HYBRID OR SUITES

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1969HYBRID OR SUITES

STUDY GUIDE

DisclaimerAORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products orservices. Although all commercial products in this course are expected to conform to professional medical/nursing standards,inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or ofthe claims made by the manufacturers.

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OVERVIEW ......................................................................................................................................4 OBJECTIVES....................................................................................................................................4INTRODUCTION.............................................................................................................................5HISTORY OF IMAGING IN SURGERY.........................................................................................5MINIMALLY INVASIVE SURGERY..............................................................................................6DECIDING TO BUILD A HYBRID OR ..........................................................................................7STAKEHOLDERS AND TEAMS ....................................................................................................7TECHNOLOGY................................................................................................................................8ROOM SIZE, DESIGN AND LAYOUT...........................................................................................9ADDRESSING POST-CONSTRUCTION CHALLENGES..........................................................10SUMMARY.....................................................................................................................................11REFERENCES ................................................................................................................................13POST-TEST.....................................................................................................................................15POST-TEST ANSWERS .................................................................................................................16

HYBRID OR SUITES

Hybrid OR SuitesTABLE OF CONTENTS

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HYBRID OR SUITES

OVERVIEWThe purpose of this study guide and accompanying video is to educate perioperative personnel about hybrid operating rooms(OR) and to review the process of planning, designing, implementing, and managing these specialized suites.

OBJECTIVESAfter viewing the video and completing the study guide, the participant will be able to:

1. Describe what a hybrid OR is2. Give examples of types of procedures performed in hybrid ORs3. Explain the factors to consider when deciding to build a hybrid OR4. Review steps involved in designing and building a hybrid OR5. Explain credentialing, training, and staffing issues related to hybrid ORs6. Understand potential pitfalls of building hybrid ORs and best ways to prevent them

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INTRODUCTION

Hybrid ORs are large, specialized sterile suites equipped withstate-of-the-art imaging equipment such as fixed C-arms,surgical robots, and computed tomography (CT) or magneticresonance imaging (MRI) scanners.1,2 Hybrid suites offerseveral potential advantages over conventional ORs. Bycombining the imaging capacity of interventional departmentswith the surgical resources of traditional ORs, hybrid ORsenable multidisciplinary teams to perform complex minimallyinvasive and open procedures in the same room and evenduring the same operative period.1-4 In addition, hybrid ORsallow physicians to decide the best surgical approach(minimally invasive, open, or a combination) at the time ofsurgery and to convert minimally invasive procedures to openprocedures if needed, without the encumbrance and risk ofmoving an anesthetized patient.1 Finally, the availability ofadvanced tools such as fixed fluoroscopy systems, CT, andMRI in the OR enables surgeons to perform immediatepostoperative assessments, increasing the likelihood ofidentifying and correcting problems immediately instead ofhaving to revise them later.5

Hybrid ORs have gained substantial popularity since the late2000s.1 This trend reflects advances in diagnostic andtherapeutic imaging, the ongoing migration of these tools intothe surgical setting, the increasing use of interventionaltechniques during cardiovascular procedures, and the mergingof fields such as neurosurgery, orthopedic surgery andmaxillofacial surgery.1,5-8 A multidisciplinary team working ina hybrid OR might combine endovascular and open surgicalinterventions to treat peripheral artery disease.4Cardiovascular and cardiothoracic procedures performed inhybrid ORs include carotid stenting, valvuloplasty, thoracicendovascular aortic repair, cardiac rhythm device and leadimplantation or explantation, pediatric aortic and pulmonarystenosis repair, and robotically enhanced minimally invasivedirect coronary artery bypass.1,2,9 Neurovascular and neuroin-terventional procedures carried out in hybrid suites include

intracranial cerebral artery stenting, coil embolization ormicrosurgical clipping of cerebral aneurysms, cerebralrevascularization for acute stroke, cerebral balloonangioplasty, microneurosurgical tumor resection, andcombined arteriovenous malformation embolization followedby microneurosurgical resection.9

But despite their clear advantages, hybrid ORs also presentsubstantial design, construction, and managementchallenges.6,7 A considerable financial investment is neededto design and furnish these spaces with the imaging andsurgical equipment needed to optimize quality of care,efficiency, and long-term goals for revenue generation.1 Inaddition, building a hybrid suite requires multidisciplinarycommunication and collaboration between numerousprofessionals such as healthcare administrators, physicians,nurses, technologists, architects and designers, general andspecialized contractors, vendors of medical and surgicalequipment, and audiovisual and other technicalconsultants.1,7,8 Furthermore, healthcare professionals who usethe hybrid OR must be fully trained in using the equipmentand must commit to building cohesive teams that arecommitted to sharing the space and addressing any conflictsthat arise.1

This guide and the accompanying video presentation brieflyreview the history of diagnostic and therapeutic imaging insurgery, examine the step-by-step process of building a hybridOR, and recommend ways to facilitate the design andconstruction process and to effectively manage the finishedspace.

