Coordinating Activity Hosp

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Coordinating Teamwork for Setting up Multi-specialty Critical Care Unit

Done byDr. Urmila Sathe

INDEX

INTRODUCTION

AIM AND OBJECTIVE

METHODS

REVIEW OF LITERATURE

RESULTS

DISCUSSION

SUMMARY

CONCLUSION

REFERENCES

Introduction Top

The 1st ever idea of having a s pecialized unit to take of the critically ill pa tients came intra existence in early 1950s11. Therefore a respiratory care unit was set upfollowing an epidemic of poliomyelitis.

Western world was always ahead in this direction. From 1970 i.e. in past 3 decades there have been tremendous advances in medicine. Technological progress rapidlychanged horizons. There was equal stride in global communication and as a result there was a vast dissemination of knowledge a ll over.

India too did not lag behind. There was a tidal progress wave in industry, economy, science and obviously in medical fraternity too. Disease pattern had changed withurbanization, violence had started out breaking everywhere, natural calamities continued and therefore more and more critical ly ill patie nts were getting hospitalized.

Having 30 bedded open, multispeciality10 crit ical care unit was need of t he hour at Sir J.J. G roup of Hospitals, Byculla, Mumbai, where this retrospective study with 6years and 9 months follow up was carried out.

Aim and Objective Top

y To establish a 30 bedded multis peciality open critical care unit with possible and available latest equipment and amenities under one head

y To approach, involve and get active support, participation, directly and indirectly from all concerned1 preclinical, clinical, paramedical, ancillary andadministrative departments.

y To obtain their suggestions, views, contribution and also their positive criticism.

y To communicate and convince all of them the need of such a CCU set up.

y To train, attract and retain all the required staff .

y To convince nursing staff particularly about the need to be trained for critical care, continued education and work for critical patients.

y To commission a critical care unit which will give satisfac tory care and to the critical patients and hence will a lso maintain turnover.

Methods Top

This study which is retrospective with a fo llow up of six years based on records maintained was carried out at Sir. J. J. Group of Hospitals which is a group of 4 hospitalswith an attached medical college called as Grant Medical College, is situated in heart of main city of South Mumbai in Bycull a area. The other 3 hospitals which form thegroup are :

1. St. Georges Hospital at C.S.T Mumbai.


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2 . Cama and Albless Hospital for women and children near C.S.T.

3. Gokuldas Tejpal hospital at Crawford Market.

These three hospitals are within distance of 3-4 km fr om J.J. Hospital, the main Hospital.

The area where main hospital, J.J. Hospita l is situated is known to be volatile for years together. All these hospita l together look after the need of 3000 indoor patients.

Main hospital has all basic specialities besides all the superspecialities from medical and surgical disciplines. Some of the superspecialities are also duplicated inperipheral hospitals mentioned above.

Operative procedures like kidney transplant, advanced cancer surgeries, laparoscopic surgeries, joint replacements, inte rventional cardiological procedures were alreadyestablished. C.T. scan and MRI U nit, an established blood bank was a lready operative.

But intensive care units were restricted to only intensive coronary care unit, Medica l intensive care unit, Burns unit and a neonatal ICU 2 .

Hence need for establishing multispeciality o pen critical care unit was very compelling.

J.J. Group of Hospitals is a s tate government set up. Therefore is also liable to be under public scrutiny.

Any action when dubious can be questioned o n the floor of asse mbly. This project was assigned to me by Dean, Grant Medica l College with pertinent orders. He a lsoinstructed me to keep a detailed record of all procedures, proposals, correspondence, fax messages, minutes of meetings.

Hence this study was possible on the records based from 1997 with a fo llow up till 2 005.

Total work of CCU was carried out i n three phases.

P hases I - step I - Ground work

The need for CCU was lo ng perceived and realized by Dean 5,10,11. As is the practice all over the world a senior consultant / professor of Anaesthesia7 had to be at thehelm of affairs in planning, implementation and evaluation of the process. The person had to have essential skills, technicalknow-how of equipment needed, experienceand competence of handling variety of seriously injured, ill cases. Having fulfi lled all the criteria I was assigned the job of setting up CCU which was like a Turn keyproject.

Dean executed two most important communications which bui lt up background for further process. There was verbal and written upward and downward communication.

F igure 1

After this communication everybody agreed on the point of need of well equipped and maintained ICU for better service to the patients with ultimate aim of their recoveryto lead normal life.Everyone was aware of the facts that over years ( 2 5 yrs) specialities had grown so too the work and patients were put in side rooms of ward turned into ICUs anddeficiencies were:

1. Inadequate instruments and equipment

2 . Insufficiently trained / untrained staff

3. Unacceptable ward conditions


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4. No dedicated medical or nursing staff

5. Difficulty in coordinating various specialists, paramedics and ancillary services

6. Preparedness for life saving emergencies was far from satisfactory.

7. Maintenance and repair of instrument was difficult.

8. Everything together was becoming drudgery.

P hase I Step II

As per instructions, staff proposal was prepared1 2 with:

1. HOD General Surgery

2 . Professor of Anaesthesia

3. HOD Biochemistry

This was sent within 30 days of

1. 1st meeting held

It was out of everybodys experience that it is generally lack of staff for which departments do not get activated / i nitiated.

