Hybrid ORs

By Don Sadler

The hybrid operating room is an emerging trend in health care that is worth paying attention to. Hybrid ORs offer significant benefits to both patients and hospitals.

“Several factors are motivating hospitals to build or consider building hybrid ORs,” says Anthony Borrelli, executive director of endoscopy product and marketing with FUJIFILM Healthcare Americas Corporation. “This starts with return on investment as providers have started to recognize the cost savings and ROI that come with implementing a hybrid OR.”

What is a Hybrid OR?

A hybrid OR is a state-of-the-art space that combines a traditional operating room with an image guided interventional suite. Equipped with both surgical equipment and instrumentation, along with dedicated advanced imaging modalities, hybrid ORs are designed to accommodate traditional surgical, minimally invasive and interventional procedures in the same space.

David Lyons, MD, FASA, Member, American Society of Anesthesiologists Committee on Facilities and Equipment and Division Chief, vascular anesthesiology at the University of Rochester Medical Center, explains that hybrid ORs are designed around permanently installed imaging hardware.

“This provides superior capabilities to mobile equipment, but also significantly impacts the OR space in terms of flexibility of configuration and positioning of equipment and personnel,” says Lyons.

Renee Hildebrand, MSN, CSSM, CNOR, RNFA, the director of perioperative services for Texas Health, has been involved in the construction of two hybrid ORs.

“Hybrid rooms raise the bar when it comes to department advancement and technology,” she says. “If used correctly, they’re a one-stop shop for a patient who might have required several different procedures in different departments.”

Anecdotal evidence indicates that there are only about 100 hybrid ORs in the U.S. today. However, this number is expected to increase significantly over the next decade because of a surge in patient population and growing number of interventional imaging procedures and minimally invasive surgeries.

According to Transparency Market Research, the global hybrid operating room market is expected to grow at a CAGR of 7.7% between now and 2031, reaching $1.8 billion. The report attributes this growth to a rise in the number of surgical procedures that will be performed worldwide during the forecast period.

Benefits of Hybrid ORs

Vasant Jayasankar, MD, MS, FACS, assistant clinical professor of surgery at Medical University of South Carolina and medical director of cardiac and thoracic surgery at AnMed Medical Center, has utilized hybrid ORs for a variety of complex vascular and cardiac procedures.

“These include transcatheter aortic valve replacements (TAVRs), endovascular AAA repairs, and hybrid open/endovascular procedures,” says Jayasankar. “The main benefit of a hybrid OR is the high-resolution advanced imaging capabilities, which are far superior to the traditional C-arm technology utilized in traditional ORs.”

Another benefit, says Jayasankar, is the ability to perform complex open surgeries that can’t be performed in traditional catheterization labs.

“This gives the surgeon and staff the benefits of both environments without the downsides,” he says. “And patients benefit from their providers being able to perform more advanced and complex procedures.”

Renae Wright, DNP, RN, CNOR, perioperative practice specialist with the Association of periOperative Registered Nurses (AORN) and lead author of the AORN Guideline for Minimally Invasive Surgery, points to another key benefit of hybrid ORs: a potentially shorter time to treatment.

“For unstable trauma patients, hybrid ORs offer the opportunity for concurrent imaging and operative procedures,” says Wright. “This eliminates the need for patient transport between the imaging and procedural areas because the two areas are combined into one space. And patients undergoing minimally invasive procedures could experience a shorter hospital stay and recovery, as well as less discomfort.”

Hospitals benefit from improved patient throughput since hybrid ORs can reduce or eliminate time spent waiting or in transport between imaging and procedural areas.

“There are also likely some perceived benefits associated with being able to market that you have a hybrid OR, which could attract surgeons and community attention,” says Wright.

According to Rob Fabrizio, director of strategic marketing and diagnostic imaging with FUJIFILM Healthcare Americas Corporation, a key benefit of hybrid ORs is that they drive collaborative care.

