Taking hybrid ORs to heart

Dr. John Byrne, chairman of the Vanderbilt University Medical Center's Department of Cardiac Surgery, says he remembers the date April 4, 2005, as if it were the birthday of one of his children.

That was the day Nashville-based VUMC's first cardiac surgery/invasive cardiology hybrid operating room opened—after six months of weekly meetings with architects—and Byrne's life hasn't been the same since.

“Our hybrid OR was among the first in the country,” Byrne says.

But he notes that “someone could have built one in the 1980s,” because all they really did was “combine 20-year-old technology with 30-year-old technology,” and he adds that the hybrid space was more a cultural breakthrough than a technological advance.

While, to most, the hybrid concept mostly involves the adding of radiology and diagnostic imaging components to the OR, the cardiology hybrid also adds the elements of the catheterization lab to the mix. In the process, Byrne says, it creates a facility that allows improved logistics, lower costs and improved patient satisfaction—and others note it also becomes a recruiting tool for top talent when it comes to medical matters of the heart.

“The idea was first met with a very high level of skepticism and resistance,” Byrne recalls. “The barriers were not the technology but the people. … The real trick was getting these people working side by side because of the traditional barriers that have separated

the specialties.”

Byrne says this merger and integration of specialties is inevitable as cardiac surgeons' techniques become less invasive and technology allows invasive cardiologists to become more aggressive.

In a report in the Jan 13, 2009 issue of the American Journal of Cardiology, Byrne and his colleagues wrote how an all-purpose cardio hybrid can be used for “every cardiovascular procedure, including traditional cardiac surgery, traditional vascular surgery, endovascular aortic procedures, electrophysiology procedures, or interventional coronary procedures.” They added that there were also financial benefits from the “synergy of teams, cross-training personnel, with overlapping of the OR team with the interventional team.”

Although construction and design costs can vary, it costs between $2.5 million and $3 million to equip an OR-catheterization lab hybrid, according to Edward Hernandez, vice president of Balfour Resource Group, a Nashville-based company that provides healthcare equipment and technology planning services.

“There's some danger of using a formula to say, ‘This type of room costs X,'” Hernandez says, because construction circumstances can have many variables. (He adds that equipment costs for neuro or vascular-specific hybrid ORs can cost from $1.75 million to $3 million to equip.)

Byrne says the space for Vanderbilt's 750-square-foot hybrid opened up when its new children's hospital opened and VUMC's existing pediatric catheterization lab moved to the new facility.

When the Smilow Cancer Hospital at Yale-New Haven (Conn.) opened in October 2009, it freed up space for a new cardio hybrid, says Ross Adam Cole, a principal with BAM Architecture Studio in New York.

“As soon as a hospital builds a new building, a game of musical chairs goes on,” Cole says.

But finding enough space isn't always easy. Byrne says at least one wall was knocked down to create Vanderbilt's hybrid, and Cole says usually 600 to 1,000 square feet is necessary for the surgical space and adjoining control room. “I've never seen anyone do this at 400 square feet,” he says.

David Miller, a principal with Earl Swensson Associates in Nashville, worked on the Vanderbilt hybrid and says the most important people to get feedback from are the project's “champion” at the institution and its equipment planner.

“We usually design these together,” Miller says, adding that most of these projects have the same starting point.

“I've learned over the years to ask the surgeon or the surgical team where they want the patient's head to be,” he explains. “When you get these basics in place, the rest of the equipment goes around that.”

Cole says one particular physician who championed the project at Yale-New Haven also wanted the patient's “mental comfort” to be given high consideration; that way the patient would not feel “like an object about to be dissected.”

The hardest part of getting a hybrid project built is the cost, according to Cole.

“Institutions have to take a deep breath,” he says, but he says the return is worth it, explaining that savings come from being able to stage two consecutive procedures, which reduces prep and recovery time and space needs. And the hybrid also frees up space, which the organization can use to develop new revenue streams.

“That's what goes on from an administrator's standpoint,” Cole says. “There's a much bigger cost savings and much bigger revenue increase that hospitals are seeing by doing it. It's really kind of a no-brainer if you look at the big picture.”

Miller says technology is the driver behind hybrid growth, but Byrne disagrees. “The technology will come and go as there will be a new camera or there will be a new device,” Byrne says. “The disruptive technology is how people are organized and how we reward and incentivize them.”