1. Mobilization of funds was totally within purview of higher rungs of administration. Estimation for raising CCU was 6 crores of Rs.

2 . Another important part was purchases of equipment and alteration of structure to accommodate CCU.

Accordingly within next 4 months meetings were calle d of concerned Head of Department from clinical si de, preclinical, from supportive services, paramedical andadministration. Important issues which raised doubts, queries, apparently were challenges were discussed.

A total meeting protocol and therefore culture was fully observed.

1. An official intimation

2 . Preceded by a personal telephone call by coordinator i.e. myself

3. Place, time, date of meeting, issues to be discussed

4. Attendance maintained

5. Minutes were circulated later for approval.

Issues discussed raised lot of discussion. They were as follows

1. Location of CCU - Where?

2 . Leadership of CCU - Who and Why?

3. Staff requirement Sceptic queries because of past experience

4. Training Who, When and Where?

5. Incentive / perks If yes, - What?

6. What happens of existing side room ICU?

7. Distribution of beds How, to whom?

This meeting was held on 14th May 1997.

Total 16 departmental Heads who were obviously and immediately concerned were called upon to attend meeti ng. 1 2 members attended the meeting.Intimation was sent to fo llowing departments:

1. General Surgery

2 . General Medicine

3. Obstetrics and Gynaecology


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4. Cardiovascular and Thoracic Surgery

5. ENT

6. Orthopaedics

7. Neurosurgery

8. Pathology

9. Biochemistry

10. Radiology

11. Physiotherapy

12 . Matron

13. Superintendent J.J. Hospital

14. Administrative officer

15. Office Superintendent Purchase section

16. Nephrology

Out of 1 2 1 was Tota lly Resistant2 were Totally in different9 were Favourable

P hase I Step III

Initially held t wo meetings had helped to break the ice with all departments sti ll there was disbelief regarding budgetary sanctions and appointment of staff .

At this stage various departments were communicated and requested to give specifications of i nstruments and equipments of their speciality which will be used in criticalcare unit. There was 100% response. If there was delay re minders were sent. Coordinator (Professor of Anaesthesia) communicated personally, telephonically as well aswith written words.

Eleven departments totally were communicated and coordinated to give and co mplete a specification list of 100 items totally. At this s tage the departments and groupscommunicated were yet in thinking stage.


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F igure 2: Emerging interdisciplinary health care team in the norming phase

Meanwhile communication at vertically hi gher level of hierarchy was happening for a very formal budgetary sanction for CCU to meet t he needs e.g. appointing new staff ,purchase of equipment and alterations of existing structure. Verbal communications and written communications which were evidence based, scientifically logical and for betterment of hospital were successful.

F igure 3

PH ASE II


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This was time to physically establish CCU with equipment and completed altered civil and electrical structure.

F igure 4

Step I

A purchase committee was formed under chairmanship of Dean, Professor of blood bank with CCU c oordinator and administrative staff, who helped out a ll theprocedures which includes.

1) Tender process

2 ) Bidding

3) Matching technical specifications

4) Demonstration of instruments

5) Delivery, installation.

For 100 items more than 300 equipment suppliers were contacted. At this juncture CCU committee was formed which had followingmembers.

1. Dean

2 . Associate Dean

3. Superintendent JJ Hospital

4. Resident Medical Officer

5. Secretary Member, (CCU coordinator Professor of Anaesthesia)

6. Associate Professor of Anaesthesia

7. Matron

8. Civil Engineer

9. Electrical Engineer

Purchase of equipment and civil work was overlapping and happening si multaneously. Occasionally for installation of e quipment e.g. liquid O xygen tank some civilconstruction was required. While altering existing ward to convert it into CCU civil and electrical engineer along with gas pipeline supplier had to have a meeting together with CCU coordinator as well as nursing staff.

Several meetings were held for items of different prices as per government rule which dictates

P urchase at

Dean level - Upto 50,000 Rs.Director medical education - Upto 3 lacsSecretary medical education- anything above 3 lacs

Everybody from administration, clinicians, paramedical, preclinical was i nvolved and had to participate in the purchase process. There was a profound dialogue at alllevels.


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F igure 5

F igure 6

Professor of anaesthesia was a member secretary to CCU committee coordinating various teams at various levels.

