Susana Perese, BS, RVT, FASE

Over the years we’ve all seen and most likely have worked in various types of clinical models, from the dedicated lab where only one type of specialty of examinations is performed (noninvasive cardiology, pulmonary, vascular, or radiology) to the now trendier model of the multi-disciplinary or “hybrid” lab. In these hybrid labs, a wide array of examination specialties are being combined and offered at a single location. Some make sense, some don’t. But what is evident is that they are being developed throughout the country and in great numbers.

I happen to work in an atypical academic setting that offers the opportunity to work in both dedicated and hybrid labs. We have a dedicated noninvasive cardiology lab and a dedicated noninvasive vascular lab in the hospital setting, and a hybrid cardiovascular diagnostic center in the outpatient facility. For your thought and consideration, I offer my perspective on this growing trend of hybrid labs.

There are many benefits to working in a hybrid lab. The most obvious and significant reason is financial. A hybrid lab allows the sharing of expenses that would normally be paid by individual departments: clinical, clerical and administrative expenses for space, supplies, staff, and equipment. This benefit is one on which administrators dwell, for all the obvious reasons, and in this economy, who wouldn’t? Patients and referring physicians benefit tremendously from the “one-stop” shop set-up. Referring physicians don’t have to call different departments and send separate requisition orders. Patients prefer to go to only one diagnostic center. And as we know, most of our patient population is older, forgetful, and slower, so having them go to a single location has been an important component of good customer service.

Operationally, we see improved patient flow through the hybrid lab at various levels. Clinically we have nursing and medical support available at all times and for all examinations; this has become important in providing efficient and expedited service. There is an ease of performing multiple exams on a single patient in one room with one machine (for example, echo and carotid ultrasonography exams). We’ve also seen improved relationships among the clinical and medical staffs, who historically usually do not work well together due to “turf” issues. In our hybrid lab model, we have a panel of physicians from various disciplines (echo, electrophysiologists, neurology, internists, vascular surgery, and radiology) who no longer work in silos but work collaboratively in the interpretation of studies and improvement of quality. We’ve also seen the expansion of fellowship programs that now offer comprehensive cardiology and vascular diagnostic curriculum which were previously restricted due to political boundaries. We are excited to see that this collaboration has also extended into the hospital setting.

Another advantage to having a hybrid lab is the cross-over in work that is required administratively. Each department would normally have individual policies and procedures, quality assurance and accreditation. In a hybrid lab, the administrative work done for one specialty lends itself to the others, thereby reducing the work at organizational levels. As you begin to work toward accreditation, you find that most of the setup work that you created for one specialty makes it easier to establish parallel programs for the others.

In a hybrid lab we have also seen advantages in the flexibility of using equipment and its peripherals for all modalities. This has become a life-saver when one system goes down and you need to consider cancelling or rescheduling patients. Another advantage has been the sharing of support systems. We have a single PACS system that allows the reading of our echo, vascular, stress, electrophysiology, and nuclear studies. Separate and distinct PACS systems can be quite costly, so we’ve seen significant cost-savings in having an integrated system. However, we will acknowledge that in a hybrid lab, one should be aware of the need and expense of “other” equipment and applications that one wouldn’t have in a dedicated lab. For example, in a comprehensive vascular service, one should have physiological instruments such as arterial Doppler, PPG, transcranial Doppler, and transcutaneous oxygen systems that would normally not be purchased.

Staffing will remain an interesting and challenging advantage. In an ideal hybrid model, staff would be cross-trained to perform all examinations. However, it is difficult to identify cardiovascular sonographers who are proficient in both echo and vascular sonography. Our labs (both hospital and outpatient) have dedicated echo and vascular techs who perform within their dedicated specialties; that is to say they are not cross-trained. Although this limits our being able to use the staff more flexibly, we do perform comprehensive high quality examinations as evidenced by our outcomes, quality correlations and accreditation in echo, stress echo, peripheral venous, peripheral arterial, cerebrovascular, and visceral vascular areas. If you consider cross-training, we believe it imperative that staff have formal didactic training and be allowed dedicated scanning time. This may be costly at the onset, but will be worthwhile once staff is independent.

Last but not least, we see collaborative diagnosis across the performance and evaluation of cardiovascular examinations: CABG: echo, pre-operative carotid duplex and vein mapping for vessel conduit; HTN: echo, renal arteries, vascular compliance; aortic root enlargement: echo, thoracic and abdominal aorta; Patent Foramen Ovale: TCD, echo.

In conclusion, hybrid labs come with challenges and added nuances, but seem to work best for referring physicians, staff, and most importantly, patients.