HISTORY OF IMAGING IN SURGERYX-rays have been used for human imaging since theirdiscovery in 1895 by German Nobel prize-winning physicistWilhelm Röntgen.10,11 Röntgen attached electrodes to a metalcoil to generate a strong electrostatic charge.11 Working in adarkened room, he directed these rays of energy through atube sealed in a thick black carton. He discovered that a paper

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plate coated with barium platinocyanide would turnfluorescent when placed up to two meters away from thedischarge tube. When Röntgen placed objects between thetube and the plate, he observed that images formed on the platethat resembled cross sections of the objects. The first“röntgenogram” (later termed a diagnostic radiograph, or x-ray) was an image of the bones, tissue, and wedding ring ofhis wife’s hand, created when she immobilized her hand onthe plate while it was irradiated.10,11

Diagnostic radiographs were first made on glass plates andlater on photographic film.12 Since then, film has largely beenreplaced by digital x-ray images. For decades after theirdiscovery, radiographs and surgery were the only methodsclinicians had to see inside the human body. But during thesecond half of the 1900s, several other diagnostic imagingtechnologies were developed. The invention of imageintensifiers and x-ray televisions in the 1950s formed the basisof fluoroscopy, which uses x-rays to create detailed, real-timestill images or video. During the 1960s, ultrasound also gainedwidespread use in fields such as obstetrics.13 In 1972, CTscans were invented, and five years later the first MRI scanof a human was performed.12

X-rays also have been used to treat human disease almostsince their discovery.12 One of their earliest applications wasas radiotherapy for skin lesions. Clinical researchers laterdeveloped techniques to treat subdermal diseases by means ofstronger x-ray machines, multiple beams, and radium.Although early radiologists used x-rays for both diagnosis andtherapy, during the 1930s radiologists began specializing ineither diagnostic or therapeutic radiology.

The surgical applications of x-rays were recognized from thebeginning.14,15 Surgeons first used radiographs to detectforeign bodies and visualize bone fractures. At that time,diagnostic radiography was performed before but not duringsurgery. Surgeons mentally reconstructed two-dimensionalradiographs into three dimensions to help them plan surgicalapproaches, alignment, and other aspects of invasiveprocedures. The advent of image intensifiers during the 1950senabled the first use of real-time imaging during surgery.15

Orthopedic surgeons used fluoroscopy to help visualize bonesduring fracture repairs. During the late 1960s, mobile C-armswere developed and subsequently became a mainstay ofimaging in the OR.8 In the 1980s, laparoscopic surgical scopeswere invented, launching the field of minimally invasivesurgery.15 Since then, the introduction of three-dimensionalimaging systems and the increased capacity and speed ofcomputers, computing networks, and digital storage mediahave further augmented the applications of radiographicimaging in surgery.

MINIMALLY INVASIVE SURGERYAdvances in clinical imaging have greatly expanded the useof minimally invasive procedures in the 21st century.Minimally invasive procedures require smaller incisions thanopen surgery and consequently can be associated withdecreased pain, faster recovery times, and lower rates ofpostoperative complications such as adhesions and surgicalsite infections (SSIs).8,16-19 Because of this, minimally invasiveprocedures often are performed on an outpatient basis orrequire shorter hospital stays compared with open surgeriesfor the same medical conditions. Advances in minimallyinvasive procedures reflect an increasing overlap betweendisciplines such as surgery, radiology, and cardiology. Thedesign and advanced imaging and surgical capacity of hybridORs help facilitate these procedures.

