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BVH Site Visit to MRI

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					                                                                                          Blackpool Victoria
                                                                                          Hospital



                                                                                                               Manchester
                                                                                                               Royal Infirmary




                                       Site Visits
                                                                                                                 Wythenshawe
                                                                                     The Cardiothoracic          Hospital
                                                                                     Centre




North West Quality Improvement Programme in Cardiac
                    Interventions
Site Visit from Blackpool Victoria Hospital Team to Manchester Heart Centre
                                24th May 2002

                                      Russell Millner

I was struck by a number of things at the time of our visit to MRI, and since
then have taken the opportunity to reflect on a number of issues. Firstly let
me say that I was highly impressed by the visit to MRI and there were a
number of features of their practice that I have already taken back to either
my own practice or would like to develop within the Blackpool unit.

I think there are some strong similarities in the size of the two units, the
available facilities and the working arrangements. Both units are under
pressure for beds, nurses, and theatre time and intensive care resources.

From the point of view of ward beds I think that the pressure to conform with
issues such as ‘consumerism’ and single sex wards will put a lot of pressure on
the current way in which the surgical ward is used. I was surprised to see
mixed sex bays outside the critical care (CSU/HDU) areas. I’m sure that this
sort of issue will be resolved with further developments. MRSA certainly
seemed to impact on the ward in a similar fashion to the impact that it has on
us. I gained the impression that the lower volume of thoracic surgery
improved the ability to increase the cardiac throughput.

Some of the nurse staffing issues are dealt with by others, MRI seemed to gain
in recruitment, both UK and overseas, on one part by being part of a
metropolitan teaching hospital but perhaps lost with increased turnover for
the same reason.

I was impressed with the scoring system that provided a documentable and
auditable trigger for intervention and will look to implement this or something
similar in Blackpool. I did feel that there appeared to be a shortage of middle
grade staff and wondered whether the SHO’s weren’t becoming a little over-
exposed, particularly at weekends.

Theatres had a similar set up to ours in that there was a twin suite, MRI have
the advantage of being part of a general suite with easy access to a staffed
recovery area though with essentially a pure cardiac practice through those
theatres it was of little obvious benefit. A potential benefit would be to be able
to expand into the adjoining theatres as space becomes available with
emigration of existing non-cardiac lists. (I have brought back into my own
practice both half-dose trasylol for all, but also to filter on bypass a number of
patients that I wouldn’t previously have considered. In particular I now filter
valve patients over the age of 70yrs).



North West Quality Improvement Programme in Cardiac Interventions               1
Site Visit Report: BVH to MRI May 2002
Anaesthetic cover seemed a problem at times. The day that we were there
sickness amongst the anaesthetists had caused difficulties. The provision of
full time dedicated cardiac anaesthetists might make managing events such as
that easier.

Perhaps the single feature where operationally I felt that MRI had a lead was
in the intensive care unit. The close proximity with the general intensive care
unit, and what appeared to be a good working relationship, allowed the
transfer of longer staying patients out of the cardiac surgical intensive care
unit without an apparent ‘loss of control’. This appeared to be a real benefit to
the unit, and in contrast to my comments above appeared to be a strength of
not having dedicated cardiac anaesthetics but those with a more divers job
plan!

To me a further strength of the unit was its information management. The use
of information technology was considerably ahead of ours and this is clearly
an issue we will need to address.

My overall impression was of a cohesive unit that continues to expand,
produces outstanding clinical results through physical resources that are
barely adequate. Whilst there are threats on the horizon my impression was
that the unit was well placed, and more importantly willing, to grab
opportunities as they arose.

Site Visit to MRI Cardiac Centre 23rd May 2002
Comments of Dr M Hartley, Consultant Anaesthetist at BVH

Comparison of facilities – MRI versus BVH

                                         MRI                        BVH

Cardiac theatres                         2 * 5 days                 2 * 5 days
Thoracic theatres                        1 & 1 day                  1 * 2 days

CSU beds                                 8                          6
HDU beds                                 5                          4

Comparison of anaesthetic staffing – MRI versus BVH

                                         MRI                        BVH
Consultant sessions

Theatre                                  32 sessions                36 sessions
CSU                                      15 sessions                6 sessions

Specialist Registrars                    4 SpRs                     1 or 2 SpRs

Clinical Fellows                         3 funded posts             0 posts

Points


North West Quality Improvement Programme in Cardiac Interventions                 2
Site Visit Report: BVH to MRI May 2002
1. MRI has an increased capacity for cardiac surgery in comparison to BVH
   due to:

    ·   Increased number of CSU and HDU beds
    ·   Funding of beds on the general ICU for management of ‘long-term’
        cardiac patients
    ·   Low thoracic surgery workload
    ·   No oesophageal surgery

2. MRI has greater consultant anaesthetic sessional cover in comparison to
   BVH, although this disparity will be corrected when Andrew Knowles
   commences on 1/10/02.

