A hybrid operating room is a special suite that allows advanced imaging to be carried out at the same time as one or more additional operative procedures. It’s that simple. It contains specialized imaging equipment including fluoroscopy and infusion equipment for radiographic dye administration. Some also contain CT and/or MRI capabilities, although the shielding required for these makes them very rare. It is generally stocked with a variety of endovascular
devices and supplies. The usual anesthesia circuits are available, as are selected surgical packs, typically related to vascular and CV surgery.
These suites are typically large, and can easily accommodate multiple operating teams. However, they are very expensive in a number of ways.
First, they take up a great deal of space. Many have the square footage of two or more standard operating rooms. Initial construction costs are very high, as are remodeling and maintenance costs. They can also tax the hospital engineering infrastructure, from electrical to plumbing to ventilation.
But if a hybrid room is available, it can deliver significant benefits to the hospital and to patient care. Intraoperative imaging can provide immediate quality assurance, and patients can undergo more complex procedures and enjoy a shorter length of stay.
Tomorrow, why use a hybrid room for trauma?
While quite a bit of trauma care is routine, involving simpler, single system injuries, a small subset of our patients sustains major, multi-system, and life-threatening ones. They require rapid access to skilled trauma professionals and advanced resources including imaging, operating rooms, and other procedures.
In most trauma centers, initial resuscitation takes place in a trauma resuscitation room in or near the ED. Some diagnostic imaging can be performed there, but more sophisticated studies may require a short (or longer) road trip. Operating rooms and other procedural areas are also usually more distant. And most importantly, each of these areas is designed for a single discipline. Diagnostic radiology has equipment, technicians, and radiologists available. Interventional radiology contains the specialized equipment needed for this more invasive procedure. ORs are designed specifically for surgical procedures, and frequently contain equipment for a single surgical discipline.
But some of our patients require it all! Think about a patient who arrives after a major car crash. Blood pressures are soft, the pelvis is grossly unstable, FAST exam is positive, and there is bleeding from the vagina.
How do we prioritize? Where do we go first? How long will it take the interventional radiology team to arrive? Where’s that external fixator equipment? Can we slip in a CT scan? Where’s OB/GYN??
The solution is right under our nose! Many hospitals have added so-called “hybrid ORs” to their operating suites in order to address the needs of their vascular and cardiovascular surgeons. This week I’ll cover everything you need to know about this important tool for trauma care. I’ll review:
- What is a hybrid OR, exactly?
- Why use a hybrid OR for trauma?
- Is the hybrid OR for trauma useful?
- Which patients may benefit from a hybrid OR?
- So you want your own hybrid room?!
Tomorrow, what is a hybrid OR, exactly?
Level I and II trauma centers that are verified by the American College of Surgeons are required to have a method for ensuring that urgent orthopedic cases have good access to an operating room (OR). Some hospitals (that have room availability) have achieved this by dedicating an OR for this purpose. In a few hospitals, the room is available 24/7, but most provide daily block time that has a reasonable release time (typically about 6am). This allows procedures to reliably get done the next morning.
Previous papers have documented many of the benefits of this practice: decreased length of stay, fewer surgical revisions, decreased cost, and of course, fewer after-hours operations. But by definition, this adds a delay of several hours to the case. If the patient comes in at 7pm, the case may not start for 12 hours or more.
Could this increase the risk of infection or other complications? The orthopedic group at Stormont Vail in Topeka KS (Level I) looked at their retrospective experience over a 6 year period. They specifically examined cases in which a time delay could increase the infection rate: open tib/fib fractures. They recorded the usual demographics, time to procedure, and broke the data down by Gustilo grade of the fracture.
Here are the factoids:
- The authors treated 297 patients with a total of 347 open fractures
- About half were treated before a dedicated ortho OR was implemented, and half after
- Average time to debridement in the dedicated OR was 13 hours, vs 5 hours in the on-call system
- Overall, the number debrided within 24 hours was the same in both groups
- Primary fracture union was significantly higher in the dedicated room group (73% vs 57%)
- Patients treated initially in the dedicated room were significantly less likely to need an unplanned procedure later (for malunion or infection)
- There was no difference in infection, non-union, or amputation rates
Bottom line: Let your orthopedic surgeon sleep if you have a dedicated OR so the work can get done first thing the next day! It saves wear and tear on the hospital infrastructure that occurs when cases are done in the middle of the night, as well as the surgeon. Besides saving time and money, final outcomes are better, too!