Numerous studies point to the advantages of minimallyinvasive approaches.16-19 In a retrospective nested case-controlstudy of 2,299 patients who underwent transforaminal lumbarinterbody fusion, laminectomy, or discectomy at a tertiary carehospital, the odds of surgical-site infection was 5.8 timeslower in patients who underwent minimally invasiveprocedures through tubular retractor systems compared withpatients who had open surgery.16

In a prospective study of 603 laparoscopic and 2,246 opencolorectal procedures, rates of SSI were fairly similar (5.8%and 4.8%, respectively).17 However, hospital readmission wasnecessary for only 4% of patients who developed post-laparoscopic infections compared with 52% of open surgerypatients with infections. Based on these findings, researchersconcluded that laparoscopic colorectal surgery is associatedwith lower morbidity rates and postoperative costs.

In a third study, a prospective randomized trial was conductedto assess clinical outcomes from open versus laparoscopicrepair of acute Achilles tendon rupture.18 The researchersreported two SSIs in the open surgery group compared withone superficial wound infection in the minimally invasivegroup. There was no significant difference in outcomes aftertwo years of follow up and no significant difference in acutepostoperative pain, range of motion, or time to return to workor sports.

Finally, researchers evaluated 80 female patients whounderwent radical vaginal hysterectomy, including 40 treatedlaparoscopically and 40 treated by means of an openabdominal technique.19 The results included a significantincrease in blood loss for the open surgical group comparedto the laparoscopic group (606 vs 343 mL, respectively,p<0.02), resulting in a more than twofold increase in thetransfusion rate for the open surgical group. In addition, open

surgery required an average operative time of 240 minutescompared to 151 minutes for laparoscopy (p=0.0001). Thetwo approaches were determined to be similar in terms ofrecurrence and complication rates.

DECIDING TO BUILD A HYBRID OPERATINGROOMPlanning and building a hybrid OR is a major undertaking.Before deciding to invest in the project, administrators andclinicians should evaluate the capacity and needs of theirhealthcare organization and develop a realistic plan of howthe space will be used.20

Budgetary considerations are often foremost. Average costsfor building a hybrid suite have been estimated at $3 to $5million.20,21 About half this amount comes from imagingequipment, and 15% is taken up by construction costs,according to an independent market analysis published in2013 by the nonprofit ECRI Institute.20 Other costs includeOR and surgical equipment (approximately 13% of total costs,or $500,000), life support equipment ($300,000), andaudio/visual equipment ($200,000).20

In addition, healthcare organizations will need to invest timeand expertise to develop detailed training protocols andcredentialing criteria for all personnel who will use the newspace.20 In some cases, additional skilled staff such asinterventional radiologic technologists will need to be hired.

Administrators and clinicians also should maintain a realisticperspective regarding the complexity of building a hybrid ORand the amount of time required. Researching and selectingequipment and planning the layout and design of the suite cantake months and requires input from numerous stakeholders.The total time from project start to finish can span 1-2 years.20

During this time period, the healthcare organization will needto pay consultants, planners, engineers, contractors, andvendors, and must absorb any losses in revenue if the projectsite was previously used for other clinical activities. Becauseof these factors, facility planners should analyze all anticipatedcosts, procedures, volumes, and reimbursements related to thehybrid OR.1 It is important to determine if the hybrid OR willbe supported by existing and future case volume.1,8

The extent of these costs means that short-term return oninvestment in a hybrid OR can be uncertain;20 however, thesesuites can represent good long-term business investments forseveral reasons. By constructing a space in which imaging,interventional, and surgical procedures can be combined,healthcare organizations can streamline workflow, which canlead to cost savings.8 In addition, hybrid ORs are designed to

better accommodate advanced and emerging techniques insurgery and interventional radiology and can facilitateinterdisciplinary teamwork between surgeons, interventionalradiologists, perfusionists, and anesthesiologists, among otherspecialties.1,20,21 This enables healthcare organizations to betterserve growing populations of patients with complexcardiovascular and neurological diseases, which can in turnprovide a competitive advantage and increase numbers ofprimary cases and referrals.8

These factors help explain an estimated 17% growth indemand for hybrid imaging systems during 2008 and 2009,compared to only a 1% increase in the market for traditionalimaging systems.8 It is projected that by 2016, most hospitalswith larger cardiac and neurosurgery services will haveplanned or implemented at least one hybrid OR.8

