WIRTTEN REPORT ON INOVA HEART AND

VASCULAR INTITUTE EXPOSURE

SUBMITTED BY:

MOHAMME NASSER ALSHAHRANI

Nurse Clinician, Cardiac Operating Room

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OVERVIEW

INOVA FAIRFAX HOSPITAL is the largest hospital in Northern Virginia and a flagship

hospital of the INOVA HEALTH SYSTEM. Located in Fairfax County, Virginia, IFH is one of the largest employers in the Unites States. Ranked nationally in 1 adult and 2 pediatric specialties. Also, a high- performing in 8 adult specialties.

It is a 927- bed tertiary care hospital, providing most medical and surgical specialties with 47,442 admissions in the most recent year reported. It performed 13,177 annual inpatient and 16,418 outpatient surgeries. Its emergency room has 142,744 visits approximately.

Inova Fairfax Hospital is a home to neonatal intensive care unit as well as pediatric intensive care unit, an oncology unit, an adolescent medicine unit, and centers for cardiac surgery and pediatric surgery.

For the institution’s cardiac services due to its uninterrupted growth, a separate

identity were given by creating INOVA HEART AND VASCULAR INSTITUTE. A state

of the art flagship program is located in the IFH campus. Considered one of the most complete, technologically- advanced medical and research centers in the United States. This institution has an excellent reputation in providing full spectrum of diagnostic, therapeutic, surgical and interventional cardiac services.

Housed in a four-story, 410,000 square foot facilities are:

i. 156 patient rooms (mostly private rooms)

ii. 48 Intensive Coronary Care beds

iii. 6 Cardiac Operating Room

iv. Numerous amenities and services for patients and careers

v. Information kiosks

vi. Video library

vii. Heart healthy cafe

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The two- week long exposure was basically on lectures, ocular observation during

rotation to some departments and in CVOR, organized by the program manager of the

hospital following a detailed schedule of the entire course. The 1st week was mainly

lectures about the institution’s programs, policies and achievements as well as rotation

to the whole hospital departments. The group was welcomed by Dr Charles Murphy,

M.D and Dr. Merdod Ghafouri, DO, FACC, FAHA, Chief Patient Experience Officer.

First Week

A lecture was given by the Clinical Educator entitled Advanced Hemodynamic

Support. It conceptualized on understanding adult hemodynamic covering theory,

monitoring, waveforms and medications.

In between to these lectures were routine hospital rounds to the whole hospital

wing, escorted by the Clinical Instructor Cindy DaHaan, R.N. While going around, she

emphasized IOWA FOUNDATION MEDICAL CARE SAFETY AND ACCESS Review (IFMC)-

a non profit organization which provides services in health care quality improvement

and medical information management. She said that IHVI has consulted IFMC to help

them improve the quality of care and lower the costs of services by combining clinical

and technical expertise in solving healthcare challenges.

A lecture was focused on Executive Nursing Leadership facilitated by the Chief

Nursing Officer Ann Marie Madden, R.N. It intents to highlight and address the

following competencies: professionalism, communication and relationship

management, skills and principles and knowledge of the healthcare environment. She

reiterated that managing a nursing department can be similar to running a business. As

nurses are in demand for leadership roles, coursework are simply a series of

requirements. Significant expertise is a top qualification as nursing leadership positions

are accountable for patient care across a broad spectrum. Managing human resources,

developing budgets and coordinating plans with other professionals are among the job

responsibilities of a nursing leader.

Another topic was also facilitated by Stephanie Donolli, Quality Consultant. She

discussed Quality Improvement and Outcome Review boasting the institution’s 18 Joint

Commission accreditation and Gold Seal Awards which are just a few of some of the

prominent award giving body for health care, commending for its par excellence in the

healthcare industry. She proudly emphasized that their hospital is deeply committed to

providing the highest quality and safest care possible. Thru the leadership of some

experts, physicians and staff have established benchmarks and goals to meet and

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surpass the standards set by each accreditation board leaders. Currently they have been

progressing and maintaining their standards at the highest possible level.

A Lean Methodology/Approach was lectured by Rolando Berrios- Montero, Senior

Lean Consultant. It is an improvement approach to improve flow and eliminate waste.

Lean is basically about getting the right things to the right place, at the right time and

in the right quantities, while minimizing waste and being flexible and open to change.

Lean thinking focuses on what the customer values: any activity that is not valued is

waste. If waste is removed the customer receives a more value added service. Lean

methodology/approach has been applied in IHVI and It has became a useful approach

for the institution in designing and redesigning services to ensure that the work being

done add value to patient care.

In Inova Heart and Vascular Institute patient satisfaction is their top priority to

maintain their excellent status in the healthcare industry. From a patient’s perspective,

excellent health care is the least that a healthcare facility can provide. IHVI has launched

Patient Experience Program headed by Dr. Merdod Ghafouri. The institution started a

patient experience survey to sort out and classify whether they are satisfying the

patient’s optimal needs. The target subject is the patient whom they had serviced, as

they are the ones giving profit to the institution so their loyalty and assurance of coming

back for care is a must. In the healthcare industry, economy depends on the adherence

and compliance of the patients.

