**4.4 Lights**

Ceiling space in a hybrid OR may be limited, particularly if a ceiling mounted system is preferred. Thus, OR lights need special attention, because they may collide with the imaging systems, pendants or display booms (Tomaszewski, 2008).

In general, two different light sources are needed in an operating room: the surgical (operating) lights used for open procedures and the ambient lighting for interventional procedures. Particular attention should be paid to the possibility to dim the lights. This is frequently needed during fluoroscopy or endoscopy.

For the surgical lights it is most important that they cover the complete area across the operating room table. Moreover, they must not interfere with head heights and collision paths of other equipment. The most frequent mounting position of OR-lights is centrally above the OR table. If a different position is chosen, the lights usually are swivelled in from an area outside the OR table. Because one central axis per light head is necessary, this may lead to at least two central axes and mounting points in order to ensure sufficient illumination of the surgical field. The movement range of the angiography system determines the positioning of the OR lights. Central axes must be outside of moving path and swivel range. This is especially important as devices have defined room height requirements that must be met. In this case, head clearance height for the OR-light may be an issue. This makes lights a critical item in the planning and design process (Tomaszewski, 2008).

Other aspects in the planning process of OR lights include avoidance of glare and reflections. Modern OR lights may have additional features, like build in camera and video capabilities. For the illumination of the wound area, a double-arm OR-light system is required. Sometimes even a third light may be required, in cases where more than one surgical activity takes place at the same time, e.g. vein stripping of the legs.

In summary, the key topics for planning the surgical light system include:


### **4.5 Hygiene**

The operating room has different and stricter hygienic requirements and standards to meet than an interventional suite. Recently, hygiene has become a strong focus in addressing quality of healthcare delivery (Kerr, 2009; Hirsch, 2008; Sikkink et al., 2008; Peeters et al., 2008). Several workflow related aspects are crucial for achieving optimal hygienic conditions in operating rooms. A surgical scrub facility immediately outside of the OR is mandatory to allow proper scrubbing in for all procedures. Hats, gloves, facemasks and proper gowns are

In summary, important aspects to be included considered are the position in the room, radiolucency (carbon fiber tabletop), compatibility, and integration of imaging devices with the operating table. Further aspects include table load, adjustable table height, and horizontal mobility (floating) including vertical and lateral tilt. It is important to also have proper accessories available, such as rails for mounting special surgical equipment (retractors, camera holder). Free floating angiography tables with tilt and cradle capabilities

Ceiling space in a hybrid OR may be limited, particularly if a ceiling mounted system is preferred. Thus, OR lights need special attention, because they may collide with the imaging

In general, two different light sources are needed in an operating room: the surgical (operating) lights used for open procedures and the ambient lighting for interventional procedures. Particular attention should be paid to the possibility to dim the lights. This is

For the surgical lights it is most important that they cover the complete area across the operating room table. Moreover, they must not interfere with head heights and collision paths of other equipment. The most frequent mounting position of OR-lights is centrally above the OR table. If a different position is chosen, the lights usually are swivelled in from an area outside the OR table. Because one central axis per light head is necessary, this may lead to at least two central axes and mounting points in order to ensure sufficient illumination of the surgical field. The movement range of the angiography system determines the positioning of the OR lights. Central axes must be outside of moving path and swivel range. This is especially important as devices have defined room height requirements that must be met. In this case, head clearance height for the OR-light may be an issue. This makes lights a critical item in the planning and design process (Tomaszewski,

Other aspects in the planning process of OR lights include avoidance of glare and reflections. Modern OR lights may have additional features, like build in camera and video capabilities. For the illumination of the wound area, a double-arm OR-light system is required. Sometimes even a third light may be required, in cases where more than one


The operating room has different and stricter hygienic requirements and standards to meet than an interventional suite. Recently, hygiene has become a strong focus in addressing quality of healthcare delivery (Kerr, 2009; Hirsch, 2008; Sikkink et al., 2008; Peeters et al., 2008). Several workflow related aspects are crucial for achieving optimal hygienic conditions in operating rooms. A surgical scrub facility immediately outside of the OR is mandatory to allow proper scrubbing in for all procedures. Hats, gloves, facemasks and proper gowns are

surgical activity takes place at the same time, e.g. vein stripping of the legs. In summary, the key topics for planning the surgical light system include:



are best suited for cardiovascular hybrid operating rooms.

systems, pendants or display booms (Tomaszewski, 2008).

frequently needed during fluoroscopy or endoscopy.