STAKEHOLDERS AND TEAMSAfter a healthcare facility decides to move forward withbuilding a hybrid OR, project leaders should reach out tostakeholders and convene two teams of specialists to work inclose coordination. These are the design and hospital teams,tasked respectively with designing the project and ensuringthat the finished space meets, as fully as possible, the needsof all physicians and clinical teams that will use it.7

Design and hospital teams that coordinate hybrid OR projectsare multidisciplinary by nature.7 Planning a hybrid OR is ahighly complex process, and design team members may hailfrom diverse specialties including architecture, clinicalengineering, information technology, audiovisual design, andhealthcare equipment planning.7 The design team also mightinclude technical consultants to help solve problems relatedto room acoustics or the need to minimize vibrations. Thedesign team should evaluate the technical needs of eachclinical discipline while also focusing on how to prioritizepatient-centered care, optimize workflow, and ensure safeoperations for patients and staff.

The hospital team consists of the physicians, registered nurses,

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and technical specialists who will handle cases in the hybridOR. This hospital team provides input on factors fromequipment and space needs to OR imaging support,anesthesiology services, perfusion support, workflow, andpostoperative care.7 In addition to surgeons and interventionalradiologists, it is essential that the team include registerednurses, radiologic technologists, anesthesiologists, andperfusionists to advise on equipment, room layout, andworkflow.7,8 Depending on the intended use of the room, thehospital team may include health care workers fromdisciplines such as cardiac and vascular surgery, neurology,cardiology, radiology, interventional radiology,electrophysiology, anesthesiology, and cardiovascularperfusion. Other team members may include the director ofperioperative services, the physical plant services director, thefinancial analyst, and other administrators who will beinvolved in developing the business plan and identifyingfunding sources.

One of the most important responsibilities of the hospital teamis to develop a clear and detailed plan of how the hybrid suitewill be used.8 This is important for two reasons: Hybrid ORsare too costly to use on a part-time basis,2 and the roomutilization plan will determine the needs for square footage,design and layout, and equipment.7,8

Project leaders should assemble the hospital team early in theproject planning process.8 The list of clinical stakeholdersshould be comprehensive to help minimize conflicts and last-minute requests related to room layout or equipment.

TECHNOLOGYHybrid ORs are equipped with numerous imaging andsurgical tools as well as an array of related equipment.Therefore, a major component of designing and planning ahybrid OR is evaluating and selecting devices for imaging,surgery, anesthesia, and related procedures and practices. Thedesign and hospital teams may need to convene several timesto review options for equipment, and all key stakeholdersshould be present at these meetings. Equipment selectionsshould occur early in the planning process because they affectfinal decisions about square footage, room layout, and projectbudget.20

Options for imaging equipment in the hybrid OR arenumerous. Standard fluoroscopy equipment includes fixedfloor- or ceiling-mounted C-arms or a multi-axis system witha robotic arm. These systems utilize a high frame rate andpower output and have enhanced imaging capacity comparedto mobile C-arms.2 Other options for imaging equipmentinclude CT systems, endoscopy systems such as fixed C-arms,

robotic surgery systems, MRI systems, magnetic catheternavigation systems, transthoracic and intravascular echoimaging systems, operating microscopes, and neurosurgicalnavigation systems.8 Because of the wide range of optionsavailable, it can be helpful to ask clinicians to distinguishbetween imaging equipment they perceive as essential anddevices that they would prefer to have but that could beacquired later depending on budget constraints.

The hospital teamwill also need toevaluate and selectequipment such ashybrid surgical tablesthat are optimized forminimally invasiveand open procedures;lighting for surgicaland interventionalradiology; anesthesiamachines; contrastinjectors; physiologicand hemodynamicmonitoring equipment;heart-lung bypassmachines; and surgery carts and storage systems.1,8 Advancedimaging tables are radiolucent and must contain no metal toavoid interference with reconstruction, navigation, and CTangiography.1 Some hybrid systems include a core base andinterchangeable table tops, one of which is suited for advancedimaging while the other is a breakthrough top appropriate fornon-imaging procedures.

A monitoring system must also be selected.1 This systemdisplays real-time fluoroscopy images, reference images, andreconstructed images as well as video feeds, camera outputs,and echocardiogram data. A bay of six or more flat screenpanels is typical and can be placed on equipment booms ormovable arms. Anesthesiologists, perfusionists, and nurses all

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play a role in monitoring the patient and should provide inputon types and positioning of monitoring equipment.

