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The MarkeTech Group

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ISSUE 1 VOLUME 14 SUMMER 2015

INTERVIEW OF THE SEMESTERHybrid room: what makes it so different? Pr. Christophe Aubé (CA) Head of Radiology Department, Angers CHU

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Interviewer: Julien Regnard (JR), TMTG Partner

JR: What kind of use do you have for the hybrid room?

CA: Just to clarify, I am not a frequent user of the hybrid room. I only used it once or twice to see how it works. I have some interventional radiology activity but almost never in this room. When the hospital opened the hybrid room, the objective was not the room itself; it was more a global approach to the concept of multi-user platform. The platform is much larger, more innovative and structuring for the hospital than just a hybrid room for cardiologists.

JR: If I understand, making everybody (all involved specialties) coming down to the platform was the primary objective?

CA: Yes, and in order to achieve that, it was decided to finalize the (purchase of the device only once everyone bought it to share the tool. We had to make sure that surgeons and radiologists would buy-in. For the radiologists, the objective was to benefit from a room with an optimal quality of images and an opportunity to perform open surgery.

JR: How was the decision taken?

CA: The idea of using a hybrid room was rooted in 2008. At that time, the need for a new vascular imaging technical platform emerged. Since we had to install a new platform, we thought we could associate surgeons to the project. We visited other hospitals to evaluate different device options. And frankly, it was somewhat disappointing; in most cases the hybrid room was not used at its full potential. In one location it was used only for vascular surgery, in another it was built with no specific goal leading to under-utilization of the "tool"; in a third location it was built for radiologists and surgeons, only they were associated afterwards; all leading to some frustrations of one or the other of the involved parties. The room is rarely used to its maximum capabilities. Therefore, after a lot of discussions and negotiations, the decision to go for a hybrid room was taken in 2012.

There are no constraints for radiologists because the hybrid room is just "too big" for them, but they are used to the tools. In contrary, non-radiologists do face the barrier of the imagery field; the room is more complex than what they are used to, so more training is required.

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JR: Is it because the interventional radiologist is midway between imaging and surgery that you took the lead on the project?

CA: For radiologists, imaging is the central device, so we make everybody come to it. It seems natural for us to share. For cardiologists, imaging is more a mean to an end. In hospitals where the room is led by interventional cardiologists, it is typically under-used.

JR: How did you manage to establish the technological choice?

CA: The technological choice for the hybrid room is more function of the integration of the equipment in the room than function of the quality of the imaging device. The most important is post-treatment, being able to use every early examination that can be done. It means PACS, RIS, image fusion, software work with and are part of the environment already in place... The idea is to guide the surgeons through the scan. Merging disciplines is very important, I want to merge my arteriography with the MRI I made earlier, in order to see exactly where I am and position myself correctly. We are looking for two things in a hybrid room; how it could be integrated in an existing room and then how to seamlessly integrate workflow and post-treatment.

JR: It means that currently, device and post-treatment software are provided by the same vendor?

CA: Yes. Everything comes from the same provider. In theory we could have selected separate building blocks but it is a waste of energy in the project, and it requires a lot of human resources and effective IT to reach the same quality of integration.

JR: How did you select that vendor?

CA: We wanted a vendor with a technical engineer available to come on site. It is the main reason why we selected this provider. With the other providers we tested, the quality of the device is equivalent but the commercial and technical supports are less effective. The decision to go with the provider was made in a dictatorial way, it would have been too time consuming to ask everybody's opinion; everyone always goes for what one knows best, not necessarily the best option. I believe that every hospital works its own way, most of the time the hybrid room is installed for one specialty and the specialty lead makes all the choices, it is inefficient.

JR: Once installed, what difficulties did you face?

