Year : 2010 | Volume
: 13 | Issue : 3 | Page : 192--195
Establishing a new cardiac surgical unit: Challenges and solutions
Yatin Mehta1, Yash Paul Bhatia2,
1 Chairman, Medanta Institute of Critical Care and Anesthesiology, Sector 38, Gurgaon, India
2 Principal Consultant, Medanta The Medicity, Managing Director, ASTRON Hospital Consultants, Haryana, India
Medanta Institute of Critical Care and Anaesthesia, Sector 38, Gurgaon, Haryana
|How to cite this article:|
Mehta Y, Bhatia YP. Establishing a new cardiac surgical unit: Challenges and solutions.Ann Card Anaesth 2010;13:192-195
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Mehta Y, Bhatia YP. Establishing a new cardiac surgical unit: Challenges and solutions. Ann Card Anaesth [serial online] 2010 [cited 2020 Aug 8 ];13:192-195
Available from: http://www.annals.in/text.asp?2010/13/3/192/69039
With the healthcare delivery system going through a major transition to ensure quality healthcare delivery at all levels a new paradigm appears to be emerging for establishment of tertiary care centers for the biggest killers of the future, namely, heart disease and cancer.
The author of this editorial and his group has been involved in planning and operationalizing several tertiary care hospitals, both in India and overseas, over two decades, which were the results of conceptualization and execution by their surgical chief, Dr. Naresh Trehan. During these endeavors, the anesthesiologists in the cardiothoracic unit have had important role in planning, supervising and commissioning of operating rooms (ORs), intensive care units (ICU)/recovery rooms (RR) and cardiac catheterization laboratory. They have also been instrumental in suggesting and incorporating several useful inputs during the formation and layout of radiology departments.
The administrators of the hospitals frequently consult the senior members of the team to gain input about the requirements from the perspective of doctors seeking to create a "beautiful" hospital. It is an eternal dilemma whether one chooses technically sound hospital or aesthetically sound one. Therefore, one should look for creating a unit which gets nominated not as the most beautiful unit but as a functionally perfect unit housed in most aesthetic surroundings.
The basic principle one should observe is that the newly established center should be able to fulfill the basic definition of quality as given by Institute of Quality - "The degree to which health services for individuals and populations increases the likelihood of desired outcomes and are consistent with current professional knowledge." 
Following the dictum of Avedis Bonadenian on three basic components of delivering health care quality, viz., Structure (stable characteristics for the providers of care and tools and resources available at their disposal), Process (activities that go on between and within the practitioners and patients) and Outcome (changes in health status attributable to antecedent health care), quality assurance in our cardiac units is also essential - this also allows us to measure the quality of the healthcare delivery at all times.
The structures include the civil infrastructure, the equipment plan and the machinery. Designing of the facility is the first challenge, wherein a definite need for sizing of the facility and the level of care needs to be decided to ensure that the unit is optimally poised to cater to the current load, with an option to upgrade to meet the likely increase in demand for more beds. Financial support for the project is the key for making such decisions; ultimately, the center so created has to be not only viable in the long run, but also profit making. Often because of lack of foresight, there is a mismatch in the requirement to availability ratio. One needs to constantly remind oneself - "Are we creating monuments or hospitals?" On the other hand, an underplanned and executed facility will compromise the basic functions and will adversely impact the quality of healthcare delivery. At this stage, it is worthwhile to refer to the local as well as international accreditation norms, relevant guidelines (e.g. American Institute of Architects guidelines (AIA)) and the available building codes. 
The space planning of each of the units such as the emergency room, the ambulatory units, non-invasive cardiac lab, invasive cardiac catheterization laboratory, OR, postoperative Areas e.g. ICU, in-patient units, preventive and rehabilitative cardiology has to be optimized, integrated and synergized. This assures a smooth flow without causing choking or functional obstruction in healthcare delivery. At the same time, one has to keep in mind the staff fatigue which could result if the units are too spread out. Ensuring staff adequacy is probably one of the biggest challenges in hospital design. Selecting the correct requirement will decide the performance of the facility. Having ensured the functional adequacy, compliance to the accreditation norms of certain bodies such as Joint Commission International and National accreditation board for hospitals becomes necessary in order to get the accreditations rapidly.
The equipment planning for a cardiac unit needs to be carried out thoughtfully after a proper need analysis (which takes into account the future trends). We need to remember that the technology is changing faster than what we can imagine. In fact it is said in lighter vain that by the time we spell the word "technology", the new order has already moved in! This is true for cardiac sciences as well; therefore, we need to plan the equipment technically adequate to meet the projections of the proposed center while keeping pace with emerging technologic needs. Opinions from colleagues who have recently contributed to the development of facilities of good standing may be sought while taking decisions.
Considering the rapid growth in the field of hybrid procedures (cardiac surgical and interventional cardiologic procedures under the same roof), one needs to plan for these expensive but mandatory suites. A state of the art cardiac operation theater with cardiac catheterization laboratory may be relevant. Such operating suites permit carrying out advanced procedures like transapical/percutaneous aortic valve replacement. Positron emitting tomography scanner or 64 slice computerized tomography scanner for cardiac imaging may become relevant in the days to come.
Also, with centralization of operating department it is possible to ensure flexibility of allocation of theater time, nonduplication and greater economy in the use of common facilities, better supervision and availability of OR in emergency. 