Before making final selections of equipment and vendors, itcan be helpful for hospital team members to visit otherfacilities with hybrid ORs.20 Site visits help cliniciansunderstand how equipment and teams perform in the hybridsuite and identify potential challenges related to projectdesign, implementation, and management. Wheneverpossible, administrators and physicians should participate insite visits so they can observe equipment firsthand and talkwith clinicians and other healthcare personnel who use it.

ROOM SIZE, DESIGN AND LAYOUTThe size, location, design, and layout of the hybrid OR areimportant considerations. Hybrid ORs require as much as1200 to 1400 square feet in area including the control roomand storage space for equipment and supplies.20 This is abouttwice the size of most standard ORs.21 In addition, a ceilingheight of approximately 15 to 16 feet is needed toaccommodate lights, booms, and ceiling-mounted imagingequipment.20 Furthermore, the hybrid OR must be wideenough to accommodate equipment and to ensure smoothworkflow even when used by sizable teams of surgeons,interventional radiologists, nurses, technologists, anesthesiapersonnel, perfusionists, and support staff.

The location of the hybrid OR should reflect the needs ofclinicians and the fact that the room must accommodatecomplex cases, multiple specialists, and large teams during asingle operative session.7 Because of space and budgetconstraints, however, there may be limited options for locatinga hybrid OR. These projects are most often remodels ofconventional operating rooms, although some facilities buildnew rooms or retrofit cardiac catheterization laboratories.1

Remodeling can be morecost-effective than newconstruction, but retrofitting anexisting space can limitoptions for square footage androom dimensions. Whethercreated through retrofitting ornew construction, hybrid ORsalso must have a positivepressure air system andlaminar airflow to achieveOR-level sterility;9 mustmeet the federal requirementfor lead line shielding forfixed fluoroscopy units;22

and may need to implementmeasures to mitigate noise orvibration from nearby airhandlers or ducts.7 In addition, the ceiling or floor may needreinforcement to accommodate the weight of fixed overheadimaging systems.

After final decisions about equipment, room size, and roomlocation are made, the design and hospital teams shouldcollaborate to determine room layout.7 This is a key aspect ofplanning because poor room design or layout can hinderworkflow and limit effective use of the space. Often it is

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helpful to design the room around the largest piece ofequipment, such as the fluoroscopy system. However, thelayout also should account for all other equipment, storage,and the workflow for each specialty that will use the room.Stakeholders should keep in mind that the hybrid ORs oftenare used by teams of eight to 20 staff. To optimize workflowand promote safe movement during procedures, a detailedplan should be drawn up that includes the footprint of eachpiece of equipment in the room as well as traffic patterns andworkflow for each specialty or major procedure.7 It may behelpful for architects and engineers to use 3-D modeling withanimated fly-throughs to help stakeholders visualize the roomwith equipment in place. Stakeholders should then providedetailed input on room layout plans.

Decisions about room size and layout can be challengingbecause they may be constrained by budgetary or physicallimitations. But whenever possible, the design and hospitalteams should also plan for contingencies such as futurechanges in caseload or the need to add equipment that requiresextra space or different space configurations.7 Examples ofcontingency planning include maximizing room dimensionsto account for larger teams in the future, ensuring that roomscan be reconfigured as needed for new types of cases, andinstalling extra fiber optic cabling to prepare for equipmentadditions.7

Designing and building a hybrid OR is a highly integratedprocess because of the amount and diversity of imaging andsurgical equipment needed. Project leaders must work withnumerous vendors, contractors, and other technical experts,all of whom must adhere to the project schedule. Somehealthcare organizations retain professional technologyproject managers to help oversee the process and ensuresmooth implementation. These persons coordinate the generalcontractor, subcontractors, and vendors responsible forconstruction, equipment procurement, delivery, installation,testing, and training. Whether or not a technology projectmanager is retained, team leaders can reduce the likelihood of

vendor incompatibility by holding weekly or biweeklymeetings of all key stakeholders and vendor representatives.5

ADDRESSING POST-CONSTRUCTIONCHALLENGES

A new hybrid suite presents several potential challenges.Training and credentialing is vital to the success of thehybrid OR, and these activities should be granted the samelevel of importance as research and decisions related to space,equipment and layout. All personnel who use the hybrid ORmust be trained in the safe and correct use of the equipment.5To ensure competency and quality, credentialing should bedeveloped for all procedures.20 In addition, personnel mustunderstand that the hybrid OR is a sterile space; should betrained as needed in sterile technique; and should consistentlywear sterile surgical attire when working in the hybrid OR inaccordance with AORN guidelines.24 Persons responsible formanaging the hybrid OR may need to devote extra time toeducating nonsurgical staff in these concepts and practices.

