My presentation on hybrid OR training. Conjunction with medtronic collaboration

1. The Cardiac Hybrid OR
A Platform for Collaboration
Dicky a. wartono ,md
Aortic surgical & intervension specialist
National Cardiac & Vascular Centre Harapan Kita
Jakarta 2014

2. Objectives
•Summarize key steps in the development and
operation of a Cardiac Hybrid OR
•Highlight Hybrid OR best practices
•Provide resources and references for additional
information about Hybrid ORs

3. Table of Contents
• A Paradigm Shift in Cardiovascular Care
• The Cardiac Hybrid OR
• A Platform for Collaboration
• Key Steps in Building and Operating
• References & Resources

4. A Paradigm Shift in Cardiovascular Care
Image courtesy of Maquet

5. Hybrid Cardiovascular Procedures
The number of hybrid and
minimally invasive cardiovascular
procedures is expanding rapidly
• Hybrid and minimally invasive
procedures have resulted in decreased
morbidity and mortality of elderly
patients
• Minimally invasive procedures reduce
hospital stays and recovery time
The success of these procedure has increased the need for increased
collaboration between cardiothoracic surgeons, vascular surgeons,
and interventional cardiologists
References: Byrne 2008, Kpodonu 2009, Nollert 2010
Most Common Targets of Hybrid
Cardiac Procedures

6. Multidisciplinary Cardiovascular Team
Old Paradigm Emerging Paradigm
Interventionalist
Patient
Cardiologist Surgeon
Patient
Interventionalist
Cardiologist
Surgeon
To ensure the success of the hybrid approach, the multidisciplinary team
approach has developed
– Facilitates joint pre-operative decision-making and intra-operative
collaboration between surgery and cardiology
Reference: Maisano 20120

7. The Cardiac Hybrid OR
Image courtesy of Maquet

8. What is a Hybrid OR?
• Fully equipped surgical suite that facilitates collaborative and
efficient patient care
– Combines all components of a cath lab and surgical OR
– The ideal setting to enable hybrid procedures to be done singly, sequentially, or
concurrently
Reference: Kpodonu 2009, Odle 2011
Potential Benefits
• Facilitates interdisciplinary approaches
to care
• May improve outcomes and safety
• Streamlines patient flow by eliminating
patient transfers and staging
• May increase access to care by
expanding population for specific
procedures
• Flexibility for future innovation in care
delivery and procedures
• Requires cross-specialty alignment
• Increases operational complexity
(including staffing and training)
• Large capital investment
Potential Challenges

9. 2012 ACCF/SCAI Expert Consensus
highlights the benefits of a hybrid suite:
• A Platform for Collaboration
– “Although the hybrid suite is designed to meet the needs of an
increasingly complex patient population, it also serves as a platform
for collaborative work between subspecialists.”
• Multi-functionality
– “In some hybrid suites, operators can perform cardiovascular
procedures ranging from the most straightforward PCI to aortic arch
reconstruction. As a result, different teams across different
subspecialties can benefit from the hybrid suite.”
2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert
Consensus Document on Cardiac Catheterization Laboratory Standards Update

10. “With the hybrid room, you have something that’s much greater, much
larger than each piece.
It really is amazing to see, once it comes together, how the thought
process of everybody involved changes. You’re no longer thinking in terms
of what any individual person or discipline does but really more in terms
of what we do together and that in the end is a clear benefit to the
patients.”
Newell Robinson, M.D.
Chairman, Department of Cardiothoracic and Vascular Surgery
St. Francis Hospital, Roslyn, NY

11. The Cardiac Hybrid OR
Key Steps in Building and Operating

12. Key Steps in Building & Operating a Hybrid OR
• Institutional Fit
• Financial Analysis
• Planning Team
• Vendor
Collaboration
• Site Visits
• Location & Space
• Room Design
• Table
• Imaging
• Audiovisual &
Communications
• IT System
• Staffing
• Training
• Scheduling
• Protocols
• Hybrid OR
Committee
• Inventory
Management
Phase I
Planning
Design &
Construction
Staffing &
Operations
Phase II Phase III

