Time Saving For Cardiothoracic Surgical Inpatients (From Admission To Discharge
A Project For Fulfillment Of Hospital Management Diploma
Introduced by Dr. Mostafa A.Elsalam Dr. Ehab Tantawy Hafez
(National Heart Institute)
Anaethists ( 26 ).
Aim of the work: Decreasing the inpatient stay for cardiothoracic surgeries to average 7-10 days.
Specific .Introduction: National Heart Institute is the oldest hospital for cardiac surgery in the middle east and it receives the highest flow for cardiac patients .
Strength points: 1. realistic. applicable.we can say it the mother of cardiac patients. measurable. Nurses :
Prefeasibility study: Idea: from our beliefs for the NHI educational and medical role in the middle east . and our goal to achieve it within one month and re-evaluate after one year.Man power / 110 cardiothoracic surgeons (43 consultants -25 registral-32 house officer or resident). we can save the cost and multiply the profit for the government and the institute so it will be accepted from all parteners involved.
equipment and surgical accessories. Long time for INR control in valvular patients.etc. 6.Decreasing the cost of stay for patients and therefore increasing the profit. 3. 2.More reputation which can put in consideration making an extension for the institute.Beds Ward beds/186 beds ( 160 health insurance and ministry of health referrals for treatment on government behalf ). ).Decrease waiting list time. 4.Enough machines .Good reputation.g. ICU resources defect (e. Less experienced surgeons to do high risk surgeries. 2. Heart lung machine air embolism. ICU nurses (64).A lot of money resources ( health insurance-ministry referrals-private sector-donations…….
. pressure cable ). Delayed post-operative echo cardiography. 3.9 operation rooms.
Weakness: 1234567Nursing problems.
Opportunities: 1.Operation nurses (36 ). 5. Wound infections (deep and superficial). Icu beds 64 bed.
Feasibility study :
Medical : since valvular and ischemic heart diseases increased in our nation and in middle east we hope to have a major role in solving the problem.better service and credibility.
. High authority recommendation for certain patients to break rules and regulations(.regulations and laws.)الوساطه و المحسوبيه 5.Some consultants may resist the project in favor of private sector. Security problems. Patient flora changes.
Political : we need to make some rules and regulations more flexible concerning pay check.
Technology : Enough machines and equipment. Social : it will satisfy low socio-economic patients. Economical : NHI has a good economical state which can be more better ( can raise the profit by 40 % ).Threats : 1234Facing policies. more reputation.
Wound infection patients cost the institute extra 300 L. 52% of patients stay in ICU less than 3 days ( 1188). 53% of patients are discharged after one week of surgery(1211). daily post –operative.E. daily ICU. Legal : the project is not against the law or regulations. 14% of patients stay in ICU 7-15 days (321).E.E. 66% of patients stay 7 days preoperative (1500 patients). 15% of patients are discharged more than 15 days . Ischemic heart diseased patients cost the institute : 106 L. 700 L. 26 %of patients stay in ICU 3-7 days (587). 177 L. Economical : Vavular heart diseased patients cost the institute : 106 L.
2011 statistics :
Total patients 2500. 8% of patients stay in ICU more than 15 days (154). 600 L.E. for antibiotics. 34% of patients stay more than 7 days preoperative (750 patients). daily ICU. daily preoperative. daily pre-operative.E.E.
. Social : social beliefs in our favor that NHI is the first and biggest hospital for receiving cardiac patients ( low socio-economical patients).etc. 32% of patients are discharged after 15 days (724). daily post operative. medical resources…. 277 L.E. Technical : available equipments . machines .
Overcrowding of ICU by patients which make lack or scarcity of available beds. 2. 5.Target:
To make total stay 7-10 days. 2.Heart lung machine without level detectors may lead to air embolism.Less experienced surgeons do high risk surgeries.Prolonged control of INR in valvular patients. 7.
Intra-operative problems : 1. 6. Patients stay pre-operative 1 day.High authority recommendation for certain patients to overcome rules and regulations concerning admission.Defect in ICU nurses because of misdistribution or special problems (pregnancy-illness-absence).Defects in resources (protamine-potassium-sodium-bicarbonateoxygenators-CVP'S-aortic balloon . ICU stay 2-3 days . etc….Menstruation of female patients. Post-operative stay in ward 4-6 days.