Step II

Establishment of successfully functioning CCU was everybodys goal. They were all motivated. As shown in dia grams on the previous page. Several teams were workingsimultaneously. Salient features of work during this phase were as follows:

y CCU committee meetings took place regularly every week

y All members of committee were directly involved with CCU work and therefore automatically, personally supervised work

y Nursing speciality is backbone of critical care and realizing this matron gave many useful suggestions.

y There were regular feedbacks as per protocol on c ivil work, electrical work and progress of CCU work fro m coordinator at all levels and also to the peers.


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F igure 7

P hase II step III

1. At this juncture it was suggested by secretary member and obviously coordinator that a required number of nurses should be trained for 4 wksin the hospitals where there are multispeciali ty CCUs to keep in readiness to start CCU. As staff requested was 1 staff nurseper bed4,7,8 asper standards, it was decided by consensus to train a batch 30 S/N at o ther hospitals coordinator who was to be Incharge of CCU had alreadytaken training at a tertiary centre in UK.

2 . Other hospitals were also requested to help out in guiding admission / discharge patterns, inventories which they readily gave. This toohappened as per norms. A telephonic communicatio n followed by an officia l letter through Dean to the Medical director of the particular hospital.

3. The supportive departments at this time were contacted to draw plans to meet daily demands of consumables food, linen etc.


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F igure 8

Coordinating help from other hospitals gave us t he idea how best to uti lize our resources to maximum benefit in creating CCU for benefit of patients.

P hase III steps I

Physical work was / structuring was complete. Equipment and i nstruments was in custody of Sister Incharge of CCU. Activating day to day work of CCU was main part. Astaff of 49 was sanctioned which i ncluded sister Incharge

1) Staff nurses, 2 ) Lab technicians, 3) Physiotherapist, 4) Resident doctors from anaesthesia and officer s / consultants. Rest of needed staff e.g. s weepers, ward boyswere mobilized from units (side ICUs, MICU) which were to merge in CCU.

1. Instrument installation:Once again equipment supplies were called and while installing instruments there was active teaching and training of staff.

2 . Newly appointed staff was joining in different batches.CCU coordinator, Sister Incharge and Associate Professor in Anaesthesia were thesteady fulcrum.

3. The rest of the departments of hospitals were routinely apprised by Dean on progress of CCU establishment at regularly held forthrightlymeetings of all departments of hospital.

4. At this stage it was very important to involve medical records department. Incharge medical records was appraised about records systemneeded for special charts of CCU patients 2 4 hrs continuous data and their transient stay, before being shif ted to ward.With all thepreparedness for admission of the patients CCU inauguration to place where money of government was invested and 1st patient fromneurology got admitted within 1 2 hrs followed by another from department of Gynaec and Obstetrics. And then there was no Down time for CCU. For initial 6 months coordinator (Figure 7) stayed day and night supervised work, gave information about patients to various consultants,contacted equipment suppliers, Dept of public works (PWD), many other department on various occasions. On job learning and teaching

process was thus started.


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F igure 9: Well-functioning Interdisciplinary H ealth Care Team

Review of Literature Top

The importance of getting all i nterested parties involved is described by various authors.

1. It is important that all interested parties are involved at the beginning of any reorganization. A multidisciplinary workinggroup including surgeons,anaesthetist, paediatricians, ward nurses, theatre staff, the professions allied to me dicine and managers may seem cumbersome but these the people whowill be required to agree and i mplement change and they should be represented. It is much easier for a multidisciplinary group, with all the interested partiesinvolved in the debate and decision- making, to progress towards an agreed goal, than for a ny single-interest group to impose its needs or wishes on theservice. The Royal College of Anaesthetists suggests including a paediatrician, anaesthetist, surgeon, pharmacists and registered childrens nurse althoughmembership may be broader.

..Paediatric anaesthesia and Critical Care in District Hospitals.

..Neil Morton, Jane Peutrell 2 4. Butterworth and Heinemaine 2 003.

2 . Clear-cut administrative policies are vital to the functioning of an ICU. An open ICU has unlimited access by multiple doctors who are free to admit andmanage their patients. A closed ICU has admission, discharge and referral policies under the control of i ntensivists. Improved cost benefits are likely with aclosed ICU and patient outcome may be better, especially if the i ntensivists have full clinical responsibilities. Some ICUs, particularly incountries withoutqualifications or training programmes in intensive care, adopt a management-in-consultation policy. A team (usually anaesthetists) looks after the day-to-dayand emergency aspects, but co-manages the patients with t he referring specialists. Whilst laudably democratic, lines of responsibility at ti mes are unclear,and acquisition of knowledge or experience may not be optimal. Regardless of whoever is in charge, li nes of management must be deli neated for all staff members, and their job descriptions defined. The director must have fi nal overall authority of all staff a nd their actions, although in other respects each groupmay be responsible to their respective hospital heads, e.g. director of nursing. Policies for the care of patients should be formulated. They should beunambiguous, periodically reviewed, and all staff should be familiar wit h them. Certain policies are universally applicable, e.g. ant ibiotic policies andcompulsory hand-washing before and after examining patients. Other depend more on local situations and personal beliefs, e.g. donning gowns and over shoes before entering the ICU-a ritual not proven to reduce cross infection. The c lear understanding of management needs to be conveyed. This will a lsolessen the future conflicts and clarifies jo b responsibilities.