**4.4 Lights** 

2008).

**4.5 Hygiene** 

positioning of light heads

mandatory, as well as access sterile processing facilities for the disposal of soiled material from open procedures. Finally, clean air, air conditioning and ventilation technologies play an important role in achieving these hygienic standards.

Today, this is mainly achieved with dedicated air-conditioning and ventilation solutions that create a limited protection zone, usually called "Laminar Airflow", even though this terminology might sometimes be technically misleading. These ventilation systems need to cover the entire aseptic environment of surgery in operating rooms, including the tables for materials and instruments. This zone allows for clean-room handovers of sterilized materials and shields the surgical team in sterilized garb, usually by a sufficiently large lowturbulence displacement air flow. Recent guidelines, e.g. in Germany, emphasize the importance of low turbulence. To meet the requirements of air cleanliness for operating theatres or other surgery rooms with strict hygienic requirements, very high volume flows of clean air are necessary. There are different solutions available to do so in an energyefficient way. Usually, low-turbulence displacement circulating air canopies are employed.

Local requirements for the hygienic aspects of Heat, Ventilation, Air Conditioning (HVAC) vary significantly. Experts knowing the local requirements need to be involved in order to ensure clearance of the hybrid OR at the end of the project. This topic is to be discussed in detail with the responsible individuals and authorities in order to avoid non compliance with local regulations.

Fig. 15. Example for a Laminar Airflow ceiling ensuring a clean environment above the surgical area

### **4.6 Room layout**

The main objective of OR design is to improve the OR workflow and enhance safety by ensuring good access and clear walkways. This sets the stage for equipment and equipment

The Hybrid Operating Room 95

*Exemplary layout and equipment for a cardiac Hybrid OR*

Fig. 16. A schematic room layout and equipment map of a hybrid OR depicts the complexity

of planning an OR that allows for efficient workflow for all parties involved

Fig. 17. Schematic Room layout with important areas for workflow considerations

for experienced planners. Fig. 18 and Fig. 19 illustrate this issue.

equipment follows this framework. Planning should always be done in 2D and with CAD, because this is the only way to identify all technical interdependencies and to allow for a reliable check of the technical feasibility of the installation. One single master plan across all equipment and vendors has to be created in CAD, while each vendor is meant to provide proper CAD blocks (Tomaszewski, 2008). However, 2D is usually not easy to "read", even

highlighted

1. Angiography system 2. Contrast injector 3. Operating table 4. Operating lights 5. Anesthesia/respirator/

(TEE/intravascular ultrasound) 8. Surgical instruments / catheter trolley 9. Electrocautery 10.Defibrillator 11.Cell saver 12.IABP

13.Ceiling pendants

injectors 6. Heart-lung machine 7. Ultrasound

planning in the OR. Devices should be easy and quick to position and park. The limited space must be utilized optimally. Ergonomic aspects are to be considered for layout and design, which should enable flexible device management to cater to the needs of the various users and procedures. A clear floor and optimized cable management allow for efficient cleaning and easier maneuvering of devices. Moreover, this avoids tripping hazards. Camera and monitor systems for displaying patient data, for educational purposes or for telemedicine, may be necessary. Thus, and because of the complex needs for viewing during hybrid procedures, a good understanding of the visualization needs is vital. Data integration and IT are becoming more and more prominent for documentation, archiving and information provision.

