Hospital Management System in C by uyb13437

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									                                             9b81ca13-9abc-4d80-87f7-f2dcd463c83b.xls




                                         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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                                             9b81ca13-9abc-4d80-87f7-f2dcd463c83b.xls




            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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