13. Vendor Collaboration
Institutional Fit
The following potential benefits should be considered when assessing
the value of a Hybrid OR:
•New interdisciplinary approaches to care
– Enhanced imaging capabilities enable more advanced procedures
•Potential to improve outcomes & safety
– Fewer handoffs between teams
– Fewer episodes of anesthesia
– Reduced radiation exposure and use of contrast
– Immediate surgical option possible if required as backup
•Flexibility for future innovation in care delivery and procedures
– Growing number of hybrid procedures and indications
– Hybrid OR may be especially suited to robotic procedures
Institutional Fit Planning Team Site VisitsFinancial Analysis
Reference: Odle 2011
The Hybrid OR has the potential to transform an institution’s cardiac patient care, but
increases operational complexity and requires a culture of collaboration.

14. Financial Analysis
• The cost to build a Hybrid OR typically ranges from $1-$5M
• Most projects take a total of 12-18 months for design and build.
• Institution needs to have the right type and volume of procedures
to justify the cost
• Equipment vendors can provide an ROI calculator
Not every institution will have the right type and volume of procedures to make the
project financially viable
Vendor CollaborationInstitutional Fit Planning Team Site VisitsFinancial Analysis
References: Belkin 2009, Kpodonu 2010, Deshchenko 2011

15. • MDs that will use the
facility
• Anesthesiology
• Radiology and echo
• Perfusion technician
• OR and cath lab
nurse/nurse managers
• Infection control specialist
Early collaboration among cross-functional stakeholders will help prevent design
flaws and friction
• Hospital administration
• Business managers
• Internal applications
technology specialist
• Information technology
specialist
• Architect
• Interior designer
• Internal hospital facilities
manager
• Building construction
manager
Planning Team
A large group of stakeholders needs to be brought together at the earliest
stages of the planning process
Vendor CollaborationInstitutional Fit Planning Team Site VisitsFinancial Analysis
Administration Medical Staff
Design/Engineer/
Construction
References: Hirsch 2008, Odle 2011

16. Design and Equipment Vendors
• Use of an overall designer/architect is important
• A consulting engineer can help craft detailed lists of requirements
and detailed RFPs as planning advances
• Review of proposals should include the core planning team
Because each Hybrid room is different, design and equipment vendors play a
fundamental role in helping the institution identify the room suited to its unique needs
Vendor CollaborationInstitutional Fit Planning Team Site VisitsFinancial Analysis
Reference: Hirsch 2008

17. Site Visits
• Visiting an operational Hybrid OR is an important step in the planning
process
– Dozens of decisions go into the development of a Hybrid OR
– Once the room is built, it will be difficult to make changes
– Site visits allow the team to understand the “whys” behind decisions
made by other institutions, and what they would have done differently
• Visits should include a multidisciplinary subgroup of the core
planning team.
Site visits are an essential step to help the planning team leverage the experiences of
other institutions
Vendor CollaborationInstitutional Fit Planning Team Site VisitsFinancial Analysis
Reference: Belkin 2009

18. Key Takeaways: Planning Phase
• The Hybrid OR has the potential to transform an institution’s cardiac
patient care, but increases operational complexity and requires a
culture of collaboration.
• Not every institution will have the right type and volume of procedures
to make the project financially viable
• Early collaboration among cross-functional stakeholders will help
prevent design flaws and friction
• Because each Hybrid room is different, design and equipment vendors
play a fundamental role in helping the institution identify the room
suited to its unique needs
• Site visits are an essential step to help the planning team leverage the
experiences of other institutions