Interventional rooms have excellent imaging capabilities, but frequently lack the prerequisites required for formal operating rooms. Operating rooms meet those required standards, but usually lack high-level imaging capabilities. Therefore, the hybrid operating room has different space requirements. The larger the better should be the basic principle for planning. Staff calculations have shown that, in hybrid procedures, up to 18 people are in the hybrid room. Current recommendations for hybrid operating rooms suggest > 70 m2 in comparison to 40-60 m2 for conventional operating rooms (space for a control and a technical room has to be added). The room has to fulfill radiation safety requirements as any other angiography room.

A key part of any conceptual design is to visit other institutions that have built a hybrid OR (Benjamin, 2008). Thereby, customers learn from best practice and understand what works best for others and what other sites would have done differently if they could do it again. Topics include type of storage space, type of angiography system, handling of the patient flow and anesthesia services, control room concept, sufficiency of space, the type of inventory control and storage they have, and usage of barcodes or infrared technology. Storage capabilities are especially important. Oftentimes there will be no personnel available to fetch devices stored outside the OR. Build-in glass cabinets have proven to be particularly useful because they allow the nurses to quickly locate materials. Design includes the following steps and activities (Tomaszewski, 2008):


Centres with close proximity of intervention rooms and ORs probably have better prerequisites than hospitals with the classic separation of interventional rooms located in the internal medicine building and operating theatres located in the surgery building. In this situation, we recommend installing the hybrid room in the surgical wing for two reasons:


### **4.7 Planning process**

The standard OR-layout is defined by the centrally positioned OR table and required access areas to the patient for anesthesia and surgery. In the hybrid OR the position of the angiography system and the table set the stage for the workflow inside the room. Other

planning in the OR. Devices should be easy and quick to position and park. The limited space must be utilized optimally. Ergonomic aspects are to be considered for layout and design, which should enable flexible device management to cater to the needs of the various users and procedures. A clear floor and optimized cable management allow for efficient cleaning and easier maneuvering of devices. Moreover, this avoids tripping hazards. Camera and monitor systems for displaying patient data, for educational purposes or for telemedicine, may be necessary. Thus, and because of the complex needs for viewing during hybrid procedures, a good understanding of the visualization needs is vital. Data integration and IT are becoming more and more prominent for documentation, archiving

Interventional rooms have excellent imaging capabilities, but frequently lack the prerequisites required for formal operating rooms. Operating rooms meet those required standards, but usually lack high-level imaging capabilities. Therefore, the hybrid operating room has different space requirements. The larger the better should be the basic principle for planning. Staff calculations have shown that, in hybrid procedures, up to 18 people are in the hybrid room. Current recommendations for hybrid operating rooms suggest > 70 m2 in comparison to 40-60 m2 for conventional operating rooms (space for a control and a technical room has to be added). The room has to fulfill radiation safety requirements as any

A key part of any conceptual design is to visit other institutions that have built a hybrid OR (Benjamin, 2008). Thereby, customers learn from best practice and understand what works best for others and what other sites would have done differently if they could do it again. Topics include type of storage space, type of angiography system, handling of the patient flow and anesthesia services, control room concept, sufficiency of space, the type of inventory control and storage they have, and usage of barcodes or infrared technology. Storage capabilities are especially important. Oftentimes there will be no personnel available to fetch devices stored outside the OR. Build-in glass cabinets have proven to be particularly useful because they allow the nurses to quickly locate materials. Design includes the


Centres with close proximity of intervention rooms and ORs probably have better prerequisites than hospitals with the classic separation of interventional rooms located in the internal medicine building and operating theatres located in the surgery building. In this situation, we recommend installing the hybrid room in the surgical wing for two reasons: 1. Immediate readiness of all OR equipment and personnel (e.g., heart-lung machine and perfusionists) and access to all surgical supply chain processes, especially in emergency

The standard OR-layout is defined by the centrally positioned OR table and required access areas to the patient for anesthesia and surgery. In the hybrid OR the position of the angiography system and the table set the stage for the workflow inside the room. Other


and information provision.

other angiography room.

situations

**4.7 Planning process** 

following steps and activities (Tomaszewski, 2008): - Define your current and future workflow and setup


