The Cardiac Hybrid OR A Platform for Collabration CASE STUDY Banner Good Samaritan Hospital Phoenix, Arizona HYBRID OR AT A GLANCE Phoenix hospital prepares for future with construction of hybrid room SIX MONTHS IN, STAFF SHARE THEIR VISION AND ADVICE FOR MANAGING CHANGE Banner Health recently completed a ground-up reconstruction of their entire operating room area. They replaced old ORs with brand new rooms, including the Phoenix hospital s first hybrid cardiac OR suite, which opened in December 2011. Opening date: December 2011 Location: Housed within the hospital s brand new OR wing Construction highlights: Planning spanned two years An OR-focused room designed for traditional and cardiac surgery Equipment selections: Standard operating room K-table to support all types of surgery Floor-mounted C-arm for imaging Oversized 50 monitor for imaging display Separate charting software and systems for OR and cath lab staff 1
The rationale Readying space for the new paradigm Already a recognized leader in heart care, Banner created its hybrid room to prepare for what lies ahead in advanced cardiac treatments. Banner had the vision to see what the future was bringing, explains Michael Caskey, MD, Cardiac Surgeon. There was a lot of research done beforehand, and they knew where the world was going, in terms of moving forward with a more percutaneous approach. Timothy Byrne, DO, Interventional Cardiologist, agrees. We needed the facility to push ahead with our structural heart program, he says. We had to have the infrastructure in place. Prior to the launch of the new room, Banner developed two first generation hybrid areas, one in the OR and one in the cath lab, but needed a permanent location with proper equipment to handle long-term demand. HYBRID OR AT A GLANCE Challenges: New construction lacked adequate ceiling heights for hybrid equipment, which required drilling into the floor to create necessary space Integrating cath lab staff and procedures into an OR-driven room required several post-launch modifications and purchases, including separate charting software and changes to monitor placement Scheduling room usage to accommodate both hybrid and standard cardiac procedures Forging new relationships among staff who did not work together previously 2
Planning Surgical staff lead planning process From the beginning, Banner envisioned a flexible room that could accommodate more than just cardiac cases. Administration pushed for an area that would suit multiple surgical teams and see high utilization. It was very important to be able to convert to any kind of OR case, says Lynn DeGuzman, RN, Director of Cardiovascular Services. You can do an appendectomy in there, because they bought a K-table that can be used as an OR table, not just a fluoro table. That was a really important decision. With surgical procedures taking precedence for the new OR, hospital administration and the cardiac and vascular surgery teams took the lead in planning. While catheterization lab staff do utilize the room, they were not involved in the selection of imaging equipment, table or other strategic decisions. The team also relied on diagrams from vendors that showed equipment placement and staff positions for hybrid rooms. The process spanned two years. I really wish we would have been part of the planning, says Byrne. However, once we got the bugs worked out, it s phenomenal. The room is great and they spared no expense; it s a beautiful room. Staff voiced the greatest learning curve over imaging placement and table selection, both of which are geared to traditional surgery rather than interventional situations. I understand the decisions, because now it can be utilized as a true OR room, since those are going to be the majority of the cases, says Steve Lucas, Cath Lab Imaging Manager. The room is still evolving; it s only been half a year. Takeaways Understand that maximizing a room s flexibility can make it challenging to meet the equipment and infrastructure needs of all clinical teams Let primary usage of the room drive key decisions, but involve cross-functional stakeholders early in collaborative planning to help prevent design flaws and friction Leverage knowledge and plans available from equipment vendors 3