19. • Institutional Fit
• Financial Analysis
• Planning Team
• Vendor
Collaboration
• Site Visits
• Location & Space
• Room Design
• Table
• Imaging
• Audiovisual &
Communications
• IT System
• Staffing
• Training
• Scheduling
• Protocols
• Hybrid OR
Committee
• Inventory
Management
Phase II
Planning
Design &
Construction
Staffing &
Operations
Phase I Phase III
Key Steps in Building & Operating a Hybrid OR

20. Location & Space
• The Hybrid room is ideally collocated near cath lab and ORs
– If ORs are separated from cath labs, it is more common to collocate near other
ORs for quick access to equipment and personnel
• If modifying or combining existing rooms:
– OR advantage is that surgical core already exists
– Cath lab advantage is that lead lining is in place
• Average room is ~1000 sq ft to accommodate people and equipment
– There may be up to 20-25 people in the room during a procedure
– Need enough space for two teams to prep
– Headroom is crucial with at least 10 feet clearance
Existing space and the cost of retrofitting will determine whether an institution should
modify or build a completely new room
Location & Space Audiovisual &
Communications
IT SystemImagingTable
References: Kpodonu 2009, Bashore 2012
Room Design

21. Room Design: Floor Plan
• Building a full-scale cardboard mockup in an unused space reveals
workflow and equipment space issues
– Vendors can develop 3D layout but this still doesn’t give as
comprehensive an understanding as a mockup
– All stakeholders need to be involved with this exercise which typically
results in changes to the room’s layout
• Flexibility and versatility of the hybrid room is very important
– Need to accommodate varying procedural requirements: different
teams, variable table positions, and various imaging modalities
• Making key decisions up front will allow team to understand, rather
than guessing, how all of the variables will work together
Making equipment and design decisions up front, along with building a full-scale
cardboard mockup of the room, will optimize the plan prior to construction
Location & Space Audiovisual &
Communications
IT SystemImagingRoom Design Table

22. Room Design: Ceiling Plan
• The ceiling plan represents one of the most
challenging steps in the planning of a
hybrid suite
• Key considerations for a very tight space
– Surgical lighting
– Monitor booms
– Laminar flow ceiling
– Cameras
– C-arm (if ceiling mounted)
• Headroom is crucial with at least 10 feet
clearance required
The ceiling plan is one of the most challenging steps requiring many components to fit into
a very tight space
Location & Space Audiovisual &
Communications
IT SystemImagingTable
Reference: Kpodonu 2009
Getty Images
Room Design

23. Table
• Table design must accommodate and optimize
usefulness and safety of imaging equipment
– Floating tables, similar to those used in the cardiac cath lab
allow full coverage of the body in most situations
– Lead shields should be incorporated into the table to
reduce radiation exposure to the operators
• Table needs to meet the requirements of both
interventional cardiologists and surgeon
– Tradeoffs will likely need to be made
– e.g. surgeon’s preference for a breakable tabletop
• Many hybrid rooms position the table diagonal to
the room in order to maximize space
The table must accommodate the needs of various stakeholders and will likely
require tradeoffs
Location & Space Audiovisual &
Communications
IT SystemImagingTable
References: Belkin 2009, Bashore 2012
Image courtesy of Maquet
Room Design

24. Imaging
• Hybrid suite imaging system will include most
advanced imaging systems for preoperative
planning and intraoperative use:
– Superior image quality
– Quick and detailed information
– Minimal X-ray exposure
– Image routing, storage and management
– Delay Obsolescence
• Displays are ideally available in all four quadrants
of the room
State of the art imaging systems may represent up to half the cost of the project
Location & Space Audiovisual &
Communications
IT SystemImagingTable
References: Kpodonu 2009, Nollert 2010
Image courtesy of Maquet
Room Design

25. Audiovisual and Communications
• Requires integration of all imaging modalities and media
• Two-way audio communication between hybrid room and control room is
important
• Real-time observation and education with remote-site conferencing are
especially important for academic institutions
• Including a telephone router allows for hands-free direct conversations
with consulting colleagues and referral physicians
Location & Space Audiovisual &
Communications
IT SystemImagingTable
References: Hirsch 2008, Belkin 2009
Room Design