..Intensive care manual by T.E. Oh


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..Design and organization of unit pg. 7. Butterworth, Heinmann Publication 2 00 2 .

3. The collective, participative and extended care for patients in crisis needs a careful thought. It is a collective decision thought. It is a collective decision of allthe colleagues. This was described in Critical Moments.

The issue of responsibility for care would appear to be centra l here Nolan (1995:305) suggests that for any movement to be made fro m a multi-disciplinarymodel (in which a variety of perspectives contribute equally to the direction of clinical care and decision making, a willingness to share responsibility must beshown. This must come not only fro m doctors but also from nurses, who traditionally have deferred to their medical colleagues, particularly in difficult end-of-life discussions. Henneman et al. (1995:359) suggest that many barriers to interdisciplinary collaboration can be traced to the socialization and education of nurses in which, in a similar way to doctors, independence rather than interdependence has been emphasized.

In spite of this difference, staff in both units emphasizes the importance of the team i n the delivery of care to patients. The i ntroduction of primary nursingand the nurse-led ward wound at eastern has gone so me way to addressing the tension between hierarchy and collegia lity (Griffiths 1997:60) and thusmade team a viable term for describing the organization of action. However, at W estern, the term seems to be applied more as a loose rubric than adetailed template for action (Grif fiths 1997:60). Chapter 3 pointed out, however that the reliance on the medical model during the ward round at Easternmeans that the nursing orientation to patie nts is frequently subsumed to a requirement to produce a proficient medical report. While t his is undoubtedlyappropriate for those patients for whom recovery is still expected, i t is problematic for those patients who are approaching death even if this has not beenacknowledged formally. Further, nurses anxieties about their opinions known vis a vis treatment plans for patients.

A further way of enhancing both interdisciplinary understanding, effectiveness and mutual support may be an adaptat ion of team debriefing after the death or discharge or patients. McNamara et al (1994: 2 34) describe the operation of a separation review in a palliative care context. This consists of a weekly,multidisciplinary meeting in which the circumstances of the illness, care and death of a patient are discussed.

. Death and dying in ICU by Jane and Sejmour 163-Open University Press 2 001.4. Importance of interactive and transparent working of meetings also was explained is different literature. Ultimately purpose of meeting should be fruitful

leading to decisions. Protocols though not mandatory should be fo llowed...

Participating effectively in meetings

Meetings formal and informal are one particular kind of group activity. They are notorious for producing heart-sink but a well run meeting can be enjoya bleand productive.First, here is some guidance on how to be an effective participant at meetings. Your may not be in charge but there are a number of constructive things youcan do to help a meeting go well.

Encourage the person chairing the meeting into good practices; e.g. ask for clarification o n the purpose of the meeti ng or for a summary of what has beenagreed at the end. Come prepared, having given some thought to what your would like to get out of the meeting a nd having readany relevant papers.

Arrive on time. If your think the meeting is likely to run over time, make a request at the beginning of the meeting for a punctual finish.

Agree what to do about taking notes : does each person take their own or does one person take them and circulate a copy to everyone else? Do you wantdetailed notes of everything you discussed or just action points? If it is not clear, ask for clarification and even volunteer to do the notes yourself.

Do not speak for too long-just a minute or two at a time s hould be long enough to make your point. Actively contribute to themeeting express your views,keep an open mind and listen to o ther peoples opinions.

Encourage everyone to participate drawn in quieter people by referring to their relevant experience or expertise.

1. Only make commitments that your are genuinely able to fulfill and make sure you do so on time. Say no clearly and non defensively if your are unable or unwilling to do something.

2 . Remember that discussion and argument about ideas will help decision making but personal rivalries will not.

Effective committee work:

All health care professionals will i ncreasingly be required to become members of formal committees or boards, e.g. there are nurse members of primaryhealth care trusts. This can be daunting if your have never served on a formal committee before and it helps to know the basic rules of how they work.

A committee is a group of people a ppointed for a specific purpose accountable to a large group or organization; example are the management committee of a voluntary organization or the health committee of a local authority. The officers are servants of the committee a nd carry out its instructions. Manycommittees have three key officers the chair, the secretary and the treasurer. As committees grow the officers often need help with their work and additionalappointment may be necessary e.g. a minutes secretary.

