The hybrid operating room may look like the shiny new toy that every cardiac specialist wants, but it may also be an essential investment for the future.
Hybrid ORs are equipped with fixed imaging systems that allow physicians to perform high-risk minimally invasive endovascular procedures with real-time imaging guidance and, if needed, convert instantly to open surgery use. The short-term return on investment may be lacking, but long term, hospital executives who want to offer competitive cardiovascular care in terms of both quality and cost should have a hybrid OR or at least be planning one for the future.
So says a recent report from the ECRI Institute, a nonprofit organization that researches ways to improve the safety, quality and cost-effectiveness of healthcare technology and services. The hybrid OR may be justified for relatively few procedures today, but trends in cardiovascular care will make the room’s amenities increasingly valuable, says Thomas Skorup, ECRI’s vice president of applied solutions.
“Looking five or seven years down the road, if a hospital wants cardiovascular services to be a key service line, it is important to establish the infrastructure and reputation to be in the space, even if it means taking a bit of a loss on the investment today,” he says.
A hybrid OR costs between $3 and $4 million to assemble, on average, because it may be embedded with up to 100 different medical devices. By definition, the room includes a fixed angiographic imaging system, wall- or boom-mounted display monitors and a heart-lung bypass machine. To accommodate all the equipment, up to 1,400 square feet of space is needed—nearly double the size of a standard operating room—according to ECRI’s report. Walls must be lined with lead to protect against radiation exposure, ceiling supports must be reinforced to accommodate equipment booms, and positive pressure is required for OR-level sterility.
Consequently, the boom in the hybrid operating room business creates a big market opportunity for manufacturers, vendors and suppliers that offer the types of technologies to make the versatile OR of the future hum.
At the moment, only a few procedures require a hybrid OR. Most notably, the transcatheter aortic valve replacement, or TAVR, is appropriate for patients who are not candidates for open valve replacement. The CMS, which oversees the Medicare and Medicaid programs, recommends that two surgeons independently determine that a patient meets the criteria for a TAVR procedure.
“Depending on the hospital, the pool of patients that are truly candidates for this procedure at this time can be quite small,” Skorup says. And if that pool is too small, hospitals are in trouble: CMS will reimburse for the minimally invasive procedure only if a hospital performs at least 20 TAVR procedures a year.
Within the next few years, however, Skorup expects the range and number of procedures requiring the hybrid OR room will grow.
“These less-invasive technologies are becoming a mainstay in terms of the way in which we treat patients,” says Michael Coady, M.D., chief of cardiac surgery at Stamford Hospital in Stamford, Conn. “The technology is developing very rapidly.”
Stamford’s hybrid OR opened last November. All its competitors already had hybrid ORs, and building its own was essential to maintain Stamford’s position as a regional healthcare facility, he says.
“We have vascular surgeons using it, we have cardiac surgeons using it, we have electro physiologists using the room, and cardiac interventionists,” he says. “It is shared pretty evenly by a lot of specialists and it is being utilized on a daily basis.”
Building the room to accommodate a wide range of specialists makes the room pay off more quickly, but it requires careful planning, Skorup says. He recommends that hospitals spend at least a year planning a hybrid OR, and the first step is to identify all potential users and bring them into the planning process at the outset.
A common mistake: Asking only one specialty (e.g., cardiac surgery) to decide how to configure equipment in the room, realizing that their volume will be insufficient to justify the expense, and then inviting other specialists to join the discussion. In those situations, Skorup says, decisions have likely already been made that will limit the flexibility of the room, and either the cardiac surgeons or the other specialists will likely be disappointed by compromises that are required to accommodate everyone.
“Building in as much flexibility so that physicians know that they can have that room fit their way of treating their patients promotes patient safety,” he says. “That puts a surgeon in a position to be as successful as possible.”
Stamford Hospital’s Coady says site visits to university hospitals and competing institutions in the local community were essential to its hybrid OR success. “They gave us tours and were very honest and open about how they did it and what they could have done better,” he says. “It’s prudent not to reinvent the wheel.”