A hospital for post-ICU patients with long term mechanical ventilation in Japan

1. A hospital for post-ICU patients with long term mechanical ventilation in Japan A.Okamura, T.Ishitani, M.Fukuda, T.Yamamura Heiseikai InoUE hospital S7W2 Chuo-ku, Sapporo 064-0807 Japan

2. Sapporo N43° Hokkaido University (1876~)Sapporo Beer (1876~) Snow Festival (1950~) Olympic Games in 1972 Pacific Music Festival (1990~)

3. Home Mechanical Ventilation 10,400 In Hospital Ventilation 5,800 National Hospitals 2,000 neuro-muscular disease, tuberculosis Other Hospitals ( University, municipal, private ) 3,800 post-ICU mechanical ventilation Tatara et al : National survey in 2005 Prolonged mechanical ventilation in Japan Total 16,200

4. Problems in acute care hospitals in Japan Japanese health care insurance system limits the reimbursement according to the length of stay in ICU. Prolonged ventilation lowers patient turn-over in ICU. - unable to accept new patients in the ICU - Prolonged ventilator-dependent patients have to be sent to ordinary ward, where staffs are not so familiar with ventilator-dependent patient management. In Japan, hospitals that specialize in post-ICU mechanical ventilation have not been organized.

5. Acquisition of a hospital in 2003 for post-ICU mechanical ventilation Renovation and implementation of hardware Staff turn-over and education Financial reconstruction Client PC for ordering, Laboratory data, radiology Co-generation power supply ( Off - grid power ) Patient monitor ( Fukuda ) Ventilator ( Servo-s ) Oxygen, Artificial Air Blood gas analyzer, Central monitor

6. Organization of special teams Risk management incident / accident report Infection control survey (micro bacterial, clinical) Pressure ulcer weekly round, treatment Education lecture, library, scientific meeting Medical record IT solution Process improvement process analysis, PDCA cycle Each team consists of doctor, nurse, care worker, office worker. The organization and activities satisfy the requirements of Japan Council for Quality Health Care ( JCQHC )

7. Staff education Morning lecture Monday – Friday respiratory physiology, blood gas analysis, VAP, VILI, ARDS, open lung strategy, etc. Invited lecture Once a month risk management, infection control, professional manner, gas/power supply, etc. Scientific meeting attending scientific meetings presenting scientific papers “ The more the individual in an organization grows as a person, the more the organization can accomplish.” - Landmarks of Tomorrow - Peter F. Drucker

8. ( reports / beds) InoUE LTAC (82 beds) non-LTAC (5375 beds) 04 05 06 07 08 (year) Risk management Number of reports activity (Year) LTAC: Long Term Acute Care

9. Infection control 4 Antibiotics (million yen) patient 3 60/12 disposal glove ( x 104 pieces) 40/8 2 1 20/4 0 0/0 ( year ) ’04 ’05 ’06 ’07 ’08 ’09 ‘10 Certified care workers Achievement test of suction practice Introduction of Tracheal suction manual CASS (continuous aspiration of subglottic secretions) Standard precaution

10. Original CASS ( continuous aspiration of subglottic secretion ) system Incidence of VAP ( ventilator associated pneumonia ) ( cases ) 30 4 P < 0.05 20 24 10 6 CASS : n=45 Non-CASS : n=81 Drainage bottle Tracheal tube Subglottic Suction port Continuous suction pump Extension tube

11. Pressure ulcer treatment Pressure ulcer treatment team 80 80 Total Patients Specialist Doctor Nurse Pharmacist Care worker 50 50 Air mattress Ventilated Patients 0 0 ‘04 ‘05 ‘06 ‘07 ‘08 ‘09 10 Pressure ulcer de novo 5 0

12. Others Neuro-muscular disease 10% 6% dead weaned Respiratory failure 29% 31% Cerebro -vascular disease 16% 42% ventilator-dependent Hypoxic brain damage 40% 26% Change of ADL Patient background and outcome 1 bed-bound 2 head-up 3 wheel chair 4 sitting 5 standing 6 walking admission discharge April 2004 – March 2009 280 cases( male 176, female 104 ) average age 73 y.o.

13. Financial condition Bed occupancy rate RevenueOrdinary profit rate (billion yen) (%) (%) 30 Revenue (fiscal year) 20 10 ordinary profit rate 0 04 05 06 07 08 09 (year) 04 05 06 07 08 09

14. Conclusion The high bed occupancy rate suggested the social need for the post-ICU mechanical ventilation hospital in Japan. The hospital that specializes in post-ICU mechanical ventilation is economically feasible. Activities of special teams decreased hospital-acquired infection and decreased the wasteful expenditures. Staff education and continuous process improvement seems to be the key elements for this enterprise.

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