Radiation safety should be a major focus of training andcredentialing because hybrid ORs are often equipped withimaging equipment that uses relatively high doses of ionizingradiation, such as fixed angiography systems. Radiation safetyofficers and managers responsible for hybrid ORs should keepin mind that surgical and other personnel may not havepreviously worked with ionizing radiation and cannot beassumed to understand the risks of radiation exposure oroccupational practices that promote radiation safety.3 Trainingin radiation safety and in the safe operation of imagingequipment should be required for all personnel who work inthe hybrid OR, and credentialing and competency evaluationsshould include radiation safety practices. If feasible, radiologystaff can train other staff in radiation safety and the safeoperation of fluoroscopy equipment.9

It is important that radiation safety practices specific to thehybrid OR be a part of the facility’s overall radiation safety

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plan.2,3 In accordance with this plan, staff must consistentlyperform all appropriate practices to keep occupational dosesof ionizing radiation as low as reasonably achievable(ALARA). In addition, procedure planning should includeradiation safety practices for personnel and optimization ofradiation doses for patients. Finally, it should be noted thatsome hybrid ORs use robots to assist with catheter placement,which can potentially reduce ionizing radiation exposure forinterventional physicians.9

Staffing is also an important consideration for the hybrid OR.In general, hybrid suites require dedicated imaging staff withexperience in endovascular techniques.1,9 For this reason,some healthcare organizations hire an interventional radiologytechnologist when they construct a new hybrid OR.Radiologic technologists are able to improve image quality,storage, and retrieval; manipulate images into diverse formats;and provide 3-D colorized rotational reconstruction ofimages.1 In some facilities, these personnel also assist withplacement of sheaths and catheters during procedures.Radiologic technologists may have different experience withvarious kinds of imaging equipment, so the applicantscreening process should take into account the specificequipment of the organization’s new hybrid OR.1 It can behelpful during site visits to other facilities to ask administratorsand clinicians about their staffing decisions and theresponsibilities of personnel during various procedures.

Lack of buy-in is a potential challenge that can linger evenafter a new hybrid OR is completed. Clinicians may notinitially perceive the clinical and organizational advantagesthat hybrid suites offer such as facilitating multidisciplinarycollaboration or new approaches to complex cases.Furthermore, clinicians who do not initially buy in to theproject may later request equipment or other resources that donot fall within the agreed-upon project scope. This can result

in interpersonal conflicts and budget challenges that threatento hinder the smooth execution of the project. To help avoidsuch pitfalls, project leaders should foster buy-in early in theplanning process by clearly describing the advantages andchallenges of hybrid suites. Leaders also should carefullyacknowledge needs and concerns expressed by clinicians fromall relevant areas of clinical practice. Site visits can helpeducate stakeholders regarding the function of hybrid ORsand requirements for optimizing use of the space.20 Before andafter the finished suite is in use, metrics can be documentedsuch as the number of minimally invasive proceduresperformed, procedure times, duration of hospital stays, andrehabilitation time.23 These can enhance buy-in by providingobjective data on improvements in patient care andefficiency.23

Disputes over space, resources, and scheduling are commonpitfalls of hybrid ORs.8 Even when managed well, thesespaces can spark conflicts between individual clinicians anddepartments regarding use of the room. Hybrid suites arefurnished with state-of-the-art equipment that is valued by arange of fields and specialties. Because of this, clinicians maydisagree about room design, equipment selection or use, blocktime scheduling, and related issues, especially if clinicians areaccustomed to competing for resources or cases. If suchconflicts become entrenched, they can impede constructivecollaboration. For hybrid ORs to succeed, they must be treatedas a shared resource, not space belonging to a particularclinician or specialty. To foster this perspective, project leadersneed to focus on cohesive teamwork and collaboration fromthe project outset. Clinicians should understand that the hybridOR exists to serve patients with complex, multidisciplinaryneeds and therefore should not be monopolized by a singlediscipline or used as an overflow room. To help preventconflicts, the staff person who manages the hybrid OR alsoshould develop room usage guidelines, convene regularmeetings to schedule block time, and ensure that this schedulefairly reflects clinical caseload.8