Committees tend to be i nformal nowadays but it is good to bear in mind the reasons for accepted codes of behaviour. E.g. the rule that only o ne personspeaks at a time, and is not interrupted, is meant to ensure a fair hearing for everyone. The rule of everyone speaking by addressing the meeting t hroughthe chair helps to prevent a number of sub-discussions developing at the sa me time. On the other hand, i t may seem more natural and helpful to addressanother committee member directly. Ultimately it is the job of the chair to set the tone which encourages all members to part icipate whilst keeping themeeting under control.

Brainstorming: this is a useful way to open up a subject and collect everyones ideas. Ask an open question to which there is no single right a nswer (Whyare we not meeting our targets?). Accept every suggestion, without comment or criticism, and write them down in list on a fli pchart or whiteboard.

Alternatively, write each idea separately on a sticky note (the kind you can peel off and move) and put these on a f lipchart. Ask the group not to startdiscussing the ideas until everybody has finished. You can make your own suggestions and write them down along with e veryone elses.

In this way all members contributions are equally valued and everyone has a chance to participate. Encourage shy members by asking anything else a ndallowing silent pauses while people think. Then you can set the group to work by asking them to put the ideas into categories and to identify the key featuresof each category.

Rounds:

A round is a way of giving everyone an equal c hance to participate. You invite each person in turn to make a brief statement. You may like to start the round

yourself or to join i n when you turn comes. E.g. ask every to make a brief stateme nt about one of the follo wing: The thing which stresses me most is

The thing I think would help most with this problem is . There are four essential rules for successful rounds, which should be e xplained and gently enforced if necessary. These are:

No interruptions until each person has finished their statement no comments on anybodys contribution until the f ull round is completed (i.e. no discussion,praise, interpretation, criticism or I-think-that too type of remark) any one can hose not to participate. Give permission, clearly and emphatically, that anyonewho does not want to make a s tatement can just say pass.

It does not matter if two or more people in the round say the same thing. People should stick to saying what they had intended to say even if someone elsehas said it already; they do not have to think of something different.

Working in a team:

A group of all clinical staff will experience is the clinical or multi professional team, consisting of nurses, other health professionals and perhaps people fro m


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disciplines outside the health service such as social work. Successful teams tend to have the following characteristics.

A common purpose and shared objectives which are known and agreed by all members.

Members selected because they have relevant expertise.

Members who know and agree their own role and know the roles of the other members.

Members who support each other in achieving the common purpose.

Members who trust each other and communicate in an o pen, honest way.

A leader whose authority is accepted by all members.Managing communication in health care, six steps to effective management by Mark Dartey, 97, Baillere Tindall 2 003.

5.Planning is made, executed as per time schedule, which will also e ncourage all the members and keep then motivated

Timetabling of implementations

We have already suggested that many of the failures of implementation relate to a lack of co-ordination of the real resources (including personnel,equipment, and building) and a lack of rea lism about timing. De lays in project implementation are not only a problem in themselves, but may cause problemsof cost overruns and frustrated expectations on the part of both staff and the community. Realistic t imetabling is therefore essential as a means of accuratecosting and maintenance of planning credibili ty. In order to minimize delays as a result of this, various managerial techniques exist. These are often giventhe generic name of network analysis. These techniques vary from crude flowcharts to the more sophisticated critica l path analysis.

A flow chart sets out, in order of occurrence, the various steps which need to be gone through, dividing where necessary where options occur and decisionto be out the main steps i n a project, such as the construction and operation of a health centre, which has already been identified as part of a programme.While the exact sequence of events may vary for different projects, t his shows the main steps for projects where building work is required. Where projectsinclude no building work, the diagram can be amended suitably. Construction of such a flowchart with dates on its is a usefulbasis for the monitoring of aproject.

An introduction to health pla nning in developing countries

.By Andrew Green

.Programmes project, implementation and monitoring, 2 47, Oxford University Press 1999.

6. Learning experience known as training is an i ntegral part. Its importance can never be underestimated. We trained menses be fore hands and continued leadingprogrammes.

Our this activity has evidence base of .

Education

Formal education for intensive / critical care nursing can be described under specialist training programmes, orientation and continuing e ducation. Formaleducation implies a teaching and learning process. A goal of formal education however should be to e ngender career long learning in the nurse. Educationalopportunities and qualifications are inherently linked to career progression.

Specialist nurse training programmes

Hospital based post basic courses in intensive care and related critical care areas have been the mainstay in preparation for specialty nursing in Australianpractice, with most states offering intensive care and / or coronary care or cardiothoracic courses in the 1980s. The co urses were often approved by the

state nurse registering authorities and their graduates were and still are sought after. Post basic courses were directed towards developing clinicalproficiency in the units in which they were based, and were highly successful in this. T hey contributed to good management of critical care patients, whether or not the nursing contribution to this was evi dent. The courses also assisted greatly in the recruitment of staff, with RNs often attracted to a hospital or unitby the courses in offered.

.Intensive Care Manual by T.E. OH

.Critical Care Nursing 37.