26. • Image integration
– DICOM-compatible system for image transfer and archiving
– Capability to route images into and out of the room
– A PACS can allow retrieval and viewing of multi-modal images
– Angiography is very data-intensive; need to provide for storage beyond the
short-term
• EMR integration
– System should link to archived images
• Inventory-management
– RFID beginning to appear
• Scheduling software
Location & Space Audiovisual &
Communications
IT SystemImagingRoom Design Table
IT System
Reference: Hirsch 2008

27. Key Takeaways: Design & Construction
• Existing space and the cost of retrofitting will determine whether an
institution should modify or build a completely new room
• Making equipment and design decisions up front, along with building a
full-scale cardboard mockup of the room, will optimize the plan prior to
construction
• The ceiling plan is one of the most challenging steps requiring many
components to fit into a very tight space
• The table must accommodate the needs of various stakeholders and will
likely require tradeoffs
• State of the art imaging systems may represent up to half the cost of the
project

28. • Institutional Fit
• Financial Analysis
• Planning Team
• Vendor
Collaboration
• Site Visits
• Location & Space
• Room Design
• Table
• Imaging
• Audiovisual &
Communications
• IT System
• Staffing
• Training
• Scheduling
• Protocols
• Hybrid OR
Committee
• Inventory
Management
Phase II
Planning
Design &
Construction
Staffing &
Operations
Phase I Phase III
Key Steps in Building & Operating a Hybrid OR

29. Staffing: Two Models
• Dedicated multidisciplinary team model
- Members usually recruited from current OR or cath-lab staff
- Reduces redundancy
- Can be difficult to maintain over time
- Leads to the development of unique hybrid skills
SchedulingTrainingStaffing Protocols
Inventory
Management
Hybrid OR
Committee
The choice of a dedicated or flexible staffing model will be driven by the unique needs of
each institution
• Flex-team (“pooled”) model
- More common today
- Cross-training of current OR and cath-lab staff
- Requires close scheduling coordination
- Blending/integrating staffs
- May be less efficient

30. • Significant didactic and hands-on education is required
– Usually 3-6 weeks for both physicians and staff
• Cross-training gives an opportunity to strengthen relationships within
the extended team
• Conducting several full-team mock cases that cover the spectrum of
procedures is valuable
• Important to have formal full-team debriefing sessions after
procedures
Training
Training is extensive, involving both didactic and hands-on education
SchedulingTrainingStaffing Protocols
Inventory
Management
Hybrid OR
Committee

31. Scheduling
• Some centers have gone to integrated OR scheduling, with open-
block time in the hybrid
• For others, a structured approach has been more effective
– e.g. certain days per week assigned to different specialties
– Teamwork and flexibility is critical due to unpredictability of scheduling
• Priority should be given to truly hybrid cases and those possibly
requiring conversion
While Hybrid procedures should take precedent, from a practical/volume standpoint
most institutions will also need to utilize the room as a functional OR or cath lab
SchedulingTrainingStaffing Protocols
Inventory
Management
Hybrid OR
Committee

32. Protocols
• Joint review and development by all the clinical teams is
essential
• Some centers have an ongoing best-practices team that meets
monthly and is responsible for updates and education
With multiple teams working in the hybrid OR, protocol development requires
compromise and adaptation
SchedulingTrainingStaffing Protocols
Inventory
Management
Hybrid OR
Committee

33. Hybrid OR Committee
• Include key stakeholders
– Start by drawing from members of planning team
• Monthly hybrid OR conference can be useful:
– Discuss cases
– Review operations, including performance metrics
– Identify and address problems
– Learn about new technologies
An ongoing Hybrid OR committee can optimize operations, address unforeseen
issues, and help with the introduction of new technologies
SchedulingTrainingStaffing Protocols
Inventory
Management
Hybrid OR
Committee