Heather Hunn, Patient Experience Leader, talked about how they have came up with

having a patient’s experience survey in IHVI. According to her, patient experience

results tell us how patients felt about the care they received at the hospital. The patient

experience results are based on a survey of questions about doctor and nurse

communication, hospital cleanliness and noise levels, medication and post discharge

instructions.

The aforementioned Strategies and programs were implemented by the hospital’s

organizational board. An important objective is to draw on a wide and inclusive base

for feedback, ideas and areas of improvement in all aspect in the field of healthcare

industry.

The remaining days of the week was exposure in the Cardiovascular ICU, guided by

Sharri Robinson, R.N, CVICU Clinical Director. She introduced the group to the staff of

the department then we surveyed each areas, impressed by the technology and system

they are utilizing.

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CVICU is a 24-bed unit specializing on the care of critically ill patients within INOVA.

Patients admitted to this unit include, but are not limited to post cardiac surgery, post

vascular surgery, heart failure requiring invasive cardiac monitoring, and other medical

or surgical diagnosis requiring intense and continuous monitoring.

Second Week

Mainly in the Cardiovascular theater observing the whole area as well as the staff on

their routine, handling of the patient and preparing the procedures scheduled for the

day. We were greeted by the head nurse of OR introducing us to the staff and gave us

a tour the whole department.

The following are brief description of each area inside the theater, the system being

utilized, policies and practices they are implementing.

CARDIOVASCULAR OPERATING ROOM STRUCTURE

1) Hybrid Theater (1)

▪ Uniquely designed for cardiac surgeons, electrophysiologists and

cardiologists to operate simultaneously on the same patient.

▪ Equipped with PHILIPS HEALTHCARE and MAQUET PHILIPS

CARDIOVASCULAR X-RAY SYSTEMS and MAQUET’s Magnus surgical table

and Philips 3D Heart Navigator Tool

2) Cardiac Operating Room

2.1) Adult (5)

- equipped with iSuite STRYKER INTEGRATED OR ( includes Stryker cam

HD In-Light Camera, Flexis Booms, Monitors and Displays System,

Documentation Station, Switch Point Infinity 3Point Control System,

NaviSuite, FlexiBooms accessories, VISUM LED II surgical lights.

- OR phones and monitors are located inside the theatre on built-in a desk.

2.2) Pediatric OR (1) (same description above)

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OPERATING ROOM STAFF IN EACH THEATER (7)

i. Consultant Cardiac Surgeon (1)

ii. Consultant Cardiac Anesthetist (1)

iii. Anesthesia Assistant (1)

( Anesthesia Assistant is an ICU nurses with 5 years experience in Critical Nursing Care, studied and trained the standards of Anesthesiology for 2 years as Master’s degree. Assists in arterial line, peripheral and central line insertions, intubation and lastly monitoring the patient during the entire surgery).

iv. Anesthesia Technician (1)

v. Scrub Nurse (1)

vi. Circulating Nurse (1)

vii. Physician Assistant (2)

( Physician Assistant is an Operating Room Nurses with minimum 5 years experience in Cardiac OR Nursing. Studied and trained on the standards of Surgery for 2 years as Master’s Degree. Assists the Cardiac surgeon during the surgery and harvests the saphenous vein for CABG cases).

In line with the cardiac services, several technological health care systems are

being applied and installed. Basically utilized to ease manual labor to every

department and to be more focused primarily to patient care. These are as follows:

i. EPIC Electronic Health Record: a computer- based patient recording system.

▪ the applications support functions related to patient care(e.g. registration

and scheduling)

▪ Anesthesia Flow sheet Record

▪ Laboratory results

▪ Nursing care

▪ Medication, etc

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ii. TransLogic Pneumatic Tube System-

An automated material transport installed to handle and deliver patients critical

items for surgery quickly and reliably (e.g. blood products, blood units, medications,

lab samples, IVFs, etc.)

iii. CYRACOM LANGUAGE SOLUTIONS PHONE TRANSLATOR/INTERPRETER-

Used for patients and relatives who are non-English speakers like for obtaining

procedural consents, health teachings, and other hospital related services that needs

translation for them to have an in-depth understanding on the hospital and procedural

services the patient going to undertake.

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PATIENT’S FLOW OF ADMISSION TO IHVI CARDIAC OR

1)Pre-Operative Unit

- Patients are directed either by the admission staff and by the ward nurse

for the in-patients, the handover to be given to the preoperative nurse.

- Pre-Operative nurses calls for the surgeon, anesthetist and circulating to

take consent and explain thoroughly the procedure to be done (Surgical

and Anesthesia Consents).

- Anesthetist inserts the arterial line and peripheral line at times

- Circulating nurse will receive handover from the Pre-Operative nurse and

as well do the physical assessment together and assures the patient’s

safety all throughout the surgery.

- SIGN-IN Phase (Surgical Safety Checklist) done by the nurse with the

presence of the surgeon, anesthetist.

