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)

2012

Introduction: National Heart Institute is the oldest hospital for cardiac surgery in the middle east and it receives the highest flow for cardiac patients ,we can say it the mother of cardiac patients.

Aim of the work: Decreasing the inpatient stay for cardiothoracic surgeries to average 7-10 days.

Prefeasibility study: Idea: from our beliefs for the NHI educational and medical role in the middle east , we can save the cost and multiply the profit for the government and the institute so it will be accepted from all parteners involved.

SMART:
Specific , measurable, applicable, realistic, and our goal to achieve it within one month and re-evaluate after one year.

SWOT analysis:
Strength points: 1- Man power / 110 cardiothoracic surgeons (43 consultants -25 registral-32 house officer or resident). Anaethists ( 26 ). Nurses :
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Operation nurses (36 ). ICU nurses (64). 2- Beds Ward beds/186 beds ( 160 health insurance and ministry of health referrals for treatment on government behalf ). Icu beds 64 bed. 3- 9 operation rooms. 4- A lot of money resources ( health insurance-ministry referrals-private sector-donations.etc. ). 5- Enough machines , equipment and surgical accessories. 6- Good reputation.

Weakness: 1234567Nursing problems. Less experienced surgeons to do high risk surgeries. Heart lung machine air embolism. ICU resources defect (e.g. pressure cable ). Wound infections (deep and superficial). Long time for INR control in valvular patients. Delayed post-operative echo cardiography.

Opportunities: 1- Decreasing the cost of stay for patients and therefore increasing the profit. 2- Decrease waiting list time. 3- More reputation which can put in consideration making an extension for the institute.

Threats : 1234Facing policies,regulations and laws. Security problems. Patient flora changes. High authority recommendation for certain patients to break rules and regulations(.) 5- Some consultants may resist the project in favor of private sector.

PEST analysis:
Political : we need to make some rules and regulations more flexible concerning pay check. Economical : NHI has a good economical state which can be more better ( can raise the profit by 40 % ). Social : it will satisfy low socio-economic patients. more reputation,better service and credibility.

Technology : Enough machines and equipment.

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.

 Social : social beliefs in our favor that NHI is the first and biggest hospital for receiving cardiac patients ( low socio-economical patients). Technical : available equipments , machines , medical resources.etc. Legal : the project is not against the law or regulations. Economical : Vavular heart diseased patients cost the institute : 106 L.E. daily pre-operative. 600 L.E. daily ICU. 177 L.E. daily post operative. Ischemic heart diseased patients cost the institute : 106 L.E. daily preoperative. 700 L.E. daily ICU. 277 L.E. daily post operative. Wound infection patients cost the institute extra 300 L.E. for antibiotics.

2011 statistics :
Total patients 2500. 66% of patients stay 7 days preoperative (1500 patients). 34% of patients stay more than 7 days preoperative (750 patients). 52% of patients stay in ICU less than 3 days ( 1188). 26 %of patients stay in ICU 3-7 days (587). 14% of patients stay in ICU 7-15 days (321). 8% of patients stay in ICU more than 15 days (154). 53% of patients are discharged after one week of surgery(1211). 32% of patients are discharged after 15 days (724). 15% of patients are discharged more than 15 days .
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Target:
To make total stay 7-10 days. Patients stay pre-operative 1 day. ICU stay 2-3 days . Post-operative stay in ward 4-6 days.

Problems delaying patient's operation and increase cost of pre-operative stay : 1.Admission of patient before operation by long time. 2.Defects in resources (protamine-potassium-sodium-bicarbonateoxygenators-CVP'S-aortic balloon , etc.). 3.Defect in ICU nurses because of misdistribution or special problems (pregnancy-illness-absence). 4.Overcrowding of ICU by patients which make lack or scarcity of available beds. 5.High authority recommendation for certain patients to overcome rules and regulations concerning admission. 6.Prolonged control of INR in valvular patients. 7.Menstruation of female patients.