3. Absence cover for annual leave/study leave etc is provided by switching
   CSU sessions to theatre sessions, providing a SpR is available to cover
   CSU.

    Ultimately, priority is given to cover of CSU, and theatre sessions are
    cancelled if availability of anaesthetic staffing is limited.

4. There is no system to regulate consultant absence, as a result of which
   theatre sessions may be lost (as happened on the day of the visit).
   Consideration could be given to a system that regulates consultant absence
   in order to avoid the cancellation of theatre sessions.

5. MRI has a consistent allocation of 4 Year 1 SpRs for a 3 month training
   module in Anaesthesia for Cardiothoracic Surgery. These SpRs receive
   training and provide support to the consultants working in theatre and
   CSU and provide dedicated ‘out of hours’ cover from Monday to Friday.
   Non-dedicated resident SpR cover is available on Saturday and Sunday.

6. Clinical fellows provide a further level of support to the clinical service.

7. Clinical points:

    ·   Routine use of pulmonary artery catheters
    ·   Dopexamine rather than dopamine
    ·   Low use of inotropes
    ·   High use of vasoconstrictors
    ·   Low threshold for IABP use
    ·   Routine use of low dose aprotinin
    ·   Routine use of intra-operative red cell salvage
    ·   Low use of blood products
    ·   Use of thoracic epidurals for beating heart surgery
    ·   Patients nursed flat on CSU
    ·   Patients only returned to the ward when low dependency ie no CPAP,
        no chest drains, no vasoactive infusions
    ·   Telemetry facility for ward patients



North West Quality Improvement Programme in Cardiac Interventions                 3
Site Visit Report: BVH to MRI May 2002
                         MRI Site Visit 24th May 2002
                       Stephen Mellars – Clinical Leader
                      Ian Barr – Senior Lead Practitioner

Theatres
There are two designated cardiac theatres at the MRI, similar in dimension to
those in Blackpool. The theatres have the use of a recovery room staffed by
dedicated recovery staff should the needs of the service require it. The three
session theatre lists are predominantly comprised of cardiac patients and
operate on a Monday to Friday. Thoracic patients are dealt with on another
designated session carried out in the general theatres by the general theatre
staff. Staff from the Cardiac theatres do not become routinely involved in
these sessions.

Change of Directorates
The Cardiac Theatres are currently discussing the possibility of moving from
the Anaesthetic and Theatre Directorate to their equivalent of our
Cardiothoracic Directorate, the Heart Unit. It proved an interesting point of
discussion that we had already successfully undergone this change. Staff
concerns about the move included uncertainty as to the level of support they
would receive from the Heart Unit, set against the loss of the familiar support
of the Anaesthetic Directorate. Cardiac theatres do appear however, to be
isolated within the Anaesthetic Directorate. As a result of these factors staff
had divided loyalties about which was the best way forward.

Operating Sessions
The planned theatre lists are generated by the surgeons a month in advance of
the operation date, theoretically a good idea in order to plan staff and
equipment resources. The operating lists on the day of operation, however, do
not reflect the planned list as emergency cases are slotted in and patients are
moved around the sessions. Operating lists do overrun and there is not yet a
culture of managing the case mix with the theatre operating time. Theatre
staff have to ‘volunteer’ to stay behind to cope with the overruns. The
goodwill is steadily declining which has been the reason for staff leaving the
department.

Adaptation development packages have been designed for 12 month periods
with a view to generating the skilled staff who are motivated to apply for
higher grades in the future. Our staff that have been recruited from overseas
have had intense initial development in order to attain registration, they have
then been allowed to develop at their own pace. We feel that the model of a
structured developmental plan favoured as a training mechanism at the MRI
should be implemented by us at the earliest opportunity. Thereby motivating
existing staff and encouraging learners.

The theatres have access to a gas analyser room that has not only the ability to
provide immediate blood gas analysis for theatres, CSU, HDU, and the general
ITU, but the facility to process all the preoperative and postoperative blood
biodchemistry samples for the Heart Unit. This facility is staffed by a Senior
M.L.S.O and not by the theatre O.D.P.’s. One of the features of this facility is
that any patient that entered the data system, either from the preoperative

North West Quality Improvement Programme in Cardiac Interventions              4
Site Visit Report: BVH to MRI May 2002
assessment clinic or as an emergency, had their details converted into a
barcode which made tracing and recording the blood samples more efficient.
Something we need to consider in the planning of the new theatres.

Patient Journey
The porter sends for the first patient on the theatre list at 07:30, to arrive in
theatre at 07:45 when the ODP and the rest of the theatre team arrive on duty.
This differs from Blackpool, as theatre staff need to ascertain the bed status
before sending for the first patient.

The theatre staff are currently taking over the role of checking in the patient
which has until recently been the role of the ward escort nurse. The ward
escort nurse is not necessarily a trained member of staff, which we consider to
be essential as patients are under the influence of premedication. Any
information about the patient should be communicated via a trained member
of staff that has had responsibility for that patient’s care on the ward.

The theatre team aim that the patient be in theatre for knife to skin at around
08:50 t0 09:00. We questioned whether this early start time reflected in time
saved at the end of the operating day, especially when the sessions were
expected to overrun.

Patient intraoperative records were registered on a live computer system with
a programme that generated a print out of events prior to the patient leaving
the department. This as a bonus in terms of time saving and accuracy of
patient record keeping and adequate computerised patient record data
systems should be installed in the new theatre build.

On the operating table the theatre approach to pressure area care was of the
same standard as our own. Patients were transferred from trolley to operating
table in the check in area, preventing congestion in the anaesthetic room,
which we currently experience. Our new theatres will have a holding bay,
which will provide the space and privacy for patient transfer.

There is a similar use of intraoperative patient warming devices received by all
off pump and thoracic patients.

The theatre instrumentation appears to be of an inferior quality to our own.
The instruments for the surgeons are universal and all are expected to use
whatever is on the set. In Blackpool each surgeon has his own set of grafting
instruments which are kept separate offering each surgeon a sense of
ownership for the instruments he uses.

Theatres had looked at prepacked sets to cut down the amount of ordering.
They did envisage that there would be problems with delivery of the packages.
The stock levels suggested would be of a low amount and there was limited
storage space to keep the packages. Staff emphasised that the making up of
the ‘pump’ boxes was used as a learning tool for new members of the team to
find the location of equipment within the theatre suite. They do not have a
staff member solely responsible for the procurement of equipment and
supplies within the department as we do. The process of ordering stock and

North West Quality Improvement Programme in Cardiac Interventions               5
Site Visit Report: BVH to MRI May 2002
stock control is used as part of staff career development, as they become more
competent then this is used as evidence.

The theatres have a very good relationship with CSU, HDU, and ITU. Our
relationship with the general ITU is poor by comparison and efforts must be
made to improve that relationship in the future.

Staffing
The theatre establishment comprises of 4 F grades, 5 D grades who were
mainly adaptation practitioners from overseas, and 5 A grade nursing
assistants. The Anaesthetic Direcorate allocated 3 ODPs to cover the theatre
sessions, however no cover was designated to CSU or Cardiology from the
cardiac ODP establishment.

The cardiac on call service is managed by utilising one F grade cardiac trained
scrub practitioner, who then uses staff from the general emergency theatre
when the situation arises. Theatre practitioners have a similar on call
commitment of 1 in 4 paid at Whitley Council rates, and are fully aware of
other payment scales currently used in other cardiac centres.

Cardiac trained ODPs are not part of the on call team, each general theatre
practitioner spends two weeks in the cardiac speciality in order to become
fully competent in planning care and defining needs. We doubt this period of
training is adequate to gain the competence and experience necessary to
provide a cardiac on call service.

One other member of the theatre team is the F grade Surgeon’s Assistant, who
currently takes the role of SHO.

Staffing levels at MRI gave us cause for concern. When the National
Association of Theatre Nurses Staffing Formula is applied to their
establishment, it does reveal adequate numbers of theatre personell for the 20
sessions operating time, however the skill level is very low to safely run a twin
suite independently. In view of the low skill mix, when annual leave or
sickness arises simultaneously the increased pressure on the remaining
practitioners to cover the sessions along with the on call commitment
precipitates higher stress levels among the team.            For example one
practitioner has covered three concurrent weekend on calls without any rest
days, a situation which is clearly unacceptable. A further question, which
arose, was that with the proposed move to the Heart Unit, would the current
use of general emergency theatre staff and general ODPs, to cover the cardiac
on calls be withdrawn? If this were the case the staffing situation would
become impossible to maintain.

Conclusion
Both Ian and myself found the MRI Site visit very informative. It was
refreshing to discover that across both sites theatre practice was of a high
standard.

Ian was paired with a Surgical Assistant instead of an Operating Department
Practitioner. This did prove to be of interest as far the overall visit was

North West Quality Improvement Programme in Cardiac Interventions               6
Site Visit Report: BVH to MRI May 2002
concerned, it would have been beneficial however, to have exchanged ideas
and comparisons of best practice with someone of equal seniority.

The structured development training model for the adaptation theatre
practitioners impressed us and as a unit we will take that concept forward.

In order to improve patient record keeping the idea of the computerised
patient records will be suggested at future planning meetings for the new
theatres. This will improve record keeping as a whole and it should be
introduced not only for the patient anaesthetic record, but as a whole package
allowing all members of the multidisciplinary team to produce records of
patient events in theatre.

The processing of blood gas analysis combined with the blood biochemistry
requirements for the Heart Unit in one facility would make efficient use of
resources within the new build. The concept that the facility is staffed by a
Senior M.L.S.O gives the unit a link with the Pathology Department whilst
being able identify any abnormalities more readily. It would also negate the
need to supply an ODP to maintain the analysers allowing them to concentrate
their skills into patient care and staff development.




                        Manchester Visit 24/05/2002
                  Alison Wilkinson, Cardiothoracic Liaison

Aim
To visit Manchester cardiac centre and compare practice in pre-admission and
home care, returning with ideas and suggestions for improvement in practice.

Observations
The obvious difference between Blackpool and Manchester pre-admission is
that Manchester has been performing pre-admission clinics since 1988, and
therefore has had time to develop and evolve into the service it is today.

There is a waiting list co-ordinator who can give an exact date of admission, or
be able to confirm that there will be an admission 4-6 weeks in advance. This
gives plenty of time to organise pre-admission clinics, therefore allowing
approximately 60% of patients to be pre-admitted.

The clinic is set in a spacious room with two beds, ECG facilities, at least two
qualified nurses, and one health care assistant. The patients also see a House
Officer who clerks the patient in, giving time to identify problems without
affecting bed-booking or theatre time.

The nurses and waiting list co-ordinator plan the clinics together, allowing
maximum flexibility.

The nurse conducts a post-operative visit to reiterate patient education and
discharge planning.

North West Quality Improvement Programme in Cardiac Interventions              7
Site Visit Report: BVH to MRI May 2002
There is no home visit service post-operatively. The patients are given a
contact number for any problems or queries they may have. The nurse I spoke
to was unsure of the percentage of re-admissions with subsequent problems
which could possibly have been addressed by the home care service.

On a final note, it was observed that the office for pre-admission staff was
away from the ward environment and the pre-admission staff and ward staff
did not appear to integrate particularly well.

         MANCHESTER ROYAL INFIRMARY VISIT – REPORT

Visit 24th May 2002
Nicola Millner – Senior Sister
Cardiac Surgery Unit
Blackpool

The site visit to MRI was particularly helpful for me as I have not had the
opportunity since fulfilling the sisters role of visiting another cardiac surgery
unit. I was particularly interested in the management of a larger unit
particularly as we will be expanding our own unit in the foreseeable future.
Issues such as training/recruitment/throughput of patients and dependency
of patients at CSU/HDU level were of interest to me.

The only criticism of the visit for me personally was that I had expected the
MRI match to be devoted to the visit for at least the morning. The sister
however had her own patient and was in charge of the CSU. I would have felt
more benefit from a one-to-one morning. Despite this we did manage to
discuss many issues and I gained a great deal of information.