“The hybrid OR is designed for multiple specialties to work together, with imaging equipment and surgical systems all in one space,” says Fabrizio. “So, a trauma patient might receive a CT scan of the head to rule out a brain bleed while a vascular surgeon addresses his abdominal hemorrhaging or a neurosurgeon addresses his spinal injury.”

“The clinical team can work in tandem,” Fabrizio adds, “which drives the best possible collaborative care. In trauma cases, this collaborative care can be lifesaving.”

Driving Efficiency and Cost Savings

Borrelli stresses the efficiency and cost saving benefits of hybrid ORs.

“For example, if surgeons begin a laparoscopic procedure but need to suddenly switch to open surgery or endoscopic/endoluminal exploration, they can do so in a hybrid OR without moving the patient to another room,” he says. “This also improves patient safety.”

Health care providers also benefit from hybrid ORs since there’s less setup time and nurses and technologists can focus on the procedure and the patient, rather than the equipment.

Clinical teams can address more than one problem on the same patient in a hybrid OR, which leads to shorter recovery times.

“Studies have shown that patients undergoing procedures in a hybrid OR experience less risk of procedural complications and infections and reduced OR time because they don’t need to be transferred between procedures,” says Borrelli.

The biggest potential disadvantage of hybrid ORs, says Jayasankar, is that the imaging tables don’t allow for the full freedom of movement in three dimensions that a traditional operating table allows.

“This can make certain open procedures more challenging to perform in these environments,” he says.

Otherwise, the biggest drawback of hybrid ORs tends to be the initial cost of building them, along with the space requirements and staff and training expertise needed to operate them. A traditional OR is about 700 square feet but a hybrid OR requires 1,000 to 1,200 square feet to accommodate the imaging equipment, control room and separate clinical teams.

“Once these details are worked out, I don’t see any significant drawbacks to adding a hybrid OR,” says Fabrizio.

“Launching a hybrid OR is a big undertaking that requires a significant resource commitment on the part of the health care institution,” says Borrelli. “However, once the new suite is up and running, the benefits appear to be worth the investment.”

The cost of building and maintaining a hybrid OR may make them prohibitive for rural hospitals that might not have the resources.

“It also depends on the types of procedures that will be performed in the operating room,” says Wright. “Utilization of the hybrid OR could be low or it could very much be in high demand.”

“The last thing you want is an expensive hybrid OR sitting empty,” says Hildebrand.

Borrelli notes that hybrid ORs can get crowded because of the need for additional equipment and staff.

“So, it’s important to choose the right technology,” he says.

Fujifilm’s ELUXEO Surgical System allows physicians to swiftly adjust their endoscopic imaging tools, which eliminates the need for multiple equipment towers. “This makes the system a space saver and problem solver in the hybrid OR,” he says.

Hybrid OR Planning Process

As you begin the hybrid OR planning process, identify your goals for the hybrid OR, your budget for the project and what types of procedures will be performed in the space.

There’s a growing list of procedures that can be performed in hybrid ORs, including many cardiac procedures that have previously been done in a cath lab. Newer procedures being performed in hybrid ORs include TAVRs, mitral valve clipping, endoscopic abdominal aortic aneurysms and aortic arch repairs.

“Hybrid ORs allow practitioners to perform a wide range of procedures in the same environment,” says Jayasankar. “Standalone catheter-based procedures, hybrid open and catheter-based procedures, and traditional open procedures can all be done in the same room.”

Most hybrid ORs include a single-plane angiographic X-ray imaging system along with surgical equipment for open cardiac surgery. Lights must have a longer arm reach and light and boom placement must allow anesthesia staff access to the head of the table. C-arms can be either ceiling- or floor-mounted, depending on what procedures will be performed in the room.

If most procedures will be interventional, the OR table should communicate with the imaging system, but this generally isn’t necessary if the room will serve primarily as an OR. Some tables feature two tabletops: one for imaging and one for surgical procedures.

The hybrid OR should include both a live and reference monitor, along with displays at the OR table for surgeons and surgical assistants and wall displays. Well-funded hospitals may have a dedicated wall just for imaging.

