**5.1.1 Applications training**

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

The Hybrid Operating Room 99

Fig. 20b. Typical training schedule of the second and third week of applications training in

Some device and imaging vendors offer hands-on trainings at conferences or in their factories or showrooms for physicians that are just starting to use imaging systems. During these trainings, experienced cardiac surgeons and cardiologists train less experienced surgeons and fellows on transcatheter procedures and imaging. Corner stone of these trainings are the hands-on sessions. The trainee is guided by an experienced cardiologist or surgeon while practicing the use of devices like catheters and valves under real image guidance by an angiography system. The system and room set-up resembles a real hybrid

Fig. 21. An experienced interventional cardiologist teaches surgeons in basic wire

the hybrid OR

techniques.

**5.1.4 Hands-on workshops** 

OR or hybrid cathlab (see Fig. 21).

experienced users and offered for approximately three days. Due to limited experience with imaging systems in the OR team, however, the training needs in surgery are much higher than for example in radiology.

Duration and content of the application training largely depend on how many different clinical disciplines use the system, on their level of experience and on the number of staff to be trained. During these trainings, the users are, depending on their scope of responsibility, being familiarized with system handling, software usage, image processing and archiving, the typical workflow in the hybrid OR and radiation protection. The trainers should be present during different clinical procedures in order to provide training and support system usage in clinical operation. Fig. 20a and Fig. 20b show an example plan for a three weeks applications training.


Fig. 20a. Typical training schedule of the first week of application training for hybrid OR

### **5.1.2 Mini fellowships at clinical sites**

Some experienced clinical sites also offer the possibility to do short fellowships. The fellow is being assigned to an experienced team for 3-5 days. During the fellowship the fellow will experience the typical workflow in a hybrid OR by accompanying the trainer through the different work steps, including treatment decisions and surgery, with the opportunity to discuss the workflow with the whole OR team.

### **5.1.3 Training in other departments within the hospital**

It has also proven to be very beneficial to send a designated Super User to a department in the hospital that is very experienced with angiography systems, for example radiology or cardiology. An internship of about one week helps the user to become familiar with system usage under the guidance of experienced users.

experienced users and offered for approximately three days. Due to limited experience with imaging systems in the OR team, however, the training needs in surgery are much higher

Duration and content of the application training largely depend on how many different clinical disciplines use the system, on their level of experience and on the number of staff to be trained. During these trainings, the users are, depending on their scope of responsibility, being familiarized with system handling, software usage, image processing and archiving, the typical workflow in the hybrid OR and radiation protection. The trainers should be present during different clinical procedures in order to provide training and support system usage in clinical operation. Fig. 20a and Fig. 20b show an example plan for a three weeks

Fig. 20a. Typical training schedule of the first week of application training for hybrid OR

Some experienced clinical sites also offer the possibility to do short fellowships. The fellow is being assigned to an experienced team for 3-5 days. During the fellowship the fellow will experience the typical workflow in a hybrid OR by accompanying the trainer through the different work steps, including treatment decisions and surgery, with the opportunity to

It has also proven to be very beneficial to send a designated Super User to a department in the hospital that is very experienced with angiography systems, for example radiology or cardiology. An internship of about one week helps the user to become familiar with system

than for example in radiology.

**5.1.2 Mini fellowships at clinical sites** 

discuss the workflow with the whole OR team.

usage under the guidance of experienced users.

**5.1.3 Training in other departments within the hospital** 

applications training.


Fig. 20b. Typical training schedule of the second and third week of applications training in the hybrid OR

### **5.1.4 Hands-on workshops**

Some device and imaging vendors offer hands-on trainings at conferences or in their factories or showrooms for physicians that are just starting to use imaging systems. During these trainings, experienced cardiac surgeons and cardiologists train less experienced surgeons and fellows on transcatheter procedures and imaging. Corner stone of these trainings are the hands-on sessions. The trainee is guided by an experienced cardiologist or surgeon while practicing the use of devices like catheters and valves under real image guidance by an angiography system. The system and room set-up resembles a real hybrid OR or hybrid cathlab (see Fig. 21).

Fig. 21. An experienced interventional cardiologist teaches surgeons in basic wire techniques.

The Hybrid Operating Room 101

1.3m for construction work and \$ 2.1 for the equipment. In the first year, starting with a very low volume of TAVI patients of 24 and consequently lower revenue of \$ 1m, the total net revenue was \$ 0.9m after reducing bad debt allowance and billing & collection. Annual total fixed costs accumulated to \$ 0.1m, variable costs for devices, labour etc. to \$ 0.9m leading to total costs of \$ 1m during year one. Consequently the net income was negative by \$ 23k in the first year. With an increase in patient volume to 37, however, already in year two a net

Table 3 gives an overview and comparison of the cost and return situation (by St. Vincent

**year 2010 (St. Vincent) / year 1 (Advisory Board)** 6200 1000 **Net revenue** 2400 900 **Total expenses** 800 1000

**year 2010 (St. Vincent) / year 1 (Advisory Board)** 800 -23

**year 2015 (St. Vincent) / year 5 (Advisory Board)** 5400 1300

Table 3. Financial comparison of pro forma from St. Vincent Heart Center and The Advisory

As a general fact, the set-up of hybrid rooms allows for the treatment of previously untreatable patients. Good examples are TAVIs. Now, patients previously deemed too old or weak for surgery, can be treated by transcatheter valve implantation. With an aging population and developments in medicine, the number of octogenarians and nonagenarians to be treated with new hybrid and minimally invasive procedures that are best performed in a hybrid OR will continue to grow. This will lead to increasing usage of the room capacity and consequently a quicker return on investment. Also, with less invasive treatment the necessity to stay in the ICU and the hospital for a long time in general decreases, along with the risk of infections. This allows discharging patients quicker, which again leads to an improved cost situation in the hospital. Furthermore hybrid rooms help to increase efficiency and decrease turnover time which can lead to additional cases being performed in the hybrid room as compared to a standard OR (Benjamin, 2008). A conventional surgical valve replacement often takes more than three hours, whereas a transcatheter valve implantation can be done in one. Calculations indicate that the mean incremental operating room profit per procedure is about \$ 1,500 per hour. If the hospital manages to add only one single hour-long case each day, the hybrid OR

In cardiac surgery, the operating room profit is usually even about 25-30% above the mean

Another soft factor that can have a positive financial impact is to use the hybrid OR to position the hospital among the technologically most advanced institutions in the area. This

**St. Vincent Heart Center** 

**Advisory Board Company** 

income of \$ 0.4m could be realized.

**Gross patient revenue in** 

**Net Present Value (NPV) in** 

**Net Present Value (NPV) in** 

Board Company (Cronin & Schroyer, 2010)

could help increase profitability by about \$ 300k p.a.

incremental OR profit (Resnick et al., 2005).

**5.2.3 Positive marketing effects** 

*Rounded figures in k USD* 

Heart Center and the Advisory Board Company).