.Butter Worth Heinmann Publication 2 003

Results Top

Table 1: Number of Admissions F or Each Year

Years No. of Admission

March 1999 - December 385

2 000 789

2001 1107

2 00 2 990

2 003 1 2 62

2 004 1339

2 005 1 2 84


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Table 2 : Types of Admissions

Year Types of Admission

Medical SurgicalMarch 1999 - December 164 22 1

2 000 2 94 4942 001 39 2 7152 00 2 2 62 62 72 003 385 8772 004 468 8712 005 53 2 45 2


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Table 3: Distribution of Beds Surgical

Year Surgical

CVTS 4

Neurosurgery 4ENT 1

General surgery 1

Isolated 2


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Table 4: Distribution of Beds Medical

Year Medical

Internal medicine 3

Gastroenterology 2

Neurology 2

Respiratory medicine 2

Endocrinology 1

Nephrology 1

Isolated 2

Five beds for step down / hi gh dependency patients.


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Table 5: Recovery Rate of CCU

P eriod Admission Recovery Death

1999 March 14th to 1999 December 385 2 41 (55%) 140 (36%)

2 000 Jan to 2 000 Dec. 789 519 (65%) 311 (33%)

2 001 Jan to 2 001 Dec. 1107 775 316 ( 2 8.54%)

2 00 2 Jan to 2 00 2 Dec. 990 7 2 8 2 62 (2 4.46%)2 003 Jan to 2 003 Dec. 1 2 62 948 311 ( 2 4.64%)

2 004 Jan to 2 004 Dec. 1339 983 400 ( 2 9.87%)

2 005 Jan to 2 005 Dec. 1 2 84 890 39 2 (30.5 2 %)

Discussion Top

Sir J.J. Group of Hospital & Grant Medical Co llege is one of premier insti tutes of this country looking after 3000 patients. It had are superspecialities and was progressingwith time with advanced technique of treatment in a variety of complicated patients, who needed also exte nded care and hence the new idea of multispeciality9,1 2 open


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critical care unit propped up. Till then patient care, intensive care was somehow carried on in side rooms of ICUS compromising on many ideal conditions. 30 bedded setup was thought was evidence based as quoted and documented in many places.

Inspite of theoretically principally10 agreeing on such a need and therefore placing the patients who need specialized care in hands of specially skilled staff for 2 4 hrs itwas not still palatable for those who were directly involved and where as those who were on lookers, came from supportive ancillary services and were indifferent to thechange that was proposed.

After initiation of s uch talk and already placed upward communication (Figure 1) those who were all wil ling for such a favourable change, in 1st meeting held, where opendiscussion was encouraged we found different responses. As expected in any organization. There were three categories / attitu des. i) Resistance, ii) Indifference, iii)

Acceptance

Those who were going to be the beneficiaries (Table 2 & Bar diagram) of the project raised many queries and were still little sceptical about the outcome. This hospital

being a government set up where there is always crunch on budget aspect and a total full stop for appointing new staff. Even though this communication was very open,horizontal, putting the patient under somebody elses leadership was difficult to di gest. The root cause was medical professionals work autonomously. Their imagerywouldnt permit such a change. It took so metime for all the members to understand that an intensive/ critical care unit is an organizatio nal unit where implementation of team work is necessity which has to start from grass root level.

New suggestions regarding staff appointment their qualifica tions came from neurosurgery department and were very thoughtful. Matron suggested that without sweepersand ward attendants department cant be started which was very practical.

Thus there was generation of ideas and departments ca me forward with applicable ideas. This participation gave sense involvement which was further enhanced byrequest for giving specification of different equipment / instruments as per specialities. This gave some hopes and motivatede verybody and there was automatic progressof involvement. For location of CC U a grand round of various hospital sites suggested was taken 5 times before finally agreeing upon a place. This decision was too ta kenwith full consensus. Book references were read out, documents of experience were discussed. As everybody agreed upon the location requirement in the given situation,a decision was arrived at.

Thus at every stage there was brainstorming and procedures were absolutely transparent.

On the issue of distribution of beds approximate division was shown and it was conveyed to all that flexibility will be important.

Bed distribution happened to satisfy everybody. (Table 3 & Pie diagram).

Apparently the well known high risk specialities required special care and have complicated patients. On examining a number of admissions it was realized that a patientof psychiatry was admitted in critical care as he s uffered cardiac arrest after electroconvulsive therapy. Similarly, another patient fro m Ophthalmology was admitted for similar problems. Normally patient from these specia lities getting admitted i n intensive care unit is uni maginable. However both the patients were treated and were

transferred out with complete recovery.

Flexibility, adjustment was one very important aspect of bed management by different teams utilizing critical care services. Obstetric patients are yet a nother sensitiveissue which is discussed at National le vel if maternal deaths occur. Every obstetric patient who needed admission always had a bed in our unit. These of course requiredlot of proper communication and co-operation amongst all the specialists.

