Hospitals across the country are creating a new breed of surgery spaces called hybrid operating rooms. Hybrid ORs combine the surgical capacity of traditional operating rooms with the imaging capabilities of a catheterization lab, two spaces that have traditionally been distinct. Placing state-of-the-art imaging and X-ray equipment in an operating room allows for less invasive, safer procedures with faster recovery times for patients. The imaging equipment helps surgeons pinpoint the area of incision and provides instantaneous feedback during procedures. For example, endovascular neurosurgical cases, such as aneurysm operations, can now be performed more safely and efficiently in a hybrid OR. As surgeons conduct these high-risk, complex cases, high-tech diagnostic imaging increases positive outcomes, enabling neurosurgeons to transition seamlessly from a closed to open procedure, without losing critical time to transport a patient to another location for imaging.

If designed with clinical flow in mind, the hybrid operating room suite can be a force for the future of interventional platforms. By combining imaging and surgical capabilities, hospitals are redefining the interventional suite, with great advantages in patient care and cost efficiency. With emergence of hybrid operating rooms comes both cultural and design implications that go far beyond the operating room itself and extend to the entire surgical suite and the hospital as a whole.  

Planning and design
The first step in planning a hybrid OR is to seek input from each of the surgical specialists who will utilize the room. Design teams should include representatives from surgical and perioperative departments, administration, facilities, and IT. The team should also tour hybrid ORs at other hospitals to experience these new types of spaces. 

During the design phase, it’s critical to use the latest 3-D drawing tools to create a clear vision of the hybrid room’s elements. Once a design has been approved, a full-scale mock-up of the space should be built. This will give the team the opportunity to identify and solve any design challenges in the room before it’s constructed.

Early vendor selection and coordination are also important steps, especially since the addition of imaging equipment adds spatial complications to the operating room. In particular, ceilings require careful consideration and advance planning, as both surgical and imaging equipment tend to be ceiling-mounted. With advance planning, designers have the opportunity to encourage vendors to work together to fit specific design parameters by facilitating conversations between them. Increasingly, vendors have joined forces to offer more synergistic solutions. For example, in the Geisinger Wyoming Valley Medical Center’s hybrid OR, two vendors teamed up to integrate their systems into one solution. One vendor’s boom mount was added to another vendor’s monitors required for the cath system, reducing the amount of ceiling-mounted equipment. Vendors are also working to offer systems that integrate IT with equipment. For example, it is now possible for staff to navigate a variety of different equipment systems, including surgical, video, and patient monitoring, from one centralized control panel.

Layout and equipment
Hybrid ORs can include a variety of imaging equipment, including either single or bi-plane, and increasingly, CT scanners (CTORs) and MRI scanners (MRORs). MRORs can range in size from 1,200 square feet to 2,600 square feet, while CTORs run from 800 square feet to 1,100 square feet. Both rooms must allow space for the control room, supply space, scrub area, locker sequence, and the generator rack room, which runs the equipment.

All hybrid MRORs require nonferrous equipment and the four zones of safety, ranging from free public access (Zone I) to strictly controlled, restricted access zones (Zones III and IV), that are identified by the American College of Radiology. If a hybrid OR is to be a flexible space used by multiple specialties that will utilize the rooms in different ways and require different room configurations, sizing the hybrid OR to accommodate each one is critical during the planning process. Hospitals can achieve ideal sizing by making sure to consult representatives from each specialty that will be using the room.

Location, location, location
Ideally, hybrid ORs should be integrated into an interventional suite—this keeps the logistics simple. However, if a hospital’s existing ORs are separated from its interventional radiology suite, then it’s important to locate hybrid rooms with other ORs. Placing the hybrid room inside a surgical suite avoids duplicating surgical support spaces, including surgical supplies, instrumentation, and equipment. This saves the hospital the additional costs for the duplicate equipment and avoids inefficiencies in the movement of clean and soiled supplies. Collocating the hybrid room also simplifies staffing concerns, as surgical support staff, perioperative nursing teams, anesthesiologists, perfusionists, and surgeons won’t have to work in more than one area on campus. 

Workflow
In order to achieve an efficient workflow in the new OR, the design team must also take into account patient flow and material supply in addition to team proximity. Hybrid ORs bring together a new spectrum of users in the same department, mixing different disciplines of surgeons with interventionalists, anesthesiologists, cardiologists, electrophysiologists, pathologists, nurses, technicians, and more. In a traditional OR, the working positions, clinical applications, equipment requirements, patient/material logistics, and scheduling for each of the above would be mutually exclusive concerns. Hybrid ORs blur those lines. They also increase the amount of staff support space required. The design of these spaces should facilitate interdisciplinary interaction among the care teams.

Proper materials for all disciplines will also need to be on hand in the surgery suite, so the planning team should consider storage for the required inventory. Will there need to be a change in materials handling in terms of supplying cases? The new kinds of procedures that take place in a hybrid OR may require new kinds of case carts, which carry the packages of materials and instruments necessary for each case. Neuroendovascular, cardiology, and electrophysiology supplies should all be available.

Hybrid ORs don’t always have to be used for hybrid procedures, either. They can be designed to allow for regular operating procedures when the imaging equipment is rotated out of the way, or for interventional imaging use. Patients commonly move from prep for a long procedure into the hybrid room, and then to a specialty intensive care unit. However, when the room is used as a traditional OR or for imaging, there will be a quicker turn-around and a higher rate of utilization of the room and its resources. This will increase the number of prep and recovery spaces required and call for additional staffing and supply storage resources.

A worthwhile endeavor
Although there are a relatively small number of hybrid operating rooms in the United States today, this number stands to grow significantly in the near future. A 2011 survey by Millenium Research Group predicted an annual growth rate of 15 percent for hybrid ORs over a five-year period. Advantages of the rooms include improving the patient experience by allowing for minimally invasive procedures that increase patient safety and decrease recovery time, while reducing the inconvenience of transferring patients from one wing of the hospital to another. For hospitals, the age of hybrid ORs opens the door to cost-saving e
fficiencies in staffing, equipment, supplies, and procedures. As with all new technologies, integrating a hybrid OR seamlessly into an existing hospital requires significant forethought and planning, but the rewards for patients and hospitals make the process worthwhile.

This is the first part of Healthcare Design’s three-part special report on hybrid operating rooms. To read the second installment, visit http://healthcaredesi.wpengine.com/article/tight-fit-designing-hybrid-or-limited-square-footage.

Catherine Gow, AIA, is principal, health facilities planning, at architecture firm Francis Cauffman (Philadelphia). She can be reached at cgow@franciscauffman.com. Brenda Byrd, IIDA, LEED AP BD+C, is a senior healthcare planner at Francis Cauffman (New York). She can be reached at bbyrd@franciscauffman.com.