2) Cardiac Operating Room

- Patients are ushered via stretcher to the OR. Two physician assistants

help the circulating nurse and the anesthesia technician in transferring

the patient to the OR bed, fix the lines afterwards and position patient

securely on the OR bed. A single square ECG pad is applied on the back

instead of the 6-lead ECG pads. To prevent pressure on the skin during

hand tucking, a special type of sponge are used and applied around the

arm. The lines are also fixed by a cotton bandage.

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- Anesthetist and anesthesia assistant do the intubation. When finished,

1st PAUSE (Surgical Safety Checklist) is being initiated by the surgeon.

Central line insertion follows.

- Urine catheterization will be done by the circulating or physician

assistant. Sterile urine catheter set being readied with a complete

materials to be used (urine bag, gloves, antiseptics, etc.).

- Surgical Prepping (as per IHVH standards) done by the circulating nurse

and physician assistant using the CHLORAPREP. Chlorhexidine soap is not

being used inside the OR. For CABG cases, a W-shaped bar is utilized to

hold the legs, to prevent them from falling. For this particular case,

prepping starts in the groin for 2 minutes with 2 pieces of CHLORAPREP;

down to the Legs for 2 minutes with 4 pieces of Chloraprep; lastly, chest

for 2 minutes with 2 pieces of Chloraprep. For valve cases, prepping is

done from the chest down to the knee area for 3 minutes with 3 pieces

of CHLORAPREP.

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- TIME OUT Phase (Surgical Safety Checklist) is being done after the draping

by the surgeon and the circulating nurse, when finished skin incision

ensues. The surgeon with the physician assistant does the dissection in

the chest while the other physician assistant does the SVG harvesting in

the leg using the ENDOSCOPIC VEIN HARVESTING DEVICE.

- On Bypass stage, the circulating calls the CVICU nurse to inform the

following data: patient’s identity, name of surgeons, procedure and

background of the procedure and the patient’s status.

- Off Bypass stage, the circulating calls the ICU nurse to inform the

following data: current IV Fluids, hemodynamic, blood gas results, blood

products, inotropes, adjunct specialized equipment or apparatus if any

(IABP, ECMO, etc).

- After off-bypass, 2nd PAUSE Phase (Surgical Safety Checklist) will be

initiated by the surgeon and the circulating nurse.

- Blood processing device known as CELL SAVER is utilized to all pump

cases. As soon as homeostasis starts, the suctioned autologous blood

which has been shed and collected during the past stages will be infused

back to the patient. Wall suction is not used on pump cases.

- After Homeostasis, SWAB FINAL COUNT is done in 3 stages: 1) before

putting the sternal wires; 2) before closing the chest cavity; 3)before skin

closure. Whilst, NEEDLE FINAL COUNT is done in 2 stages: 1) during the

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homeostasis. The counted needles once correct will be discarded

immediately and deducted from the initial needle count; 2) for the

remaining needles it will be counted during the SKIN CLOSURE.

INSTRUMENT COUNT does not applied for pump cases, excluding to the

rule are the small instruments ( bulldogs, vein needles, etc..) and surgical

supplies accessories ( clips, snuggers, blades, etc.. ). These are being

counted during the initial setup.

- After skin closure and dressing, SIGN OUT Phase (Surgical Safety

Checklist) is being done by the surgeon. Patient will be undraped and

cleaned, transferred to the ICU bed and transported to the ICU with the

Anesthesia team and the circulating nurse.

- Non-Raytec swab and sticky tape are applied as dressing and changed

after 8 hours by the ICU nurse. Patient will have full bed bath after

extubation, as chloraprep solution is still on the skin of the patient which

causes dryness.

- Instrumentation (as per IHVH standards): Basic Heart Set is divided into

two sets: 1) SET A- set of instruments used for skin incision until ON

BYPASS. This particular set has been prepared by the CSSD on the MAYO

plate, covered by green towels and arranged in sequence of usage of the

designated surgery. The GOAL of this preparation is intended during

emergency cases for the sets to be ready in less than 30 seconds. 2) SET

B- set of instruments to be used during ON BYPASS stage until skin

closure. Extras or Supplementary instrument/sets are opened depending

on the case.

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- In case of any malfunctioning in any instrument, the circulating nurse

puts a yellow sticky label on it so the CSSD can recognize and fix it.

- SET UP (as per hospital standard): For pump cases- 2 back tables and 3 mayo tables are located at the foot side of the OR table. Scrub nurse stands at the side of the surgeon, Perfusionist at the back side of the surgeon while the Physician assistants are facing the surgeon.

- At the preparation area (in between) extra sets and sutures are placed

for urgent needs.

- Surgeons has a uniform standard set up without variation. Sets, accessories, sutures are all opened during the setup (chest tubes, water seal chest drain, pacing wires, etc.). Saw used is battery operated.

- CABG surgery has an average time of 4 hours from skin incision to closure, 40 minute gap from being inside the OR till skin incision, and 15 minutes from skin closure till going out from the theater.

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The course was totally enlightening and I'm very thankful for the privilege given to me. I was able to acquire and gather knowledge with regards to the work ethics, programs and policies implemented at IHVI. With these ideologies I could impart the informations to my department to raise the standards on the quality of care rendered to patients.