Case Study: Design, Construction, and Implementation of a Cardiac Hybrid Operating Room at Sutter Memorial Hospital in Modesto, California.
CASE STUDY - CARDIAC HYBRID O.R.
St. Francis Hospital | Roslyn, New York
Early team involvement, strong space planning yield smooth construction process for New York hospital.
HOSPITAL RENOVATES TWO TOP-FLOOR OR SHELLS TO CREATE FIRST HYBRID CARDIAC SUITE
St. Francis Hospital in New York has long been a leader in cardiac care, gaining national recognition for its heart program and being the only designated cardiac care center in the state.
In July 2011, it opened its first hybrid operating room suite as part of a comprehensive renovation of its cardiac center. The center now features the latest tools and imaging equipment, six cardiac operating rooms, and a new post-anesthesia care unit, all located next to the cardiac catheterization lab.
HYBRID OR AT A GLANCE
• Top floor of St. Francis Hospital in Roslyn, New York
• Part of a renovated cardiac center which features new equipment, six ORs and a post-anesthesia unit
• Located next to cardiac catheterization lab
• Combined two 400 square foot operating room shells
• Completely retrofitted the space to hybrid specifications
• Hired an architect with healthcare and hybrid OR experience
• Construction lasted approximately 12 months
• High-resolution multi-axis 3-D CT system
• Floor-mounted, robotically controlled
• Synchs with x-ray mapping technology
• Provides real-time images of the heart and vascular system
• Integrated video with multiple monitors in the suite
• Less than 10’ ceiling heights hampered design, equipment selection
• Merging cath lab and surgery teams required formal communication
• High quality imaging equipment quickly boosted staff demand for the facility
New techniques, increased volume drive hybrid OR decision
Rapid developments in medical equipment and the introduction of less invasive cardiac procedures spurred St. Francis’ clinical staff to pursue a hybrid facility.
Adds Richard Shlofmitz, M.D., Chairman of Cardiology at St. Francis, “It allows us to stay on the cutting edge of interventional procedures.”
To maximize the value of their new room, St. Francis envisions multiple disciplines utilizing the facility, so long as staff receive thorough training on equipment. Participating specialties include interventional cardiologists, cardiac surgeons, vascular surgeons, pediatric cardiologists, neurosurgeons and electrophysiologists.
While the price tag for a hybrid room usually exceeds the cost of its independent components, the end result can bring many benefits to an institution, and that end value made the difference for St. Francis.
“Ultimately, not only is it a more efficient use of your talent, it provides a better outcome and product to the patients,” says Newell Robinson, M.D., Chairman of Cardiothoracic and Vascular Surgery. “And, there are advantages of case referrals—traction of cases that would come to your institution hoping to be treated in a better way.”
Planning starts with commitment at all levels
Construction of the hybrid OR suite at St. Francis took roughly a year, but the planning and design process spanned a much longer timeframe. Its final roll-out coincided with the second phase of the hospital’s Master Facilities Plan, a multi-year operation.
Getting early buy-in from all stakeholders was a key component, which ultimately led to a smooth planning cycle and satisfied staff.
“You can’t dip your toe in the water,” advises Robinson, who was instrumental in championing the new facility and its benefits. “You have to study it and decide if you want to do it.”
He continues, “The first challenge is funding—convincing management, up to the level of the board, that this is economically a viable proposition.”
Robinson advises others to identify early on where investment is critical, and where savings can be achieved.
Understanding the room’s potential volume and pathology will also drive the project in the right direction, according to Richard Matano, M.D., Director of Vascular Surgery.
“One of the key components in selecting equipment is realizing what your goal is,” explains Matano. “What is the pathology you’ll be treating? You want to have the ability to treat all pathology, but knowing what you’re heavy at is very helpful.”
Adds Robinson, “Make sure you have the volume that would support a hybrid OR. You don’t want a venture where you’re getting teams working together, putting a tremendous amount of capital in, if you don’t have the volumes.”
• Obtain stakeholder commitment at project initiation
• Secure funding early
• Know where to compromise on cost
• Ensure demand exists to support the room
• Let pathology, patient focus guide decisions
Design and Construction
Ceiling height poses design challenge in OR overhaul
Once the hybrid OR received the green light, St. Francis selected an architect who had significant healthcare experience and familiarity with the hybrid OR concept. The hospital had shell operating rooms in place from earlier construction, and chose to combine two corner rooms to accommodate the new hybrid facility. This decision provided just under 1,000 square feet of work space.