SUMMARYHybrid suites integrate advanced imaging devices into thesterile environment of the operating room.1,2,21 When plannedand executed well, hybrid ORs can facilitate complex,minimally invasive, and interdisciplinary procedures, enhancequality of care, and potentially increase a healthcareorganization’s referrals and long-term revenue.20,21 However,hybrid suites take up a substantial amount of space (up to 1200to 1400 square feet of area and 15 to 16 feet of ceilingclearance); are complex, costly, and time-consuming to build;and must be managed carefully to optimize staffing, training,credentialing, and equipment needs.20 In light of these

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challenges, stakeholders should be involved early in theplanning process, create a detailed plan for using the space,provide ongoing feedback regarding design, layout, andequipment, and work together constructively to share thehybrid suite. Making site visits to other hybrid ORs andtalking with clinicians who use them also can helpstakeholders select the equipment and design that best meettheir needs. For the project to succeed, design and clinicalplanning teams must work closely with contractors,equipment vendors, and technical experts.7 All personnel whouse the hybrid OR should undergo training and credentialingon sterile practices in the hybrid OR, radiation safety practices,and proper use of imaging and surgical equipment.

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REFERENCES1. Schaadt J, Landau B. Hybrid OR 101: a primer for the OR nurse. AORN Journal. 2013;97:81-100.2. Nollert G, Wich S. Planning a cardiovascular hybrid operating room: the technical point of view. The Heart

Surgery Forum. 2009;12:119-124.3. Bartal G, Vano E, Paulo G, Miller DL. Management of patient and staff radiation dose in interventional radiology:

current concepts. Cardiovasc Intervent Radiol. 2013 Jul 16. [Epub ahead of print]4. Yurekli I, Gokalp O, Gunes T, Yilik L, Gurbuz A. Simultaneous hybrid peripheral re-vascularization: early results.

Vascular. 2013 Mar 21. [Epub ahead of print]5. The Advisory Board Company. Making the case for the hybrid operating room.

http://www.aameda.org/Conference/ACCA/ConfHandouts/documents/PreConIIIHybridOR2-per.pdf AccessedJuly 17, 2013

6. Gebhard F, Riepl C, Richter P, Liebold A, Gorki H, Wirtz R, König R, Wilde F, Schramm A, Kraus M. [Thehybrid operating room. Home of high-end intraoperative imaging]. Unfallchirurg. 2012;115:107-120. [Article inGerman]

7. Perry J, Katz A. Two in one: planning a hybrid operating room. Health Facilities Management.http://www.hfmmagazine.com/hfmmagazine/html/WebExclusives/WebExclusives_TwoInOne.html Accessed July20, 2013

8. Hybrid ORs: What’s behind the increasing demand? OR Manager. 2011;27:7-10.9. Odle TG. Managing transition to a hybrid operating room. Radiologic Technology. 2011;83:165CI-185CI.

10. Van Tiggelen R. Since 1895, orthopaedic surgery needs X-ray imaging: a historical overview from discovery tocomputed tomography. JBR-BTR. 2001;84:204-213.

11. The Nobel Prize in Physics 1901: Wilhelm Conrad Röntgen.http://www.nobelprize.org/nobel_prizes/physics/laureates/1901/rontgen-bio.html ccessed July 27, 2013.

12. The British Institute of Radiology. History of Radiology. http://www.bir.org.uk/patients-public/history-of-radiology/ Accessed July 26, 2013

13. University of Cambridge. Making visible embryos: Making obstetric ultrasound.http://www.hps.cam.ac.uk/visibleembryos/s7_2.html Accessed July 19, 2013

14. Assmus, A. Early history of x rays. Beam Line. 1995;10-24.15. Gieles, PM. Image-guided surgery: digital imaging as a support to patient treatment. MedicaMundi. 1995;40:54-

63.16. Ee WW, Lau WL, Yeo W, Von Bing Y, Yue WM. Does Minimally Invasive Surgery Have a Lower Risk of

Surgical Site Infections Compared With Open Spinal Surgery? Clin Orthop Relat Res. 2013 Jul 12. [Epub aheadof print]

17. Dobson MW, Geisler D, Fazio V, Remzi F, Hull T, Vogel J. Minimally invasive surgical wound infections:laparoscopic surgery decreases morbidity of surgical site infections and decreases the cost of wound care.Colorectal Dis. 2011;13:811-815.