Having created the infrastructure, the establishment of processes and protocols need a lot of emphasis. This includes staffing norms, training, and an environment to create an assurance that the systems and processes would work when required. The moment of truth is when the patient requires to use the facilities at the hospital (a mobile coronary care unit in the event of an acute coronary event); that is when the challenge meter starts ticking. The assurance of availability of an adequately equipped and staffed ambulance on 24/7 basis is itself a huge challenge. Accepting to provide advanced transport mechanisms such as an air ambulance with the same above mentioned conditions will stretch the hospital resources to the maximum. Well-designed protocols with adequate training and re-training of staff and use of modern communication technology can be handy in assuring the excellence of this practice; this is also a requirement as per the accreditation norms of most of the accreditation bodies.
A well-equipped emergency with a focus on the needs of cardiac patients is vital. In order to convert the "usual" emergency areas to those with focus on cardiac care, a special holding area with well-equipped cardiology services and trained staff may be created to overcome this challenge. Many of the hospitals are now putting up a "Heart Command Center", which focuses on specialized infrastructure, medical equipment (e.g. echocardiography machine, intra-aortic balloon counterpulsation, ventilators, pacemakers, etc.), monitoring equipment and manpower to specially cater to cardiac emergencies in the emergency department to meet this need.
The out-patient services should be planned, keeping in mind a multidisciplinary approach, such that cross reference between cardiology, cardio-thoracic surgery, nutritional services and diagnostics is made available in the same geographic area, saving steps and time for the patient and the family.
The adequacy and optimization of diagnostic services based upon work load and its flexibility to accommodate newer technologies need to be considered. It is necessary to assure availability of services in the shortest time so that timely reports may be made available within a short time [i.e. pneumatic tubes, Hospital Information System (HIS), (Picture Archiving and Communication System (PACS)], causing least discomfort to the patients and their attendants. The non-invasive cardiology services ideally should be available in the out-patient department itself while invasive cardiology services could be suitably located with easy access to recovery area (where patients are nursed after undergoing cardiac catheterization), ORs and day care with integration to electro-physiology and other specialized units. Strong, Standard operating procedures (SOPs) need to be developed to ensure safe and smooth activity for patients as well as for health care providers.
The ORs for cardiac services are required to cater to various types of surgeries and such multitasking requires more space than the conventional ORs. An adequate zoning, proper air conditioning controls as per the American Society of Heating, Refrigeration and Airconditioning Engineers' guidelines along with support areas with adequate sterility assurance are the core requirements. However, the success of the cardiac surgery services is highly dependent upon the practices being followed in the ORs. The fundamental requirement recommended by AIA for cardiac OR are large size (>600 square feet), seamless, washable walls preferably painted with antibacterial paint, laminar flow with preferably separate ducting and positive air pressure in each OR, and high-intensity three Light Emitting Diodes operating lights. There should at least be two mobile pendants with additional O 2 and CO 2 flow meter for off pump coronary artery bypass graft surgery and scavenging for anesthetic gases and nitric oxide and temperature control within the OR.
The ICUs should be close to the ORs with facilities for isolation (positive/negative pressure cubicles  with windows), hand washing facilities in each cubicle, easy access to head end, e.g. pendants/power columns, pneumatic tubes and support areas like store, pantry, counsiling room, stat lab, duty doctor and ICU consultant room, etc.
The authors suggest the following points to young colleagues involved in establishing a new cardiac surgical hospital:
Spend quality time with the architects and project team.There are a large number of contractors/subcontractors involved in creating the facility. All of them have their own pace, time tables and agendas. Bigger projects cause bigger delays! It is rare that projects are completed in the stipulated time and budget.One has to be meticulous with the workers and follow up their performance on a daily basis.All prices are negotiable! At times it is shocking to learn how high the dealers' profit margins are and how much cheaper one can buy equipment/services than the rack rate!Get your elbows dirty!
It has been mentioned in the last few paragraphs about systems, processes, protocols, SOPs, while it is well understood that the outcomes of cardiac services are highly dependent on these factors; yet there is one common factor which impacts all these and that common factor is the Human Resources. Availability of adequately trained multidisciplinary team consisting of doctors, nursing and paramedical staff in addition to adequate administrative support is the real challenge. The adequacy in numbers as per the staffing norms for different sections of the cardiac unit is a challenge by itself in view of global shortage of trained medical manpower. More so, is the availability of specialized nursing and paramedical staff. A strong credentialing and privileging mechanism needs to be put in place to ensure that only adequately qualified and trained people are authorized to undertake any activity within the system. The identification of training needs of each individual and organizing in-house or specialized training at defined regularity could be the key to meet this challenge. So, the answer here lies in ensuring proper need-based human resource planning with proper selection mechanism, followed by training.
Having established the infrastructure and the protocols, one should concentrate on the outcome. As we said in our definition of Quality "The Quality has to result in increasing probability of achieving the desired outcome." Recording of the outcomes and putting a trend analysis in place to ensure continuous quality improvement has to be a part of the whole process. All the investment in terms of infrastructure, effort, time and money needs to converge in getting the desired results.
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|2||Joint Commission International Accreditation Standards. 3 rd ed. PDF book (electronic book); 2007. p. 260. (PDF internet publication, no publication city|
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|4||Intensive Care Unit Planning and Designing in India Guidelines (Indian Society of Critical Care Medicine) 2010 in press.|