Clinical and operations staff all emphasize that exceptional space planning is vital to the project’s success. Numerous site visits and discussions with equipment vendors helped educate the St. Francis team on their options.
“Physical space is a challenge,” states George Huryn, R.A., Vice President of Facilities. “Not just in length and width, but vertically. Most rooms are done in existing facilities, so you’re confined by whatever your structural ceiling heights are. That’s a problem, because there are a lot of things that go above the ceiling: duct work, medical gas piping, structural steel to hold up the hybrid equipment.”
For St. Francis, a top floor location proved the biggest construction hurdle. Ten foot clearance from floor to ceiling is the ideal height, according to Huryn.
“The type of equipment we put in required a minimum of nine foot, four-and-a-half inches, and we had just a couple inches above that to clear,” explains Huryn. “Headroom is crucial.”
In the end, lack of vertical space meant prioritizing which equipment would move on ceiling-mounted booms and finding creative alternatives to house other necessary technology.
“We just couldn’t fit everything up in the ceilings,” Huryn recalls. “You have lights, you have booms, you have large air diffusers. They all need their own swing spaces. In our case, we sacrificed the anesthesia boom. We ran flexible hoses, which allowed us clearance for some other pieces of equipment.”
• Space planning is vital to success
• Leverage site visits to see potential solutions
• Observe a ten foot minimum ceiling height for maximum flexibility
• Start equipment research early
• Prioritize the elements that must be ceiling mounted
Open Communication Resolves Conflicting Requirements
Huryn emphasizes the importance of stakeholder input in making these types of decisions.
“You can’t just leave it to the architect’s judgments,” he says. “You really need involvement from the staff. And I mean everybody: nursing, surgeons, anesthesia, perfusion. They all have to make their needs clear, and sometimes there are conflicting requirements.”
In addition to numerous team meetings, setting up a physical replica of the space enabled staff to envision the room, test potential scenarios and agree on final arrangements. St. Francis made cardboard cutouts of various devices and even had staff volunteer as mock patients.
Huryn concludes, “We probably consumed half our planning time looking at different vendors. I tell others, get your planning done early. There are dozens of decision points that you have to make for each room. It’s much easier to plan if you know what you’re going to be putting into the room early, rather than later on.”
• Create a life-size mockup to visualize final arrangements
• Input from stakeholders at all levels is mandatory
• Expect conflicting requirements; be prepared to compromise
• Vet recommendations from architects and equipment vendors with the clinical team
State-of-the-Art Imaging System Brings Clarity, Flexibility
When it came to imaging, St. Francis chose a high-resolution, multi-axis 3-D CT imaging system, which synchs with x-ray mapping technology to provide images of a patient’s heart and vascular system in real time. The unit is floor-mounted and robotically controlled.
“The imaging system has to be site-specific,” notes Robinson. “We wanted to have the ability to move imaging equipment at a moment’s notice, and utilize it for whatever we needed. Ceiling height, and sterility with cleaning overhead rails, were potential problems.”
The hybrid OR also features video integration. Monitors throughout the suite can pull up vital signs, x-ray images or real-time images through an endoscope to assist clinical staff. Remote access also allows consulting physicians, such as radiologists in other locations, to view and advise when needed.
Staff have quickly gravitated to the new technology, and praise its capabilities.
“The absolute clarity that you see is amazing, as well as a replay,” says Shlofmitz. “I have four, five, six screens up where I can see my angiogram report, echoes, CAT scans, all being shown as I’m working with a patient. The size makes it so much easier to see what you’re doing.”
Vascular surgeons like Matano appreciate the speed and control that high-quality imaging within the suite provides, which eliminates wait time for CAT scans, x-rays and ultrasounds.
Adds Shlofmitz, “You need foresight, because one of the problems is that when you see how well it works, everybody wants to get in that room. It’s amazing technology. You want to project what you’re going to need in the future, so that when you build it, you’re not regretting you didn’t do more.”
• Equipment requirements are site specific
• Choosing a floor-mounted unit addressed ceiling constraints
• Prepare for high-quality imaging to boost physician demand for the room
Staffing and Operations
Blended Heart Team Gains New Perspectives
A shared workspace means a new level of collaboration for the cardiac surgeons and interventional cardiologists at St. Francis. Blending the distinct cultures, personalities and work styles of the OR and cath lab required communication on many levels.