At this stage co-ordination of teams was taking place at two levels

y Vertical hierarchy from Dean to Health Minister

y Downwards from Dean to various departments

In phase I & step II

Staff structure, planning was assigned professor of Anaesthesia, general surgery and biochemistry. Further implementation of these recommendations was taking placewith teams at hi gher rung (Figure 3) though CCU coordinator was a common factor. As the purchase process began different instruments needed for different specialitiesstarted being delivered in for demonstration. At this stage these interactive communication gave a sense of group formation with motivation to achieve a goal. Though aproper protocol of communication was followed there were not any barriers either at higher levels i.e. from Dean onwards or downwards.

Eleven departments which were asked to give specification for the i nstruments, equipments which could be used in future for patients in critica l care are as follows:

y Pathology

y Pharmacology

y Biochemistry

y CVTS

y Ophthalmology,

y Radiology,

y Obstetric and Gynaecology,

y General Medicine,

y General Surgery,

y ENT and

y Physiotherapy

It was an acid test to convince individual heads of the department why the purchase instrument will not be o n the inventory of their own department but will be with CCU .


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Where on reference they will operate the machine / instrument / equipment, give their valuable opinion. Such queries were raised by departments like Radio logy, ENT.They wondered why purchase of USG machine and bronchoscope had to be in custody of critica l care. The idea of a interdisciplinary, multidisciplinary unit was still notseeping in, beyond their imagery. They could not e nvisage such a virtual reality.

In phase II Physical existence of CCU started taking place. Many more departments came into picture. (Figure 4).

Coordinating this team work was different i n nature. Clinicians and nursing staff were actually requested to visit the si te and explain their diffic ulties. There were lots of discussions at weekly meetings of CCU committee.

There was mutual understanding and co-operation between public works department, government architect (Figure 6) on one side and consultants on the o ther hand.

There was no ambiguity in these two teams. Our demands and needs were clearly conveyed to them and nothing was imposed on us10. Looking at the other side a ny

lacunae left by us in planning was pointed out by them and was readily corrected e.g. a major item like f ire extinguisher had to be i nstalled. There was NO CONFL ICT inthis part of team management or when coordinator insisted on number of power points and illumina tion with explanation for its needs it was readily agreed upon a ndprovided (Figure 7).

Needless to say, as mentioned in previous pages there was direct feed back to secretary every week by a fax messages followed by written communication.

Government was investing 6 crores of rupees from tax payers and therefore other hospitals were also consulted to get best f or our set up.In phase three we were initially in norming phase changing over to forming phase rapidly. T his was a ongoing process. This was followed for 6 years 9 months. (Figure 2 ,9)

The results of Table No. 1 & 2 show the tremendous response and need for all departments, which was not possible without a genuinely coordinated teamwork!

Table 5 shows mortality rate in critic al care, a follow up f rom March 1999 to December 2 005. The mortality percentage is quite acceptable and within quoted limits as per Intensive care manual by T.E. O h. Though it is c larified that no ICUs should be co mpared which each other.

Establishing critical care unit was a management activity and therefore the results of tables discussed above do not require use of statistical tests. As this activity did notinvolve any collection of data for set of hypothesis and hence the statistical tests are not applicable .

INITIAL EX P ERIENCE O F ACTIVATING CCU :

(What can be called as TEETHING problems):

y Instruments / equipment working Hands on experience on a live patient whose responsibility of life lies with you, and is very different experience. E.g. apatient on ventilator. Small technical problems are ample. Hence company engineers / maintenance personnel were called on several occasions and evenat odd hours. They all obliged.

y Power failure Mumbai never had power cuts or load shading. Hos pitals are always spared. CCU was started only after a lternative (Generator)arrangement was made and was functional. Ho wever with patients on life saving e quipment even few seconds gap of power and change over to generator used to be alarming and threatening.

y Admission norms / referral norms and guidelines were already issued, so too, Admission / discharge norms. Still it took about 2 months for the work to bestreamlined. As consultants / unit heads were used to a utonomy. Whatever small conflicts happened were resolved at rounds basically with communication.Many outside hospital consultants approached us for referring and transferring patients to critical care unit. They were explained admission procedure.

It was evident there was utter need for such a s pecialized unit.

y Assembly Questions Any public set up, i.e . a government undertaking is always under public scrutiny as mentio ned right in the beginning.

Many questions were raised on the floor of t he assembly but higher offices had a complete record and feedback which was ready at hand and therefore could satisfypeoples representatives and hence government image was never tarnished. Thus was always elevated in the eyes of voters.

Two teaching programmes/wk continued to go on to this date where all departments concerned and unconcerned are invited. This keeps the high morale of CCU staff who works as a family. CCU won 5 awards at different levels for best performance in the hospital competition which was a great incentive.

They were as follows.