2. Availability of anesthesia and surgical intensive care

imaging system as a general guideline

Fig. 16. A schematic room layout and equipment map of a hybrid OR depicts the complexity of planning an OR that allows for efficient workflow for all parties involved

Fig. 17. Schematic Room layout with important areas for workflow considerations highlighted

equipment follows this framework. Planning should always be done in 2D and with CAD, because this is the only way to identify all technical interdependencies and to allow for a reliable check of the technical feasibility of the installation. One single master plan across all equipment and vendors has to be created in CAD, while each vendor is meant to provide proper CAD blocks (Tomaszewski, 2008). However, 2D is usually not easy to "read", even for experienced planners. Fig. 18 and Fig. 19 illustrate this issue.

The Hybrid Operating Room 97

Table 2. Overview of key aspects to be considered during the planning and design process

To take advantage of the multiple advanced imaging capabilities of state-of-the-art fixed angiography systems, extensive training for physicians, nurses and technicians is crucial. Most members of the OR team are not familiar with fixed angiography systems. Only if they are well versed in and comfortable using it, they can take full advantage of the imaging and

Training of the team can be achieved by different concepts. However, at least one member of the OR team should be trained in very detail in order to use the system to its full potential. This person should serve as a trainer for the other team members and should take responsibility for the imaging. A good possibility is to ask colleagues from the radiology department to take over the training of the OR team member, since they are very familiar with imaging. This specially trained team member should then train several super users, who are also very familiar with the system. By ensuring that multiple OR team members can operate the system very well, 24/7 coverage can be provided in the hybrid OR - also for

The individual scope of training depends on the responsibility of the OR staff as well as on the workflow set-up. If for example the surgeon himself operates the angiography system, he will be among the ones undergoing training in system handling and operation. If, by contrast, the system is operated by a radiographer, the surgeon will not need to be trained in

Training possibilities are multiple. Principle training may be achieved by training in the hospital's own hybrid OR by the provider of the imaging system (applications training), at other clinical sites by experienced physicians and technicians (mini fellowships), in other departments within the hospital, and at hands-on workshops, usually organized by the

When purchasing an angiography system for the hybrid OR, applications training is usually provided by the vendor of the imaging system. This training is generally intended for

emergency cases on weekends or during night shifts, if required.

Cross-functional team Angiography system Surgical versus angiography table Lights and illumination

Workflow and standard room set-up

Audio- and video integration including visualization and display placement

IT-integration (HIS, PACS)

Location and space requirements incl. ancillary spaces for technical room,

Ceiling suspension units and services on these units (number of sockets, gases etc.)

Mobile and other equipment, needs and position: anesthesia, monitoring and hemodynamics, injectors, ultrasound, heart

storage, etc.

and lung machine

detail.

industry.

**5.1.1 Applications training** 

**5. Other considerations 5.1 Training for imaging** 

workflow capabilities of a hybrid OR.

Fig. 18. Example for a 2D drawing of a hybrid OR plan capturing all interdependencies that has limited readability for the parties involved

Fig. 19. Examples for 3D presentation of a hybrid OR plan, ensuring a common vision of the future facility across all parties involved

3D visualization helps to illustrate the 2D plan, so that full understanding from all parties involved is ensured. Most medical equipment suppliers and architects have the ability to represent in 3D, such that all elements of the final outcome of the OR can be included in this visualization. The following checklist provides an overview of key aspects for consideration during the planning and design process:

Fig. 18. Example for a 2D drawing of a hybrid OR plan capturing all interdependencies that

Fig. 19. Examples for 3D presentation of a hybrid OR plan, ensuring a common vision of the

3D visualization helps to illustrate the 2D plan, so that full understanding from all parties involved is ensured. Most medical equipment suppliers and architects have the ability to represent in 3D, such that all elements of the final outcome of the OR can be included in this visualization. The following checklist provides an overview of key aspects for consideration

has limited readability for the parties involved

future facility across all parties involved

during the planning and design process:


Table 2. Overview of key aspects to be considered during the planning and design process
