Moving a catheter laboratory inside an operating theater is no easy matter. While hybrid interventional operating rooms (ORs) carry the promise of increased revenue and patient safety, they also come with a sizable price tag, technical considerations and potential turf battles.
Enthusiasm with a price tag
Proponents for hybrid ORs can be very sure of the necessity of them. "We can't move forward with improved patient care without the hybrid suite," says Wilson Y. Szeto, MD, surgical director for transcatheter cardio-aortic therapies at University of Pennsylvania Medical Center-Penn Presbyterian Medical Center in Philadelphia. Yet, these hybrid models of intervention and surgery collaboration come with a fairly hefty price tag, in the range of seven figures.
"The return on investment is a question mark and no one can guarantee that it will be cost effective for the hospital," says Niv Ad, MD, chief of cardiac surgery at Inova Heart and Vascular Institute in Falls Church, Va.
Despite the cost, pioneers like Inova, Penn Presbyterian and Cincinnati Children's Hospital make a compelling case for the hybrid lab, explaining that the suites are essential for cutting-edge procedures such as transcatheter valve repairs, while boosting throughput and enhancing patient safety.
Procedures, economics, safety
The Heart Institute at Cincinnati Children's Hospital houses one of the U.S.'s only pediatric hybrid labs. The suite is unique from other perspectives as well, says Russel Hirsch, MD, director of the cardiac cath lab. "We are an academic facility and don't have to justify everything on the profit motive," he explains. However, Hirsch and colleagues had to demonstrate that the lab would be income-neutral and that it was necessary for essential procedures. At the same time, the administration insisted that the new suite could not displace bread-and-butter cardiac cath procedures.
When Penn Presbyterian started evaluating a potential hybrid lab in 2006, the planning team homed in on procedures. Percutaneous valve procedures were a major selling point during the planning stage as a hybrid suite makes the process easier. "To convince the administration of the importance of the hybrid lab, we had to demonstrate that it would be fully utilized, which meant designing the room to accommodate coronary procedures and vascular work, and more importantly, conventional open heart operations," recalls William H. Matthai, MD, an interventional cardiologist.
Today, the Penn Presbyterian hybrid lab is used in hybrid mode about 40 percent of the time, and vascular and surgical procedures round out the case mix. Vascular procedures also complete the procedure list at Inova Heart and Vascular Institute, which uses its hybrid suite for transcatheter valve procedures, revascularization and electrophysiology procedures, including atrial fibrillation and ventricular tachycardia ablations. Although vascular procedures don't require a hybrid suite, they help keep the room busy and can be moved to a standard OR equipped with a C-arm as demand for the hybrid room increases, says Ad.
At Cincinnati Children's, which retrofitted existing spaces into two hybrid rooms in 2007, staff have realized that the hybrid model confers multiple advantages including enhanced patient safety, process improvement and quality control, says Hirsch.
For example, the team has multiple options for a newborn requiring stenting of ductus arteriosus to maintain pulmonary blood flow: a percutaneous procedure, hybrid stent or surgical shunt. With the hybrid lab, the team can plan for the least invasive option. However, if it becomes apparent that the percutaneous procedure is not possible after the patient is in the lab, the team can call the cardiac surgeon to complete the procedure without waking the patient from anesthesia, moving him or her back to the unit and prepping for surgery the next day. "We can assure the family that one way or another the patient will be taken care of that day," says Hirsch.
Cincinnati Children's has employed an open model in the lab. Children with high-risk cardiac lesions or medical issues like severe pulmonary hypertension incur tremendous risks with the induction and reversal of anesthesia at every cardiac catheterization to assess hemodynamic function.