Keys to Success in Designing a Hybrid Cath Lab
A new trend is emerging in cardiac services — the hybrid catheterization lab. There is some controversy over the specific definition (A cath lab where they will also do surgery? An OR where they have fixed imaging?), but hybrid cath labs combine the traditional diagnostic functions of a cath lab with the surgical functions of an operating room. Most existing cath labs are not large enough to convert into hybrid labs, so hybrid labs are typically placed in locations adjacent to surgical suites. Only a handful have been developed thus far, mostly focusing on pediatric procedures, but the applicability and advantages of these labs are becoming increasingly evident.
Many interventional specialists are seeking hybrid facilities. Interventional cardiologists (adult and pediatric), along with cardiac, vascular and neuro surgeons have a number of procedures that are well-suited for hybrid rooms. These include abdominal aortic aneurysms (AAA), peripheral stenting, percutaneous valve repair, minimally invasive direct coronary artery bypass (MIDCAB)/stent and aneurysm coiling.
Despite most architects’ and hospitals’ experience designing and constructing cath labs and ORs, the design and construction of a hybrid room is not as simple as a pure combination of the two. What are the challenges in designing a hybrid cath lab? Following are three areas on which to focus:
The hybrid cath lab must serve two functions: diagnostic and surgical. That means a multi-disciplinary merger of medical professionals who have a stake in the space. Interventional cardiologists play the primary role in cath labs. Blending that function with an operating room, however, means that surgeons will now have a role within what was formerly just a cath lab.
Clearly, a team approach is required for the successful implementation of the hybrid lab. Planners and architects need to realize and understand the respective roles of each team of medical professionals, finding ways to balance each team’s requirements. Hospital administrators obviously need to take the lead, and set a tone of teamwork and cooperation among the clinicians.
Staffing within the room includes cardiology, electrophysiology, surgical, anesthesiology, perfusion and echo teams in addition to the nursing/support staff. Determining the various layout scenarios for each team to do their work during a particular procedure is challenging.
Critical to obtaining the buy-in of all teams is the recognition that a hybrid cath lab can serve patients in an innovative way. Offering the ability to diagnose cardiac conditions and quickly move patients to a recommended surgical procedure is a clear benefit of these facilities. Making sure that everyone on the clinical platform is in sync with that concept is an absolute necessity.
Several issues are important during the planning process that will impact the design of the hybrid cath lab. Equipment location, vibration, HVAC and radiation exposure all require special consideration.
Because the bi-plane is extremely sensitive, vibration testing is necessary to determine if mitigation is required. Vibration sources that can affect the lab operations are normally generated from within the hospital. Fan units in proximity to the lab are a frequent source of vibration. Ideally, eliminating vibration at the source is the preferred approach; when complexity does not make this feasible, other vibration isolation techniques may be required.
The location of equipment is crucial. Each clinical discipline will bring a different set of equipment into the hybrid lab, causing potential conflicts over space and placement. Finding compromise locations that still optimize efficient use of that equipment can be a challenge; the teamwork mentioned above will come into play. This includes engineering staff to predict and plan for the numerous facility issues such as power, HVAC and various building infrastructure services.
Radiation is a constant concern in cath labs, and more so in a hybrid lab. In the cath lab setting, medical personnel wear lead aprons for protection from radiation. In the hybrid lab, all personnel, including surgical, would be required to wear aprons during any procedure requiring even minimal amounts of concurrent imaging. Additionally, a radiation safety physicist will determine how much of the lab must be shielded. Radiation protection is provided by mass, which is usually done by lining the walls with lead panels.
Additional ventilation and cooling systems may be required in the hybrid lab that would not be necessary in a typical cath lab. Since medical personnel will wear lead aprons, their comfort will be affected, possibly requiring lower air temperatures. More importantly, many surgeons require lower room temperatures as a method of controlling patient metabolism. In many cases, a hybrid cath lab may need to operate at temperatures as low as 60 degrees Fahrenheit.
Most existing cath labs are code compliant, but have insufficient space for hybrid procedures. The bi-plane unit has particularly rigid vertical space requirements. To accommodate that unit, a ceiling height of between 9’ 6” and 9’ 9” is required. Creating that ceiling height within an existing medical complex can be challenging. Existing plenum spaces (space between the ceiling and structural floor above) may be cramped and usually contain numerous ducts, electrical conduits and other mechanical equipment. Medical centers that were built with an interstitial floor make the insertion of a hybrid cath lab much easier; unfortunately, these are the exception rather than the norm.
Cabling, wiring and hoses — all part of modern medical equipment — should be off the floor to facilitate housekeeping and eliminate tripping hazards. Careful placement of each component is necessary and adequate oversight of vendors who often install that equipment is crucial.
For most projects, the highest Infection Control Risk Assessment (ICRA) controls will be needed during construction. The staff in adjacent spaces must be made aware that renovations can and will be disruptive. Noise, utility shut-down coordination and construction access are only a few of the disruptions during the renovation period.
The hybrid cath lab offers significant advantages in the concurrent diagnosis and treatment of patients requiring cardiac procedures — facilitating a rapid-response approach as never before. The design and construction of the hybrid lab requires extra care and planning, but will result in a more effective facility. To successfully manage the development of these new and innovative rooms, it is clear that communication and coordination among all disciplines — clinical, architectural, engineering, and strategic — is critical.
Jack Kerr is a Senior Healthcare Architect and Planner at Array Healthcare Facilities Solutions. He brings thirty years of healthcare planning and design experience with particular focus on diagnostics and surgery. He has recently emerged as an expert on the burgeoning trend of hybrid suites. Jack can be reached at at (610) 270-0599 or firstname.lastname@example.org