Problems delaying patient's operation and increase cost of pre-operative stay : 1. 3.).Admission of patient before operation by long time.
Post –operative pericardial effusion. 4. intra-aortic balloon.Delayed post-operative ECHO cardiography.Prolonged INR control in valvular patients .Some mistakes involving infection control. chest infection . renal failure patients. 5.etc…).Delayed weaning of inotropes ( debutrex –adrenaline .3.
Problem solving :
Protocol for admission of patients :
1. 6. cerebro-vascular stroke. 3. delayed weaning from mechanical ventilator.Prolonged ICU stay due to delayed recovery.
Post-operative problems : 1. 2. Contact between the patient and institute at least 2 telephone numbers and address.Less experienced anaethists make hazards for patients in arterial line-CVP line –intra-tracheal intubation and induction. The patient must be fully investigated and prepared before admission.No regular post-operative follow up of patients. emergency patients without ward beds . Wound infections (deep and superficial). Call the patient one week before the day of admission (ischemic patients stop aspocid and plavex and start subcutaneous clexan 40 i.u 1*1/valvular patients stop marevan and start cal-heparin amp every 8 hours). 3. 2.
. 4. 7.
3. 5. Start with 10 mg marevan for 3 days then 5 mg from 4th day. Avoidance of food containing vitamin k. Enough resources and stores ( enough safe stock ). Good storing of marevan and keep it away from light and humidity.
Protocol for INR control in post-operative patients :
1. Admission one day before operation at 9 am maximum (CBC. Availability of heart lung machine with level detector to decrease risk of air embolism. 2. Asking female patients about menstruation history(call by physician). INR investigation day after day.
. 6. Transferring of cerebro-vascular and vascular patients to specialized hospitals related to the general organization for teaching hospitals and institutes. 4. 5. 4. Daily follow-up of patients by consultant and decision making for drug weaning .4. Aspocid 150 mg second day of operation after securing the bleeding. creatinin. Admission of patients by risk(euro score).blood and plasma preparation and chest xray). Avoid drugs increase INR. 5. Solving of nursing scarcity by staffing new nurses. liver enzymes. 3. Prediction of marevan resistance pre-operative . 6. 2.
Protocol for ICU system regulation :
1. nurse assistants and medical secretary. 7.ventilator weaning and ICU discharge.
Proper antibiotics. Stopping cortizon if taken. Good scrubbing and cleaning of patients before scrubbing. 5. Treatment of any septic focus. Antibiotic prophylaxis for 48 hours.
Post operative: 1.
. By g lycosylated haemoglobin( HbA1c) <8 . 3. 6. Intra-operative clipping of hair by electrical shaving machine single use or body shaver of females. 4. 7.Protocol for Prevention of wound infection :
1. 4. 8. 3.M. 7. Good haemostasis and closure. 2. 6. 5. 2. Early rewiring of diagnosed medistinitis. Pre-operative control of D. Don’t open any operative dressing before 48 hours. Control of diabetes mellitus. Daily dressing in the ward. Good self hygiene of patients. Decrease time consuming during operation to decrease exposure. Decrease excessive use of diathermy.
yearly from the previous data. in 15 days preoperative. 32% (724 patients ) cost 1972176 L. 3-7 days in ICU . in 17 days postoperative. 34% (750 patients ) cost 1192500 L. 20 days in ICU. from the previous data.E.E.E.
ii. i. in one week preoperative.E. If the patient discharged 4-6 days after ICU we will save 3187761 L. 26% (587 patients) cost 1408800 L.
From the previous statistics and by calculation we find : 66% ( 1500 patients ) cost 1113000 L.E. If the patient stayed 2-3 days in the ICU we will save 6145800 L.E.E. in 12 days postoperative.E. iii. 14% (321 patients) cost 2889000 L. 15% (315 patients ) cost 1215585 L.E. 8% (154 patients ) cost 1848000 L. from the previous data. 7-15 days in ICU. If the patient admitted one day before surgery according to our protocol we will save 2305500 L.E.