34. Inventory Management
• A designated inventory-manager can partner with cath lab and
surgical OR counterparts to ensure proper stocking
• RFID is beginning to appear in more institutions
• Some centers have additional inventory in the equipment room
adjacent to the hybrid OR
Inventory management is essential to smooth operations but is often
overlooked during the planning phase
Reference: Belkin 2009
SchedulingTrainingStaffing Protocols
Inventory
Management
Hybrid OR
Committee

35. Key Takeaways: Staffing & Operations
• The choice of a dedicated or flexible staffing model will be driven by the unique
needs of each institution
• Training is extensive, involving both didactic and hands-on education
• While Hybrid procedures should take precedent, from a practical/ volume
standpoint most institutions will also need to utilize the room as a functional OR
or cath lab
• With multiple teams working in the hybrid OR, protocol development requires
compromise and adaptation
• An ongoing Hybrid OR committee can optimize operations, address unforeseen
issues, and help with the introduction of new technologies
• Inventory management is essential to smooth operations but is often
overlooked during the planning phase

36. Summary
• Hybrid ORs are becoming a standard part of cardiovascular programs
and have the potential to improve patient care
• There is no standard model that can be broadly applied today
• The decision whether to build, how to build, and how to manage a
hybrid OR will need to be customized to the unique circumstances of a
particular institution
• Hybrid ORs require close cooperation by a cross-specialty team
• The cost is typically $1-$5M and requires an 18-month total planning
process

37. Acknowledgements
Banner Good Samaritan Medical Center
Phoenix, AZ
Portneuf Medical Center
Pocatello, ID
St. Francis Hospital
Roslyn, NY
University of Kansas Hospital
Kansas City, KS
This overview was developed with input from personnel at the following
institutions:

38. The Cardiac Hybrid OR
References & Resources

39. Published References
Bashore TM, Balter S, Barac A, et al. 2012 American College of Cardiology Foundation/ Society
for Cardiovascular Angiography and Interventions Expert Consensus Document on
Cardiac Catheterization Laboratory Standards Update. J Am Coll Cardiol 2012;59: 2221-
305
Byrne JG et al. Hybrid cardiovascular procedures. JACC Cardiol Interv 2008;1:459-68.
Hirsch R. The Hybrid Cardiac Catheterization Laboratory for Congenital Heart Disease: From
Conception to Completion. Cath Cardiovasc Interven 2008;71:418-28.
Klein LW et al. The catheterization laboratory and interventional vascular suite of the future:
anticipating innovations in design and function. Catheter Cardiovasc Interv 2011;77:447-
55.
Maisano F et al. Hybrid rooms for transcatheter valve interventions: rationale, vision and
technical requirements. Intervent Cardiol 2010;2(10):503-10.
Kpodonu J. Hybrid Cardiovascular Suite: The Operating Room of the Future. J Card Surg
2010;25:704-9.
Kpodonu J and Raney A. The cardiovascular hybrid room a key component for hybrid
interventions and image-guided surgery in the emerging specialty of cardiovascular
hybrid surgery. Interact Cardiovasc Thrac Surg 2009;9:688-92.
Odle TG. Managing transition to a Hybrid Operating Room. Radiol Technol 2011;83(2): 165CI-
181CI.

40. Online References
Belkin M. The design and implementation of hybrid operating rooms. Veith Symposium 2009
(www.veithsymposium.org/pdf/vei/2761.pdf).
Deshchenko O. Special report: the case for the hybrid OR. DOTmed.com (August 2011)
Nollert G et al. The cardiovascular hybrid OR: clinical and technical considerations.
CTSNet.org (March, 2010).
From theHeart.org:
Vassiliades TA and Zimrin DA. Hybrid revascularization: the best of both worlds.
(www.theheart.org/documents/sitestructure/en/content/programs/1065241/transcript.
pdf)
Miller R. Hybrid revascularization strategy driven by new technology, and soon, new data.
January 31, 2011. (www.theheart.org/article/1179057.do)
From Cath Lab Digest (CathLabDigest.com):
Kerr JF. Keys to success in designing a hybrid cath lab. 2009;17(3).
Kpodonu J. The cardiovascular hybrid surgical room: evolving into the future of
cardiovascular surgery. 2012;20(3).
Rihal CS. Hybrid lab planning and perspectives. 2010;18(11).