18. Kołodziej L, Bohatyrewicz A, Kromuszczyńska J, Jezierski J, Biedroń M. Efficacy and complications of open andminimally invasive surgery in acute Achilles tendon rupture: a prospective randomised clinical study—preliminary report. Int Orthop. 2013;37:625-629.

19. Yu JJ, Yang WX, Wang XM. Laparoscopically-assisted radical vaginal hysterectomy with five years follow-up: acase control study. Eur J Gynaecol Oncol. 2013;34:156-158.

20. ECRI Institute. Hybrid operating rooms: with a focus on endovascular hybrid ORs.https://www.ecri.org/Forms/Documents/MS13084_HybridOR_Market_Analytics_Snapshot.pdf Accessed July 17,2013

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21. AORN Newsroom. Hybrid ORs set the stage for cutting-edge care. http://www.aorn.org/News.aspx?id=23287Accessed July16, 2013

22. National Council on Radiation Protection and Measurements. Structural Shielding Design for Medical X-RayImaging Facilities. NCRP Report No 147. Bethesda, MD: National Council on Radiation Protection andMeasurements; 2004.

23. Popilock R. The power of hybrid operating rooms: how to best advance surgical capabilities and competitiveposition in today’s healthcare community. http://healthcare-executive-insight.advanceweb.com/Features/Articles/The-Power-of-Hybrid-Operating-Rooms.aspx Accessed July 27, 2013

24. Association of periOperative Registered Nurses (AORN). Recommended practices for sterile technique. In:Perioperative standards and recommended practices. Denver (CO): Association of periOperative RegisteredNurses (AORN); 2012 Dec. p. e62-90.

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1. Hybrid operating roomsa. require less attention to sterile technique than in

traditional ORsb. integrate advanced imaging equipment into a

sterile OR environmentc. require about the same amount of square

footage as a traditional ORd. are less expensive to build than traditional ORs

2. Factors to consider when deciding whether to builda hybrid OR includea. whether the project budget is adequate to meet

essential costsb. how the hybrid OR will increase the

organization’s long-term revenuec. whether skilled staff are available to support

operation of advanced imaging equipmentd. all of the above

3. The average cost of building a hybrid OR (in USdollars) is closest toa. $500,000b. $1 millionc. $3 to $5 milliond. $10 to $12 million

4. The primary cost of building a hybrid OR comesfroma. imaging equipmentb. constructionc. surgical equipmentd. life support equipment

5. The average time required to build a hybrid OR isa. 3 monthsb. 6 monthsc. 9 monthsd. 1 to 2 years

6. The floor area (square footage) of a hybrid OR canbe up toa. 300-500 ft2

b. 700-900 ft2

c. 1200-1400 ft2

d. 1900-2100 ft2

7. During the early stages of planning a hybrid OR, itis MOST useful toa. invite only the most important stakeholders to

planning meetingsb. finalize contracts with vendorsc. schedule site visits at other facilitiesd. hire an interventional radiology technologist

8. Which is the BEST way to ensure smoothimplementation and results during a hybrid ORproject?a. hold quarterly meetings of vendors and key

stakeholders to keep everyone on the same pageand prevent vendor incompatibility

b. clearly agree on how the space will be usedbefore selecting equipment or designing theroom

c. finalize equipment choices at the last minute toensure purchase of the latest models

d. prevent conflicts by permitting just one or twophysicians from each department to provideinput on equipment

9. Common supervisory and management challengesrelated to hybrid ORs includea. last-minute design or equipment requests from

cliniciansb. developing competency assessments and

training programs for staffc. resolving disputes about scheduling and use of

space d. all of the above

10. To ensure competency and quality, credentialingcriteria for the hybrid OR should be developeda. for all procedures performed in the hybrid ORb. only if requested by physicians who are using

the hybrid OR c. only if requested by the manager responsible for

the hybrid OR d. based on 6 months of input from personnel who

are using the new equipment

POST-TEST

HYBRID OR SUITES

Multiple choice. Please choose the word or phrase that best completes the following statements.

HYBRID OR SUITES

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POST-TEST ANSWERS

HYBRID OR SUITES

1b2d3.c4.a5.d6.c7.c8.b9.d10.a