Inova Health Moves Forward with Hybrid OR

Hybrid operating rooms combine the diagnostic functions of a cath lab with the surgical functions of an operating room. Once only found at academic medical centers, they are growing in popularity as regional medical centers across the country are adopting them.

Fewer than 100 U.S. hospitals currently have hybrid rooms, according to the ECRI Institute, an independent nonprofit that researches the best approaches to improving patient care. But the number is expected to climb in the coming years.

Why? Because hospitals are using less-invasive approaches to replace heart valves and insert stents, which require advanced imaging equipment and specialized surgical equipment. As these types of minimally invasive procedures become more popular, they require more sophisticated imaging than what is currently available in most cardiac ORs.

Inova Health is a leading not-for-profit health system that built a hybrid OR. Inova has a reputation for maintaining a progressive cardiovascular program. For more than 30 years, cardiac surgeons at Inova Heart and Vascular Institute have performed heart surgery on more than 30,000 adult and pediatric patients. Its medical firsts include the region’s first heart transplant in 1986, the first open heart surgery in 1997 and the first heart and double-lung transplant in 1997.

Inova’s flagship hospital, Inova Fairfax Hospital in Falls Church, Virginia, has one of the largest cardiac programs in the region, with seven cardiac catheterization labs and four electrophysiology (EP) labs. The hospital performs approximately 6,500 cardiac catheterizations and 2,500 EP procedures each year, and introduced the first hybrid OR to the Washington, D.C. region.

Why Build a Hybrid OR?

Hybrid ORs are unique because they combine a traditional OR with the high-quality x-ray imaging system of a cath lab. With this technology, cardiac surgeons, electrophysiologists and cardiologists can operate together on the same patient, reducing surgical time and allowing patients to recover faster and with less risk of complications.

According to Stephen Pala, Director of Cardiac Cath and EP Labs for Inova Fairfax Hospital, one of the primary reasons Inova decided to build a hybrid OR was to provide a safe environment that would allow physicians to perform high-risk, minimally invasive cardiac procedures such as transcatheter valve replacements, catheter ablation of atrial fibrillation and complex lead extractions, complex stenting procedures, and the mini-maze procedure.

Hybrid ORs have the added advantage that if physicians encounter any complication during an interventional procedure, they can switch to an open-heart procedure in a matter of seconds. In the past, patients would have to be transferred to an OR located elsewhere in the hospital or schedule for surgery at a later time. Hybrid ORs allow physicians to perform complex procedures in the safest environment possible, thereby providing world-class care.

In addition, Inova’s hybrid OR is unique because it’s the first one in the country to pair Philips Healthcare’s cardiovascular x-ray systems with MAQUET’s “Magnus” surgical table in a single work environment. Philips’ 3D Heart Navigator combines 3-dimensional computed tomography (CT) images of a patient’s cardiac anatomy into a single image with an overlay of the live x-ray fluoroscopy information. MAQUET’s “Magnus” OR table system features a carbon-fiber table top, which provides near 360-degree radio translucency, and allows optimum x-ray images in interventional procedures and minimally invasive operations. By combining static 3D images with the live 2D images, Inova physicians receive a clearer view of a patient’s anatomy, helping them to achieve the best clinical outcome. Integrating these two devices make it possible for Inova physicians to perform both minimally invasive procedures and open surgery in a single space.

Overcoming challenges

Since hybrid ORs typically cost millions of dollars to build, the decision needed to be approved by the health system’s administration and Board of Directors.

The Board decided that Inova needed a hybrid OR in order to remain competitive and offer patients world-class care. As cath labs have become relatively common at smaller hospitals, Inova has built a niche for itself by performing more complicated vascular surgeries in carotid and renal arteries. Building a hybrid OR and focusing on minimally invasive procedures also allows Inova physicians to engage in cutting-edge research and clinical trials.

To add to the complexity, Inova does not employ its cardiac surgeons and cardiologists. In fact, it has over 80 physicians from 30 different cardiac practices that perform procedures at its hospital. Though this can pose a number of challenges, from standardizing physician preference items and OR scheduling, it wasn’t the case at Inova. Thanks to a supportive administrative team, they were able to meet this challenge and move the project forward.

Inventory management

Inventory management is a major issue for Inova’s cardiovascular program. Not only are cardiac devices expensive, but because Inova specializes in complicated catheterization procedures, there are fewer purchasing options for these items and less opportunities for discounts.

This issue is exacerbated by the large and diverse group of physicians, making it difficult to create consensus around specific physician preference items. To maintain their budget, Inova’s cardiac cath lab team needed to determine:

• How much inventory do we have?
• Where is it located?
• Is inventory stored in multiple locations or is it stored where it is used?
• Are the same products managed differently at different locations?
• How should we seek to understand inventory value, usage trends and demand forecasting?

Inventory management issues are especially prevalent for the hybrid OR, since Inova’s cath labs are located on the ground floor and the hybrid lab is located on the second floor with the cardiovascular operating rooms (CVOR). Unless specific measures were implemented, it would be easy to have too much or too little inventory in the new hybrid lab. Taking precautionary measures, the cath lab team created a cart to transfer the specific items necessary for each procedure to the CVOR.

Inova partnered with its medical supply distributor, Owens & Minor, to help manage its complex inventory needs. In February 2009, Inova installed Owens & Minor’s Clinical Supply Solutions (CSS) product, which is designed to reduce inventory for high-cost specialty areas such as the cardiac cath and EP lab, while increasing revenue through improved charge capture and providing real-time business analytics.

According to Pala, Owens & Minor’s CSS plays an integral role in annual financial audits and inspections by telling his team the exact value of their on-hand inventory. Not only does it provide usage data, but it allows staff to determine inventory levels without requiring them to walk to each OR and physically count items. It also helps provide the information necessary to reduce and eliminate products they don’t use, improve the ordering process (largely based on preset targets) and lastly, find comparable products to help with the negotiation process. Over the course of 2.5 years, CSS has helped Inova identify cost-saving opportunities totaling $4.6 million.

Owens & Minor’s CSS tool has also helped Inova address some new issues it faces with suppliers.

“Manufacturers are starting to drag their feet when it comes to product delivery. They don’t want to deliver products next day or second day air anymore, as a way to save money,” Pala said. “As a result, we’ve had to increase our inventory levels so we don’t run out of product.”

“I can’t imagine what it would be like not to have CSS,” said Pala.

By focusing on medical advancements, such as the hybrid OR, Inova Health hopes to distinguish itself from its competitors by providing the latest in minimally invasive cardiac procedures and doing what it does best — saving people’s lives.

Stephen Pala, Director of Cardiac Cath and EP Labs for Inova Fairfax Hospital, can be contacted at steve.pala@inova.org.

Note from the editor: This article was written by Lauren Belliveau, Vice President Surgical Services for Owens & Minor, with input from Stephen Pala, Director of Cardiac Cath and EP Labs for Inova Fairfax Hospital.