Ideas for Changes In Practice

Bed-bathing on the night shift

It is not current practice for the night shift to bed-bath any patients in
Blackpool, all bed-bathing is carried out on the early shift. This leads to a very
hectic, rushed atmosphere and pace for the nurse and patient. I was
particularly struck by the much calmer atmosphere at MRI, which seemed to
leave all staff and patients far more relaxed. The seemed to be because all
bed-bathing is performed on the night shift.            Our patients suffer a
rollercoaster of bedbathing, dressings, physio, CXR etc., which tends to leave a
first day post-op patient exhausted. It would be beneficial for all concerned if
the patients who would be most likely for discharge to the HDU or ward had
their care spread over a longer time period and bed-bathing on the night shift
seems appropriate.

Also allocating nurses in the morning the HDU can be a problem, as all staff
dislike mornings on the HDU. The main reason being lack of space which
leads to stress for the nurses. Bedbathing four patients and transferring them
to chairs, avoiding dressing trolleys, chart tables, bedside table, patient
belongings, medical personnel in a very cramped area is not a popular way to

North West Quality Improvement Programme in Cardiac Interventions               8
Site Visit Report: BVH to MRI May 2002
spend the morning. Bed-bathing just two patients on the night shift would
alleviate this and it may not be so difficult to get nurses to spend the morning
on the HDU. Spreading the main bulk of the workload and furniture shifting
before Drs start their rounds has to be beneficial.

Transfer of long term patients to the general ITU

Our long term patients are not automatically discharged to the general ITU,
thus several beds can become blocked in the CSU causing cancelled cardiac
surgery. The long term treatment and care of these patients would be
improved if transferred to the general ITU where their particular problems are
being dealt with every day. Historically there is not a good relationship
between CSU/ITU for many reasons. This particular problem is beyond my
control but I feel to try and strive towards this practice would be beneficial for
the long term patients. MRI practice is to discharge a patient to ITU after 48
hours. In Blackpool I would like to see a week on CSU and then discharge to
ITU. The injection of cash into the ITU to facilitate this practice is obviously
the key and worth further thought for our future practice.

Medical Devices

Our documentation is not as advanced, MRI had made more headway with
this area. I have obtained relevant forms for our own use.

Bedside Safety Checks

Every handover at each bedside from nurse to nurse was followed by several
tick lists covering ventilator settings, resus equipment and infusions. The
seems a valuable method in reducing mistakes with drugs and ensuring each
bedspace is kept as safe as possible. It takes minutes every shift but is of vital
importance. Again, relevant documentation retrieved for our use.

Nurse Led PAFC Removal

Extubation From Pressure Support

Policy for Prone Positioning of Patients

My colleague in her report has covered the above topics.

CAUTIONS

Use of Agency Staff

To reduce the problem of short-staffing, MRI use agency nurses to make up
the numbers, there seems to be at least one agency staff per shift. I think this
has produced a long term problem. Pay is greater on the agency than for
normal contract hours. I felt this has led to many nurses reducing their
contracted hours and joining the agency working on their own units to make
up these hours to earn more money. The ratio of MRI full time staff to
Blackpool seemed to be much lower. Blackpool pay overtime to their staff

North West Quality Improvement Programme in Cardiac Interventions                9
Site Visit Report: BVH to MRI May 2002
who will work over 37 ½ hours a week as and when they are needed. It would
be practically impossible for MRI to provide the service without the agency
now which is a situation I would want to avoid us getting into. Alternatively
we are training B grades and have far more A grades (1 per shift). I expected
MRI to have a bigger complement of staff but found we were doing quite well.
The sister in charge at Blackpool, rarely takes a patient and purely manages
the unit and all patients care. This is mainly due to the fact CSU/HDU are
split sites and the sister in charge is require to cover both.

MAJOR DIFFERENCE

The dependency of the HDU patients and what was meant by the term “fast-
track”. Our HDU being staffed by CSU has much more dependant patients
who require inotropes, CPAP etc. Fast-tracking is classed as spending several
hours on the CSU before transfer to the HDU. Patient discharged to ward 1st
day post-op. We seem to push patients through the system faster, but with
few readmissions to HDU/CSU. We may use a CSU bed 3 times in one day –
1st day patient discharged, followed by a fast-track patient, then patient last on
list for overnight stay.




North West Quality Improvement Programme in Cardiac Interventions               10
Site Visit Report: BVH to MRI May 2002

				
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