CA: There are no constraints for radiologists because the hybrid room is just "too big" for them, but they are used to the imaging devices. In contrary, non-radiologists do face the barrier of the imagery field; the room is more complex than what they are used to therefore additional training is required for them to master the techniques. A radiologist should always be available to help non-radiologist specialists. Another finding is that a technologist too should be available in the room at any given time. At first, I was tempted to only have nurses in the room, but was convinced by the team of users from a hospital we visited. In this hospital they had only nurses to operate in the room; surgeons voiced that someone who really knows the room, able to manage it was compulsory. The technologist is present to help users with room specific difficulties and make sure people use the room at its maximum capabilities. In addition, in our setting, technologists are in charge of post treatment (CT, MRI…), not only in the hybrid room but in the whole hospital, making their involvement essential.

JR: And I guess it is the technologist that brings radioprotection expertise?

CA: Yes, and it is a really important point. We have two dosimeters, one active and one passive, in addition patient dose is always indicated in real time. It is unnecessary to record and display physician's radiation level because they are now aware and prepared about the risks. The hospital has trained, 3 years ago, and we rely now on a radiophysics and radioprotection unit. During any given procedure "radioprotection" is following a strict process, every 5 minutes there is an alarm that can be heard and the surgeon has to go out and say "5 minutes"; then 5 minutes later it rings again and the surgeon goes out and says "10 minutes" …etc. It is a boring but efficient process.

JR: All these organizational elements are supported by the provider?

CA: The provider participates in the training process. Vendors are typically pleased to work with us on this kind of room because it is a showcase for them. The main problem related to training is that it should be provided by highly experience and knowledgeable engineers and those are expensive. The vendor typically sends its "qualified" staff the first couple of days and then trainees or junior engineers are brought in because we need to have someone all the time at first. I did not work a lot in the room but I was not satisfied. When you ask them if you can do something, the regular answer is that they do not know and have to ask.

JR: Did you get good surprises?

CA: The first good surprise was that people understood they could share. All users understood that if they needed something another user had, they could just ask to exchange. It is a unique platform that works the same way than a grouped room. Another good surprise was the good relations established between all users; I was convinced that there will be a lot of clashes but in the end all went smoothly. I will always remember after that first procedure. One of the surgeons prone to be unsatisfied said "thank you everybody, it was a good morning", he was satisfied with the room and everybody was happy to work there.

 

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I N T E R V

JR: And bad surprises?

CA: In fact, I did not expect the room would "fail on us", the problem is the same as in any operating room, teams have to transfer the patient in another room during the intervention. In that case the provider says "we are coming" but, even if it is quick, the patient has to be moved. Moreover, it is difficult to make users consider the whole sector as an operating room. For example, in case of emergency, infarct or haemorrhage, mobile intensive care unit (SAMU) comes in a hurry and it is difficult to make their staff enter clean into the sector, without their shoes for example.

JR: Are there any specificities for this kind of platform?

CA: Regarding hybrid room legislation, it is not really clear yet; there are no strong regulatory requirements, only good practice suggestions. Even the National Health Authority (NHA) only has suggestions, no real pieces of legislation. Nothing enforces the hospital to follow the suggestions but, if the NHA comes in to control the room it can be closed down. We have an ISO 7 with good radioprotection standard and NHA came for a control and made us change a few things.

JR: Is there something that you want to have done in a different way?

CA: I would not have opened it 5 days a week right from the beginning. I would have opened progressively to get people used to an optimal filling of the room. The room is not yet used in an optimal way, for example some users have a tendency to take things for granted and could ask for staff for two hours; sadly we cannot open the room only for two hours, we book staff for at least 7 hours. However, I do not think it is the provider’s role to set this up. I sometimes need the hospital administration to say "no" and to play an authoritative role.

JR: What should be the provider’s role?

CA: Provider could be more present on two aspects; they could provide feedback on what happened in the other hospitals that installed hybrid rooms. For example, explain the reasons why the room did not work as well as expected in some institutions. They could improve technical support by providing experienced staff longer, as well as, providing strong recommendations regarding the use of the device. In our team, we have to ask everything. I think the way we are working is very rewarding for the provider; they could make more efforts to support our activity.