Reference: Use of the Dedicated Orthopaedic Trauma Room for Open Tibia and Femur Fractures: Does It Make a Difference? J Ortho Trauma 32(8):377-380, 2018.
Every hospital wants some gadget or other. First, it was a robot. Or two. Now, it’s a hybrid operating room.
What is this, you ask? It’s a mashup of an operating room and an interventional radiology suite. It’s new. It’s big. It’s cool (literally, which is an issue for trauma surgeons).
More and more hospitals are adding hybrid rooms at the request of their vascular surgery teams. These rooms allow for both angiographic and open operative procedures, potentially at the same time. They are perfect for endovascular procedures that need some degree of hands-in work as well. They are frequently used for thoracic endovascular repair of the aorta (TEVAR), repair of abdominal aortic aneurysm (AAA), and transcatheter aortic valve replacement (TAVR).
These rooms would seem to be perfect for some trauma cases as well. Some injuries require a mix of interventional work and open surgery. Think complex pelvic fractures and extremity vascular injuries.
But before you go rushing off to the hybrid room with the next patient you think might benefit from it, consider these issues:
- You must first secure access to the hybrid room. Just because you want it doesn’t mean you can get it. This room was probably built with other services in mind. You must work with them closely to set up rules and priorities. Consider questions like, can a trauma case bump an elective one?
- Decide what specific cases can be done in the room. Don’t waste it on procedures that can be done in any old OR. Ideally, it is for multi-team cases and must take advantage of the radiographic capabilities of the hybrid room. If it doesn’t, it should be done in any other room of appropriate size.
- Check your hardware. Make sure that anything you might attach to the hybrid table actually will attach to it. Frequently, the side rails are missing and the table thickness is different than a standard OR table. Check all of your retractor systems for compatibility. If your neurosurgeons use a skull clamp like a Mayfield, make sure it will attach to the table. If they do not, look for adapters to make it possible. Don’t discover this on your first trip to the room.
- Watch for hypothermia! These are big rooms, and are difficult to heat up uniformly. In addition, the electronics in the room may be heat sensitive, so you may not be able to raise the temperature to the levels you are accustomed. Place heating systems under and around the patient as much as possible, warm everything that goes into them, and monitor their temp closely.
- Treat the equipment with respect. This stuff is delicate, and must be used by other surgeons for sensitive procedures. Don’t break it!
Even though it’s called trauma surgery, the operative experience in trauma tends to be somewhat limited. This is due mostly to the fact that most trauma centers see predominantly blunt trauma. Yes, there are hospitals around the world where the penetrating injury load remains high and there is operative experience aplenty.
But in the US, the vast majority of trauma centers see mostly blunt trauma. Surgical residents in the US are required to log 10 operative and 20 nonoperative cases to successfully meet residency completion requirements. And blunt trauma is tending to get less and less operative in nature. A good example is the evolution of blunt solid organ injury to mostly nonoperative management.
So what is happening with surgical resident operative trauma experience? And has there been any impact from the work hour restrictions that have gone into effect in the US? A study from Harborview, Denver Health and Seattle Children’s looked at the ACGME operative logs for surgical residents annually from 1989 to 2010. They combined the data into 5 year blocks, with the last two having work hour restrictions in place.
Some interesting findings:
- Overall mean caseload of major cases (all types) remained steady at about 925 per resident
- Mean trauma operative caseload decreased from 76 to 39 (beginning of work hour restrictions)
- Mean trauma operative caseload remained steady at 39 for the 7 years in which work hour restrictions were in effect
- The number of intra-abdominal trauma operations decreased from 31 to 17, and the number of liver/spleen operations decreased from 5 and 4 to 3 and 2
Bottom line: Resident trauma operative experience has declined and stabilized in the US. This is due to the evolution of our management of blunt trauma. Unfortunately, this decline will reflect on how well prepared surgeons at outlying hospitals are, and in the quality of emergency surgery they may provide. The impact will be felt most by seriously injured patients who cannot be taken to a high level trauma center initially. We need creative solutions to address this issue, such as mini-clerkships in trauma or structured experiences at high level trauma centers for surgeons in outlying hospitals.
Related post: ED at the busiest hospital in the world!
Reference: ACGME case logs: surgery resident experience in operative trauma for two decades. J Trauma 73(6):1500-1506, 2012.