Site Visit Assessment sheet:

Part A: Hospital General Information

Name Tel e-mail

Hospital name:

Director

Main Cardiac Surgeon:

Main Cardiologist

Main anesthetist

Part b: ICU

title number comments

ICU Beds

ICU Monitors

ICU Ventilators

Blood gas Machine

Warming blanket

Syringe pumps

Infusion pumps

Drugs: (General)
Inotropes

Antibiotics

Diuretics

Antifungal

Analgesic

IV Narcotics

Disposales: (Syringes, Face

Mask for Kids, Urinary Tubes,
NG tubes, Gloves…)

ICU Location and Access

Staff:

Nurses

RT

Intensivists

Oxygen and medical Gases

General Comments (ICU)

Intermediate Beds HDU

Overall ICU Assessment

Part C: Operating Rooms

title number comment

Operating Room

Staff (Anesthetists, Nurses)

Medical gases

OR Tables

Ventilators

Monitors & transducers.

Anesthesia gases

Narcotics and Muscle

relaxant

CPB

Oxygenators

Filters

Tubings

Infusion and Syringe Pump

Drugs:
Heparin, Protamine

Blood Products:
PRBCS
FFP
Platelets
Catheters

Prepping technique

Draping

Gowns and Gloves

Sutures

Surgical Instruments
 Surgical tubes and grafts

OR Location

Over all OR assessment

Part D: Ward

Beds

Nurses

Monitored Beds

telemonitors

Echo Machines

Overall Ward assessment

Part E:

Cathlab

Cath rooms

Cath Machine

TEE

Types Of Catheters Available

Gowns

Lead Aprons

Cath Lab Monitors

Haemodynamic Measurments

Cath lab nurses

Availability of anaesthesia in
cath lab

Overall Cathlab assessment

Part F: Liabilities and provisions:

Financial

Training

Way of patients recruitment

Other provisions

Need for temporary work

permit and its requirements

Part G:

Team Needed.

Surgical Team =

Cardiology Team =
Part H:

Overall Visit assessments: