Hospital Pre-Visit Checklist by olk11750

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                                        PRE-VISIT CHECKLIST

           To Be Filled in by The Hospital

           Name of the hospital to be visited



           Perfusion Department Details

           Head Of Perfusion Contact Details:

           Name:

           Title and Grade:

           Contact Number:

           Email address:

           Team Members:

           Qualified Staff:
                                                                 Involved in Training   Teaching Qualification
           Name                         Position       Grade     Y/N                    Y/N




           Trainees

           Name                         Grade                    Year in Post




                                                                                        Y/N
           Are the Trainee's registered with the College of Clinical of Perfusion?




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           Organisational Structure

                                      Name

           General Manager

           Line Manager

           Clinical Director

           Lead Surgeon

           Head of Perfusion

           College Tutor

                                                                                 Number
           Perfusion Team             Qualified
                                      Trainee
                                      Vacancies
                                      Limited Registration




           Management Issues
                                                                                 Available for interview Y/N
           Formal meetings            General Manager / line manager
                                      Clinical Director
                                      Finance manager
                                      Perfusion Team - Head of Perfusion
                                      College Tutor
                                      Senior
                                      Staff
                                      Student
                                      Limited Registration




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           Budget Holder - Responsibility of:

                                                                                    Y/N
           Are regular Finance Meetings held?
                                                                                    ratio
           On Call level
                                                                                    Y/N
           Spare Perfusionist available during normal working hours
           If not, has this been Risk Assessed?




                                                                                    In place? - Y/N
           Appraisal system
           Personal Development Plan
           Departmental Meetings - with minutes
           Line Manager Meetings
           Risk Management / Assessment
           Staff Induction
           Locum Staff Induction




                                                                                                      Y/N
           Do the Perfusion staff perform CPB procedures at other Hospitals?


                                                                                                      Y/N
           Does the Hospital have a linked Private Unit where CPB procedures are performed?
           Is the Perfusion department responsible for the supply and maintenance of equipment
           at another hospital (NHS or Private) or linked unit?

           If you answered YES to either/both of the above questions :
           please complete the Linked or Private Hospital sheet (click on the named orange Tab below to open)
           in addition to the current document.




           Facilities
                                                                                    Y/N
           Number of Theatres
           Critical Care Beds - Number
           Adult - Cases per annum
           Paediatric Cases per annum
           Links to Other Units for additional training Y/N
           Computer Terminals available - number
           Computer Terminals with internet access - number




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           Current Training Status
                                                                                          Y/N
           Do you currently train students?
           Do you wish to train students in the future?

           If you answered YES to either/both of the above questions please complete Training Issues
            section below
           If you are not currently training, or do not wish to be considered for training status please proceed
           to the Continuing Education section

           Name of the Perfusionist responsible for training:

           Contact number

           E-mail address

           Training Issues
                                                                                          Available Y/N
           Hospital induction programme
           Training Manual
           Logbook
           Equipment Protocols
           Anaesthetic Protocols
           Surgical Protocols
           Emergency Protocols
           Library Facilities
           Named Mentor
           Wet Lab
           Research
           Personal Development Plan




           Will Trainee's be supervised by a dedicated named Clinical                     Y/N
           Perfusion Scientist when performing clinical perfusion procedures?
           Will the student be trained with Adult CPB procedures?
                                        Paediatric CPB procedures?
                                                                                          Y/N
            Links to other training centres?
           Emergency protocols practised regularly?
           Regular departmental meetings?
           Hospital accommodation available?
           Time allocated to the student for study?
           Internet access available?
           Perfusion Journals and books available?
           Access to Medical Audit and training days?
           Training fee's supported by the trust?
           Record of cases performed




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           Continuing Education

                                                                                    opportunity to attend? Y/N
           Seminars
           Lectures
           Wet Lab

                                                                                    Available Y/N
           Research




           Emergency Protocols

           How often are Emergency Protocols practiced?

                                                                                    Available Y/N   N/A
           Record of staff practice
           Oxygenator Changeout
           Gas supply failure
           Power failure
           Pump Boot Rupture
           Centrifugal Head Changeout
           Air embolism
           Spare equipment in theatre
           Copy of the protocol in theatre
           Signed yearly review




           Routine Protocols
                                                                                    Available Y/N   N/A
           Bypass setup
            Pre bypass check list
           Bypass management
           Cardioplegia administration
           Drug administration
            Double checking system
           Fluid administration
            Double checking system
           IABP
           VAD
           Cell Saver
           H/Filtration
           CO2 flooding during CPB
           VAVD
           Copy in theatre
           Signed yearly review




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           Guidelines                                                             Available Y/N
           Surgeons preferences
           Anaesthetist preferences
           Blood gas management
           Electrolyte management
           ACT management
           Copy available in theatre
           Signed yearly review


           Responsible for Quality control:
                                                                                  N/A             N/A
           ACT
           Blood gas analysis
           TEG
           Platelet function
           Heparin Management System -HMS




           Additional Responsibilities
                                                                                  Y/N
           IABP
           ECMO
           Cell Salvage
           Heart/Lung Retrieval
           Platelet Therapy


           Monitoring and Documentation


           Minimum Standard Of Monitoring during CPB

                                                                                  Y/N
           Are all monitors and alarms regularly calibrated and maintained?




           Monitoring of clinical parameters acquired directly from the patient

                                                                                  Y/N
           ECG
           Systemic Arterial pressure monitoring
           CVP monitoring
           Core body temperature
           Urine Output monitored
           Pulse Oximetry
           Expired CO2 tension/concentration




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           Monitoring associated with the cardiopulmonary bypass circuit

                                                                                    Y/N
           Arterial Oxygen Saturation
           Venous Oxygen Saturation
           Blood flow rate
           FiO2 alarm
           Gas flow alarm
           Arterial line pressure
           Cardioplegia delivery line pressure
           Arterial blood temperature
           Heater/Cooler water temperature
           Record of all fluids administered
           Record of filtrate volume (haemofilter)
           Continuous In line Monitoring
                           PO2
                           PCO2
                           pH
                           Hb
                           Potassium

           Measurements available at a near patient facility
                                                                                    Y/N
           ACT monitoring
           Blood gases
           Red cell concentration (haemoglobin or haematocrit)
           Potassium
           Glucose

           Measurements available at an on site facility
                                                                                    Y/N
           Clotting studies
           Calcium
           Lactate

           Safety Devices
                                                                                    Available Y/N   N/A
           Power failure alarm-
           with a battery powered back-up unit for the CPB machine

           Torch

           Bubble detector with an alarmed automatic cut out facility

           Level sensor -
           with an alarmed automatic pump cut out facility (hard shell reservoir)

           Retrograde Flow Alarm or occlusion device
           when using a Centrifugal pump

           Anaesthetic gas-scavenging apparatus
           whenever volatile agents are used in the CPB circuit

           Out of range temperature alarm on the heater/cooler unit

           Are the above Minimum Standards of Monitoring used on EVERY case?
           If not, please detail below the reasons why:




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           Documentation
                                                                                     Y/N
           Pre-Bypass Checklist
           Electronic documentation record
           Data Management System
           Perfusion datasheet put in the Patients notes


           Management

           Hospital Incident Reporting System                                        N/A   N/A
           Departmental
           Hospital
           Paper documentation
           Electronic documentation
           Equipment Failure Reporting


           Audit                                                                     Y/N   N/A
           Perfusion conduct & practice
           Perfusion case record validation

           Medicines Policy                                                          Y/N   N/A
           In place & agreed for perfusion
           Medicines policy in discussion at present
           Medicines policy discussed but no satisfactory outcome achieved

           New Developments committee
           All new practices/procedures agreed                                       N/A   N/A
           by committee prior to starting

           Ethics Committee
           Approval before commencing new                                            Y/N   N/A
           tests or procedures

           Policies committee
           All protocols/guidelines accepted by                                      Y/N   N/A
           Hospitals committee

           Service Contracts                                                         Y/N   N/A
           In place for all perfusion equipment


           Comments:




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           LINKED/PRIVATE PRE-VISIT CHECKLIST

           To Be Filled in by The Hospital

           Name of the Linked/Private Hospital


           Perfusion Department Details

           Head Of Perfusion Contact Details:

           Name:

           Title and Grade:

           Contact Number:

           E-Mail address::

           Team Members:

           Qualified Staff:

           Name                           Position                  Grade




           Management Issues

           General Manager

           Budget Holder - Responsibility of:

                                                                                 Y/N
           Are regular Finance meetings held ?

           Who is responsible for the Perfusion on-call cover
           at this unit?

                                                                                 Y/N
           Is there a spare Perfusionist available if required?
           If not, has this been risk assessed?




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           Facilities
                                                                                 Y/N
           Number of Theatres
           Critical Care Beds - Number
           Adult - Cases per annum
           Paediatric Cases per annum




           Emergency Protocols

           How often are Emergency Protocols practiced?

                                                                                 Available Y/N N/A
           Record of staff practice
           Oxygenator Changeout
           Gas supply failure
           Power failure
           Pump Boot Rupture
           Centrifugal Head Changeout
           Spare equipment in theatre
           Copy of the protocol in theatre
           Signed yearly review




           Routine Protocols
                                                                    Available    Available at N/A
                                                                    on site      main hospital
           Bypass setup
            Pre-bypass check list
           Bypass management
           Cardioplegia administration
           Drug administration
            Double checking system
           Fluid administration
            Double checking system
           IABP
           VAD
           Cell Saver
           H/Filtration
           CO2 flooding during CPB
           VAVD
           Copy in theatre
           Signed yearly review




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           Guidelines                                                Available    Available at
                                                                     on site      main hospital
           Surgeons preferences
           Anaesthetist preferences
           Blood gas management
           Electrolyte management
           Act management
           Copy available in theatre
           Signed yearly review




           Responsible for Quality control:
                                                                     Y/N          N/A
           ACT
           Blood gas analysis
           TEG
           Platelet function
           Heparin Management System - HMS




           Minimum Standard Of Monitoring during CPB


                                                                                  Y/N
           Are all monitors and alarms regularly calibrated and maintained?




           Monitoring of clinical parameters acquired directly from the patient

                                                                                  Y/N
           ECG
           Systemic Arterial pressure monitoring
           CVP monitoring
           Core body temperature
           Urine Output monitored
           Pulse Oximetry
           Expired CO2 tension/concentration




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           Monitoring associated with the cardiopulmonary bypass circuit
                                                                                    Y/N
           Arterial Oxygen Saturation
           Venous Oxygen Saturation
           Blood flow rate
           FiO2 alarm
           Gas flow alarm
           Arterial line pressure
           Cardioplegia delivery line pressure
           Arterial blood temperature
                            water
           Heater/Cooler water temperature
           Record of all fluids administered
           Record of filtrate volume (haemofliter)
           Continuous In line Monitoring
                            PO2
                            PCO2
                            pH
                            Hb
                            Potassium




           Measurements available at a near patient facility
                                                                                    Y/N
           ACT monitoring
           Blood gases
           Red cell concentration (haemoglobin or haematocrit)
           Potassium
           Glucose

           Measurements available at an on site facility
                                                                                    Y/N
           Clotting studies
           Calcium
           Lactate

           Safety Devices
                                                                                    Available Y/N N/A
           Power failure alarm-
           with a battery powered back-up unit for the CPB machine

           Torch

           Bubble detector with an alarmed automatic cut out facility

           Level sensor -
           with an alarmed automatic pump cut out facility (hard shell reservoir)

           Retrograde Flow Alarm or occlusion device
           when using a Centrifugal pump

           Anaesthetic gas-scavenging apparatus
           whenever volatile agents are used in the CPB circuit

           Out of range temperature alarm on the heater/cooler unit




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           Are the above Minimum Standards of Monitoring used on EVERY case?
           If not, please detail below the reasons why:




           Documentation
                                                                                Y/N
           Pre-Bypass Checklist
           Electronic documentation record
           Data Management System
           Perfusion datasheet put in the Patients notes




           Management

           Hospital Incident Reporting System                                   Y/N    N/A
           Departmental
           Hospital
           Paper documentation
           Electronic documentation
           Equipment Failure Reporting

           Medicines Policy                                                     Y/N    N/A
           In place & agreed for perfusion
           Medicines policy in discussion at present
           Medicines policy discussed but no satisfactory outcome achieved




           Service Contracts                                                    Y/N
           In place for of all perfusion equipment

           Equipment                                                            Y/N
           Is there spare hardware available in case of failure?

           Comments:




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