2 001- Award for ward boys Professor 2 003 - Award for sweepers2 004 - Award for sister Incharge, staff nurses2 005 - Award for sister Incharge, staff nurses

CCU 1 1st prize for best unit with shield for successive 3 years

Thus ultimately coordinator of critical care unit professor of anaesthesia presumed a role of leadership on all the fronts connected to CCU. It was essential to bringabout this change of giving the speciali zed care under one head which was to save equipment, staff a nd maintenance under single leadership from beginning10 (Hospital

Administration Vol. 1, Module 1 , Pg 46). It gave an impetus and continuity. Higher authorities were supportive.

On every aspect of planning a democratic way, transparent administration was meticulously observed and the final goal was never out of site.Though there was no fixed time limit imposed for completion of the project, as unit was started withi n a year there were no queries raised by anybody for delay. Rest of the results of critical care is speaking for themselves as discussed earlier.

Managing and directing both functions were done by coordinator. Communication had a big role in the given circumstance. No efforts were spared in communicating morethan 340 functional units (refer to Figure 10). These consist of a big bulk of equipment suppli ers. This was inevitable when such units are speciali zed to take care of thepatients who are critically ill and have potentially reversible lesion. All the equipment had to be used for the purpose for which money was invested. CCU record isfollowed up for 6 years and 9 months. It is functioning to full capacity.

Summary Top

After tenacious efforts lasting over a period of about 18 months a physically and functionally existing CCU was visible. Exactly on 350th day fro m formal orders of purchase of equipment, CCU was inaugurated and 1st admission of the patient took place. It was a 1st critical care unit of i t s kind with government set up in state of Maharashtra.

As at start itself higher offices were convinced about need of open multidisciplinary CCU i t was relatively easy to co-ordinate for

1. Purchase of equipment


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2 . Procuring a place

3. Sanctioning staff for CCU

Dean, the head of the institute first sounded the change that was to take place to all concerned heads of departments and hadidentified that an anaesthesiologist wouldbe a proper person to be Incharge and co -ordinate team activities as is the practice over the world.

Meetings held thereafter were always a open communication. Everybody was encouraged to ask questions and give suggestions, po int of view. Partici pation of alldepartments which existed whether concerned directly / indirectly was solicited and response was very encouraging. Hospitals otherwise / outside a lso obliged protocolsand formalities were meticulously observed.

Before embarking on actual commissioning of CCU, a required number of staff nurses were trained. CCU coordinator and Incharge an anaesthesiologist herself wasalready trained. Thus CCU which was looked a t with sceptism turned out to be tremendous success.Initial 18 mont hs time gave along rope for everybody to accept and adapt to the change a nd work in a team.

Conclusion Top

Multispeciality CCU was need of:

y The time and this change had to be brought about successfully. Existing situation then was far from satisfactory.

y Effective management of this change necessitated communication, motivation, resulting in teamwork which has to be coordinatedin multidisciplinary patientmanagement.

y The said change was brought about very gradually, with transparent adminis tration and regular communication.

y J.J. Hospital is a huge establishment and coordinat ing teamwork was a mammoth task. Weekly meeti ngs were taking place and regular feedback was givento superiors.

y Except little resistance initially ice thawed quickly enough evident by yearly rise in turn over of CCU indicating trust and fai th in CCU teamwork.

References Top

y Adams A P & Cashman J P. Recent Advances in Anaesthesia & intensive care, 2 004, Chapter 9,Page 2 10. Published Jaypee Brothers.

y Baggot Role Medicine & Medical, Professor of Health & Health care page 45 Macmillan press.

y Brown Gillian, Esdaile Susan. Becoming an advanced Healthcare Practitioner 2 003, page 2 41 Butterworth Publications.

y Civetta Joseph, Robert Taylor critical care, 199 2 , Joining the team, chapter 5, 9 Published by J. B. Wipinwalt c/o.

y Divetia J.V. Conference publication of 1 2 th slate conf of ISA 2 004 critical care medicine & a naesthesia.

y Drinka Theresa, Clark Philip. Health cane teamwork I n Interdisciplinary Practice & teaching 2 000. Page 160, 2 8, 30.

y Jain Pravin Kumar. Principles & practice of critical care 1998; Page- 2 3.

y Mathai G. Role of nurses in CCU. Indian Journal of Critical Care. Page-63; June-July 1997.

y Maurice King. Primary Anaesthesia 1986. Primary Intensive Care. Page-141 Oxford Medical publication.

y Reddy Souri Dr. Hospital services and planning, Module-3, Page-18, 30,31 ,38,39,6 2 ,63,146,163,166,167.

y Sundaram Meenakshi. Organization of CCU in a small hospital 2 005 Conference Lectures is a Com 2 005 Calcutta.

y Wolowicka Laura. Team work intensive care Proceedings of 10th Annual conference of ISCCM 2 004. Chapter 63, Page 2 90.

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