Shore University Medi-cal Center, Neptune, N.J.The authors have disclosed that they have no financial relationships to this article.
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_ _ _ .
1.6CONTACT HOURS
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 abouta. half the size.b. the same size.c. twice the size.d. 3 to 4 times larger.
3. Primary components of a hybrid suite includea. portable x-ray machines.b. fluoroscopy equipment.c. medical lasers.d. stationary tables.
4. Surgeons performing procedures in hybrid suites typically viewa. the patient’s anatomy directly.b. the patient’s 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 ina. 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. appendectomyb. knee arthroplasty
c. ICD insertiond. Cesarean delivery
7. Before planning a hybrid OR, which of the following should be established?a. a clear vision of useb. the financial costsc. staffing requiredd. the imaging technology to be used
8. Which is key to the success of a hybrid suite?a. surgeons as key stakeholdersb. nurses as key stakeholdersc. a medical architectural design teamd. a multidisciplinary team
9. Hybrid suite planning may take up toa. 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 dollarsb. between 1 and 2 million dollarsc. between 3 and 9 million dollarsd. over 10 million dollars
11. Benefits for nurses caring for post-hybrid procedure patients includea. fewer practitioners to interact with.b. fewer patients to care for.c. increased patient care time.d. decreased patient care planning.
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 thea. 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 excepta. 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 bya. reducing operative suite bookings.b. reducing workloads.c. scheduling additional work in non-OR testing/
16. Risks that can be minimized when using hybrid procedures include all excepta. 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 bettera. patient satisfaction.b. staff satisfaction.c. staffing levels.d. cost-efficiency.
Hybrid OR: Is it in your future?GENERAL PURPOSE STATEMENT: To provide th e 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.
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