Design and construction New technology requires attention to details Even with entirely new construction, Banner still encountered space constraints. The rest of the new ORs opened several months ahead of the new hybrid room, which was initially finished as a shell. When it came time to install equipment, contractors discovered they needed additional ceiling height. There were some delays, says Caskey. They ended up drilling down the floors because it wouldn t fit the C-arm. Banner installed multiple monitors, including an oversized 50-inch monitor. Staff praise the quality, which quickly pushed up clinical demand for the new room. The imaging is so great they don t rely as heavily on the C-arm, says DeGuzman. The heart team did uncover small problems that required post-launch fixes, especially once cath lab staff and imaging specialists began using the room. There were a couple of things that were installed in the wrong place, as far as radiation protection, explains Lucas. We also had to get a couple cables that allowed the assist to plug in, because their module was totally different than the equipment we use in the lab. Takeaways Focus on the details when researching and selecting technology Identify differences in systems and requirements between cath lab and OR equipment needs Work closely with architects and engineers to ensure adequate ceiling height Expect minor glitches when operationalizing the room for the first time 4
Staffing and operations New room facilitates first combined heart team In addition to new technology, Banner s hybrid OR also facilitates a new way of working for the hospital s interventional cardiologists, surgeons and clinical support staff. Its first few months of operation included learning new equipment and forging new relationships as a combined staff. Prior to opening the hybrid OR, the two teams worked almost completely independently. Over the years, OR and cath lab had nothing to do with each other, explains Lucas. We didn t really communicate with them other than when we d rush a patient for emergency bypass. Now, we re working with their managers and their teams on a regular basis. Creating a cohesive environment was not without its challenges. When you re melding these two cultures, they re very different, Byrne acknowledges. It s been an interesting experience, because it s not where we [the cath lab staff] live. And so we re guests there, and there have been some challenges regarding that. Room ownership, scheduling, and sterility procedures all came into play. For example, the nursing staff from the cath lab encountered a hurdle when they discovered that the OR team utilizes an entirely different charting system. The way we chart in the cath lab is totally different than the way you chart in the OR, explains DeGuzman. We use one system for meds and certain things, and in the OR they use a different product. And it s not necessarily user-friendly for any nurse to just get on and start using [the system]. We had to outfit the room and that was a last-minute thing. It s an evolution. Each team comes in from a different point of view, Caskey says. Initially, it s very difficult for everybody, because everybody s got their own built-in ways. I think there s a whole lot of learning that goes on from all sides. But it takes time. And you have to have a certain degree of openness. Regular heart team meetings helped Banner staff improve communication and develop standard procedures for the room. They also focused on team building activities and post-procedure communication to increase engagement and follow through. Part of the problem, these crews come in and out and work with us, but they don t always see the end result, Caskey explains. The patient goes to the ICU. They never see or hear from them again. So we re talking about bringing some people back so they can see the end result. That s becoming successful. 5
Cross-training optimizes staffing Banner has also seen results from cross-training among cath lab and OR staff, which allows them to reduce the number of in-room personnel during combined procedures. This allows Banner to maintain its volume of cases in the cath lab at the same time joint procedures occur in the hybrid OR. When we first started valves, we had six of our own cath lab people in the room, states Lucas. Now, we re down to five, and shortly after the case begins, we can streamline down to four. Ideally, we want to get it down to three by utilizing more OR staff to take over the roles of scrubbing at the table and assisting in that aspect. Now, during a hybrid case, two RNs, one RT for x-ray and two CVTs make up the team. One stays bed side with the patient, and one scrub person prepares the device. Once the device deploys, one of the RNs and one RT/CVT in the scrub role can leave the room. That leaves one nurse monitoring and charting, the other at bedside, circulating and pacing when the time comes to deploy, explains Lucas. We re hoping that with some training the OR nurse will take over that role, then the second table can be taken over by an OR staff member, because until a more involved intervention is needed, that nurse is likely on standby. Takeaways Open communication and formal meetings speed rapport and reduce issues Sharing procedure outcomes with the full team generates engagement and ownership Cross-training OR staff reduces the number of cath lab team needed for joint procedures 6
Room demand causes scheduling challenges Developing the ideal scheduling protocol continues to be a work in progress. Only six months in, demand for the room already exceeds availability. Today the room sees usage for everything from conventional and vascular surgeries and valve procedures to interventional radiology, cardiology and even fetal medicine. We re going through the growing pains of trying to manage this room, Caskey states. It s an operating room. It s an angiogram suite. It has multiple uses, multiple people using it. He adds, There s so many people that want to use this room, and there s such limited time. The valve program receives block time each Monday with capacity for three procedures, but other slots are filled first come, first serve by traditional surgery and interventional procedures, all of which can be delayed by more urgent cases. The problem is if an emergency occurs, and needs to utilize the hybrid OR, our team gets bumped, explains Sarah Bertram, RN, Valve Coordinator. When that happens, staff is not able to leave at a reasonable time. There are days we are not starting our third case until 8 pm, which makes for a long, chaotic day. Cath lab staff also find turnover between cases to be more time consuming in the new room, which slows down scheduling. Caskey believes a dedicated manager for the hybrid OR will resolve some of the scheduling challenges. He advises others to staff this position early on. I would make sure to hire a manager to specifically manage that room and all the personnel that come in, and set rules, he says. Have periodic meetings to make sure everybody understands what the rules are, the management of the room, the time of the room. He adds that just because the room is located in the OR area, a surgical team member would not need to manage it. Adds Byrne, My advice is to be very methodical. If we can get block time, I think that s going to be huge. Caskey suggests developing a clear hierarchy for cases, and prioritizing which procedures truly mandate the hybrid OR. I think if you can prioritize what goes in there, who gets time and what doesn t really need to go in there, he says. Can you take some of those procedures and move them to radiology? Can you take some of those procedures and move them to the cath lab? Takeaways A single hybrid OR manager can facilitate scheduling and set rules for usage Establishing block scheduling is one way to deal with this challenge Sharing a facility with general surgery can limit availability for true hybrid procedures 7
Looking ahead No turning back for combined heart team, structural heart program In the end, Banner sees the hybrid OR as the centerpiece of a growing structural heart program, and an investment well worth the cost and the initial growing pains experienced by staff. The benefit of working with the OR is that we ve established a relationship that hadn t been there for years, Lucas states. The teamwork that s going on is incredible. Byrne advises others to be respectful and approach every challenge as a moment of teaching or learning. There s all these little subtleties and challenges, he says. At the end of the day, I ve found if you are kind and understanding, and you teach as you go, that s probably the most important message I can get across. Banner is already analyzing the viability of a second hybrid suite, even though the new OR construction does not have the infrastructure to support another room without additional renovations. I m building the business case for a second hybrid OR right now, says DeGuzman. I don t think anyone really forecasted how popular the room would be. The team agrees that the hybrid OR and combined heart team represent the future for cardiac care. There s no going back, says Lucas. We made that commitment once we transitioned to the hybrid room. It s better for the patient. It s better for outcomes. It s just a better environment overall. About Banner Health Banner Health is one of the largest nonprofit hospital systems in the country with 23 acute-care hospitals and health care facilities and more than 36,000 employees. Banner Health is a recognized national leader in the prevention, diagnosis and treatment of heart and vascular conditions. Patients rely on Banner for advanced procedures, compassionate care and outstanding rehabilitation and support programs. Banner Health surgeons perform thousands of heart, lung and chest procedures; the hospital offers minimally invasive heart procedures as well as robotic-assisted surgery. Banner Good Samaritan Hospital is located in Phoenix, Arizona. www.bannerhealth.com This case study reflects the views and experiences of Banner Good Samaritan Hospital and its staff and are not the views of Medtronic. Results and experiences may vary. Contributors: Sarah Bertram, R.N., Valve Coordinator Timothy Byrne, D.O., Interventional Cardiologist Michael Caskey, M.D., Cardiac Surgeon Lynn DeGuzman, R.N., Director of Cardiovascular Services Steve Lucas, Cath Lab Imaging Manager 8 UC201206538 EN 2012 Medtronic, Inc. All Rights Reserved. Printed in USA