41. Online References
From Endovascular Today (EVToday.com):
Peeters P et al. The catheterization lab of the future (March 2008).
Benjamin ME. Building a modern endovascular suite (March 2008).
Eagleton MJ and Schaffer JL. The vascular surgery operating room (August 2007).
From Imaging Technology News (ITNonline.com):
Fornell D. Planning for a Hybrid Suite (July 8, 2010).
Fornell D. How to Plan for a Hybrid OR (September 21, 2011).
Mateo D. Hybrid Suites Open Doors (March 3, 2010).
From Cardiovascular Business (CardioVascularBusiness.com):
Making the Case for a Hybrid Interventional OR (May 2011; article 27223).
ACCA: Making the Case for a Hybrid OR, How One Hospital Did It (April 2011; article
27258).
Cath Lab Update: Hybrid Adoption and PCI Imaging Tools (August 2010; article 23370).

42. Related Guidelines
Coronary Revascularization Guidelines
Hillis LD et al. ACCF/AHA guideline for coronary artery bypass graft surgery. JACC
2011;58(24):e123-e210.
Levine GN et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. JACC
2011;58(24):e44-e122.
Wijns W et al. Guidelines on myocardial revascularization: the Task Force on Myocardial
Revascularization of the European Society of Cardiology (ESC) and the European
Association for Cardiothoracic Surgery (EACTS). Eur Heart J 2010;31:25-1-55.
Endovascular Guidelines
Fanelli F and Dake MD. Standard of practice for the endovascular treatment of thoracic aortic
aneurysms and Type B dissections. Cardiovasc Intervent Radiol 2009;32:849-60
Hodgson KJ et al. Clinical competence statement on thoracic aortic repair (TEVAR):
multispecialty consensus recommendations, a report of the SVS/SIR/SCAI/SVMB Writing
Committee to develop a clinical competence standard for TEVAR. J Vasc Surg
2006;43(4):858-62.

43. Related Guidelines
Transcatheter Aortic Valve Replacement Guidelines
Holmes DR and Mack MJ. Transcatheter valve therapy: a professional society overview from
the American College of Cardiology Foundation and the Society of Thoracic Surgeons.
Ann Thorac Surg 2011;92:380-89.
Tommaso CL, Bolman RM, Feldman T, et al. SCAI/AATS/ACCF/STS multisociety expert
consensus statement: operator and institutional requirements for transcatheter valve
repair and replacement: Part 1 TAVR. J Am Coll Cardiol 2012.
Cardiac Catheterization Laboratory Standards
Bashore TM, Balter S, Barac A, et al. 2012 American College of Cardiology Foundation/ Society
for Cardiovascular Angiography and Interventions Expert Consensus Document on
Cardiac Catheterization Laboratory Standards Update. J Am Coll Cardiol 2012;59: 2221-
305

44. Additional Resources
• For Hybrid OR case studies, visit www.hybridOR.medtronic.com
• For detailed information about Hybrid OR equipment, to take a virtual tour of a
Hybrid OR, or to find information about alliances that offer integrated solutions,
visit the websites of hybrid equipment manufacturers (partial list)*
– GE
– Siemens
– Maquet
– Philips
– Skytron
– STERIS
– Toshiba
• The Advisory Board Company (www.advisory.com) has developed extensive
Hybrid OR reports and analysis for member institutions
* Medtronic does not recommend or endorse any manufacturer or their equipment and appearing on this list should not be
construed as a recommendation or endorsement.
UC201206539 EN © 2012 Medtronic, Inc.

45. Thank You