Based on her experience, Hildebrand offers a number of crucial factors to consider in the planning and construction of a hybrid OR, including the following:

• Room layout: The control room needs to have full visibility of the entire patient. “Many rooms have built-in support columns that can’t be moved,” says Hildebrand.

• In-room storage: Hildebrand recommends including a storage room off one end of the hybrid OR for perfusion supplies in case you have to convert to a cardiopulmonary bypass case.

• Strategic placement of items: These include glove boxes, outlets, hand gel, clippers, white board, X-ray apron hanging posts and the surgical pause poster. “The exact placement of these items sometimes isn’t planned for until the end of the project, so they’re just put wherever there’s room, which often isn’t the best place for them,” says Hildebrand.

• Booms and lights: Make sure OR lights don’t interfere with the C-arm or booms. “And if booms are placed in the room, make sure they don’t conflict with the C-arm and monitors,” says Hildebrand.

• Bed selection: This is critical, says Hildebrand, “because some beds can interfere with the C-arm range of motion.”

• Floor color: Hildebrand recommends any floor color except blue, because “most hybrids are vascular in specialty and the primary suture used in vascular cases is blue.”

Keys to Hybrid OR Success

Wright stresses that developing a successful hybrid OR program involves more than just the design and construction of the room. It also requires developing and training perioperative team members who will work in the space.

“Team members must be comfortable with the needs of the patients receiving care in the space and know how to use the room’s technology and equipment,” says Wright. “It is the responsibility of the interdisciplinary team tasked with developing and overseeing the program to make sure there is a plan in place for hybrid OR team training.”

Jayasankar believes that perioperative team members need to have a good understanding of both the open surgery world and the catheter world.

“It can be challenging to master all aspects of both types of procedures, but I think it’s important to make the effort to learn as much as you can,” he says.

According to Lyons, there are key differences between providing anesthesia in a hybrid OR compared to a traditional OR. These are related to patient access, patient positioning and equipment positioning.

“The C-arm must be free to move, which can substantially limit physical access to the patient during the procedure,” Lyons explains. “The anesthesiologist must take this into account and ensure that all the monitors and vascular access devices are in place and appropriate for the full range of possible procedures, including endovascular or open surgery.”

“Additionally, all anesthetic and monitoring equipment must be positioned to accommodate the motion of both the patient and imaging equipment,” adds Lyons.

Another anesthesiology consideration is the fact that an angiography table typically used in a hybrid OR is limited in its mobility compared to a regular OR table. “Specifically, they are unable to flex or raise the back into a ‘beach chair’ position,” says Lyons. “Appropriate patient positioning is an important part of inducing anesthesia safely – it has a significant impact on ventilation with a face mask and the placement of a breathing tube.”

Lyons points out that the advanced imaging systems in hybrid ORs allow many procedures to be performed under sedation rather than general anesthesia.

“However, conditions can change rapidly and there may be a medical need for general anesthesia after the procedure is underway,” he says. “Given the physical restrictions of the hybrid OR, it’s important to have a plan for how this will be executed.”

Teamwork is Critical to Success

Hildebrand stresses the importance of teamwork when it comes to hybrid OR success. “There’s often a collaboration between different departments, such as the OR and cardiac cath or interventional radiology departments,” she says. “Simulations prior to a go-live date are critical with the entire team, including anesthesia and surgeons/proceduralists.”

Fabrizio stresses that a hybrid OR is only as good as the technology in the room.

“Choose a reputable technology vendor that offers next-generation imaging equipment and surgical systems with consistently proven dependability,” he says. “Look for high-performing, small-footprint compatible systems and technology that provides multiple uses, along with a vendor that delivers timely support and service.”

Wright believes more research on the outcomes of patients treated in hybrid ORs is needed to guide further development of these spaces, along with research into best practices for workflow.

“This will enable perioperative teams to maximize efficiency and productivity and optimize patient outcomes,” she says.