Intra-operative problems : 1.Less experienced surgeons do high risk surgeries. 2.Heart lung machine without level detectors may lead to air embolism.
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3.Less experienced anaethists make hazards for patients in arterial line-CVP line intra-tracheal intubation and induction. 4.Some mistakes involving infection control.

Post-operative problems : 1.Prolonged INR control in valvular patients . 2. Wound infections (deep and superficial). 3.Delayed weaning of inotropes ( debutrex adrenaline ,etc). 4.Prolonged ICU stay due to delayed recovery, delayed weaning from mechanical ventilator, cerebro-vascular stroke, intra-aortic balloon, chest infection , emergency patients without ward beds , renal failure patients. 5.Delayed post-operative ECHO cardiography. 6.Post operative pericardial effusion. 7.No regular post-operative follow up of patients.

Problem solving :

Protocol for admission of patients :

1. Contact between the patient and institute at least 2 telephone numbers and address. 2. 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. The patient must be fully investigated and prepared before admission.
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4. Admission one day before operation at 9 am maximum (CBC, creatinin, liver enzymes,blood and plasma preparation and chest xray). 5. Admission of patients by risk(euro score). 6. Asking female patients about menstruation history(call by physician).

Protocol for ICU system regulation :

1. Solving of nursing scarcity by staffing new nurses, nurse assistants and medical secretary. 2. Daily follow-up of patients by consultant and decision making for drug weaning ,ventilator weaning and ICU discharge. 3. Transferring of cerebro-vascular and vascular patients to specialized hospitals related to the general organization for teaching hospitals and institutes. 4. Enough resources and stores ( enough safe stock ). 5. Availability of heart lung machine with level detector to decrease risk of air embolism.

Protocol for INR control in post-operative patients :

1. Aspocid 150 mg second day of operation after securing the bleeding. 2. Start with 10 mg marevan for 3 days then 5 mg from 4th day. 3. Avoidance of food containing vitamin k. 4. Good storing of marevan and keep it away from light and humidity. 5. INR investigation day after day. 6. Prediction of marevan resistance pre-operative . 7. Avoid drugs increase INR.

Protocol for Prevention of wound infection :

1. Pre-operative control of D.M. By g lycosylated haemoglobin( HbA1c) <8 . 2. Treatment of any septic focus. 3. Stopping cortizon if taken. 4. Intra-operative clipping of hair by electrical shaving machine single use or body shaver of females. 5. Decrease time consuming during operation to decrease exposure. 6. Decrease excessive use of diathermy. 7. Good scrubbing and cleaning of patients before scrubbing. 8. Good haemostasis and closure.

Post operative: 1. 2. 3. 4. 5. 6. 7. Dont open any operative dressing before 48 hours. Control of diabetes mellitus. Antibiotic prophylaxis for 48 hours. Daily dressing in the ward. Good self hygiene of patients. Proper antibiotics. Early rewiring of diagnosed medistinitis.

Conclusion

From the previous statistics and by calculation we find : 66% ( 1500 patients ) cost 1113000 L.E. in one week preoperative. 34% (750 patients ) cost 1192500 L.E. in 15 days preoperative. 26% (587 patients) cost 1408800 L.E. 3-7 days in ICU . 14% (321 patients) cost 2889000 L.E. 7-15 days in ICU. 8% (154 patients ) cost 1848000 L.E. 20 days in ICU. 32% (724 patients ) cost 1972176 L.E. in 12 days postoperative. 15% (315 patients ) cost 1215585 L.E. in 17 days postoperative. i. If the patient admitted one day before surgery according to our protocol we will save 2305500 L.E. yearly from the previous data. If the patient stayed 2-3 days in the ICU we will save 6145800 L.E. from the previous data. If the patient discharged 4-6 days after ICU we will save 3187761 L.E. from the previous data.

ii. iii.

Thank you

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