“We work more intimately with nurses, PA’s, CT lab, anesthesia and the surgeons. It’s been a nice collaborative effort. We have a deeper respect, a deeper appreciation for what we each do,” states Dawn Zioba, R.N., Cardiac Cathorization Lab.
“It’s taking the term ‘team’ to a much higher level than I ever anticipated in my career,” states Linda Rivenburg, R.N., who has worked as an OR nurse for more than 20 years.
St. Francis adopted formal meetings to coordinate their first procedures, a strategy that helped staff understand each other’s roles and identify potential issues.
“We spend a lot more time now preplanning procedures, preprocessing images,” explains Robinson.
“Before we never really were inclined to do it. Now, it becomes key for just about everything we do.”
Team meetings afterward gave staff an opportunity to continually refine their processes.
“The debriefing aspect after the procedure was a very important part of building this team,” states Robinson. “It’s not a matter of criticism, but bringing team members together to talk about why did this take place and what was said, why it was said.”
Adds Rivenburg, “The first seven or eight procedures, we were constantly changing where people were going to be. I can’t stress enough the importance of making sure you use the size of the room as efficiently as possible.”
Good working relationships among clinical staff also improved the transition process.
“Everybody embraced the situation,” explains Shlofmitz. “It’s exciting for us to do something new and innovative.”
George Petrossian, M.D., DIrector of Interventional Cardiovascular Procedures, adds, “There’s no question that the cath lab environment and the OR environment are two different worlds. And for this goal, they blended nicely. I have been very impressed.”
• Pre-existing positive relationships are important to the hybrid OR program’s success
• Use planning meetings to identify potential issues, boost communication
• Use formal debrief meetings to improve processes and build a strong heart team
• Expect changes in room setup, staffing to result from early procedures
Cross-Functional Collaboration Builds Respect, Skills
Robinson stresses that fear of change, of a new environment, should not derail the switch to a hybrid
“I thought there would be more resistance to coming together, to crossing over and working in a different place,” Robinson says. “That’s a benefit to anyone who’s planning this—one of the things you might fear the most is not really going to be a big issue, if planned out properly.”
In fact, both cardiologists and surgeons credit the interdisciplinary involvement with broadening their knowledge and skills, building their respect for colleagues and improving their referrals.
“I have more respect for the surgeons because I’ve seen what they do, the way they work,” says Petrossian. “And I think the same applies to them. The relationships have really grown because we know we can’t do this alone.”
• Be open, flexible and focused on a common goal
• Don’t let fear of change derail a hybrid effort; the actual transition involved much less staff resistance than anticipated
• Working together broadened skills of both surgical and interventional teams
• Hybrid environment fostered mutual respect and improved referrals
Second Hybrid Room, Increased Efficiency on the Horizon
Moving forward, St. Francis sees the hybrid OR facility as a cornerstone of an innovative heart program focused on the best possible patient care. Among its immediate goals is continuing to hone the interdisciplinary process.
“At the end of the day, we not only want to be able to do more complex things and do them better, but we want to be able to do them efficiently,” says Robinson.
The team members believe another hybrid room will happen sooner rather than later, as advanced cardiac procedures move hybrid ORs from the exception to the norm. St. Francis has a second space available that’s ready to build when volumes require it.
Likewise, with a combined heart team in place, there’s no looking back. All agree the interdisciplinary approach benefits hospital, staff and patients alike.
“If you are all working with one common goal to take care of the patient, it’s going to be good for the institution, decrease length of stay. You’re going to have a better reputation for the hospital. Patients are going to want to come back,” concludes Shlofmitz.
About St. Francis Heart Center
St. Francis Hospital, The Heart Center® is New York State’s only specialty designated cardiac center and a nationally recognized leader in the diagnosis, treatment, and prevention of cardiac disease.
This case study was created with the assistance of St. Francis Hospital and its staff. It reflects their views and experiences and is not the views of Medtronic. Results and experiences may vary .
George Huryn, R.A., Vice President Facilities
Richard Matano, M.D., Director of Vascular Surgery
George Petrossian, M.D., Director of Interventional Cardiovascular Procedures
Linda Rivenburg, R.N., Cardiac OR
Newell Robinson, M.D., Chairman, Cardiothoracic and Vascular Surgery
Richard Shlofmitz, M.D., Chairman, Cardiology
Dawn Zioba, R.N., Cardiac Catheterization Lab