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

in Japanin Japan

A.Okamura, T.Ishitani, M.Fukuda, T.YamamuraA.Okamura, T.Ishitani, M.Fukuda, T.Yamamura

Heiseikai InoUE hospitalHeiseikai InoUE hospitalS7W2 Chuo-ku, Sapporo 064-0807 JapanS7W2 Chuo-ku, Sapporo 064-0807 Japan

Sapporo

N43°

Hokkaido University (1876~)Hokkaido University (1876~)

Sapporo Beer (1876~)Sapporo Beer (1876~)

Snow Festival (1950~)Snow Festival (1950~)

Olympic Games in 1972Olympic Games in 1972

Pacific Music Festival (1990~)Pacific Music Festival (1990~)

Prolonged mechanical ventilation in JapanProlonged mechanical ventilation in Japan

In Hospital Ventilation 5,800

Home Mechanical Ventilation 10,400

National Hospitals 2,000

Other Hospitals ( University, municipal, private )

3,8003,800

neuro-muscular disease, tuberculosis

post-ICU mechanical ventilationpost-ICU mechanical ventilation

Tatara et al : National survey in 2005

16,200Total

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-ICUIn Japan, hospitals that specialize in post-ICUmechanical ventilation have not been organized.mechanical ventilation have not been organized.

Acquisition of a hospital in 2003for post-ICU mechanical ventilationRenovation and implementation ofhardwareStaff turn-over and educationFinancial reconstruction

Co-generation power supply( Off - grid power )

Oxygen, Artificial Air

Patient monitor ( Fukuda )Ventilator ( Servo-s )

Blood gas analyzer, Central monitor

Client PC for ordering, Laboratory data, radiology

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

Organization of special teamsOrganization of special teams

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 )

“ The more the individual in an organization grows as a person,the more the organization can accomplish.”- Landmarks of Tomorrow - Peter F. Drucker

Staff educationStaff 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

0

1

2

3

4

5

6

7

8

9

InoUELTAC(82 beds)

non-LTAC(5375 beds)

( reports / beds)

04 05 06 07 08 (year)

Risk managementRisk management

Number of reports activity

LTAC: Long Term Acute Care

0

100

200

300

400

500

600

700

05 06 07 08 09

level 5

level 4

level 3

level 2

level 1

level 0

(Year)

Standard precautionCASS (continuous aspiration of subglottic secretions)

Tracheal suction manual

Achievement test of suction practiceCertified care workers

’04 ’05 ’06 ’07 ’08 ’09 ‘10

1

2

3

4

0 0/0

20/4

40/8

60/12

Antibiotics(million yen)

disposal glove ( x 104 pieces)

( year )

Introduction of

Infection controlInfection control

patient

4

Continuous suction pump

Drainage bottle Tracheal tube

SubglotticSuction port

Original CASS ( continuous aspiration of subglottic secretion ) system

Extensiontube

CASS : n=45 Non-CASS : n=81

10

20

30

( cases )

Incidence of VAP ( ventilator associated pneumonia )

6

24

P < 0.05

Pressure ulcer de novo

Total Patients

Air mattressVentilated Patients

‘04 ‘07 ‘08‘06‘05

80

0

50

80

0

50

‘09

5

0

10

Pressure ulcer treatmentPressure ulcer treatment

SpecialistDoctorNursePharmacistCare worker

Pressure ulcertreatment team

280 cases ( male 176, female

104 )

average age 73 y.o.

Patient background and outcome 　

Hypoxic brain damage

Cerebro-vascular disease

　　　　　　

Neuro-muscular disease

Others Others

Respiratory failure

42%

26%

16%

6%10%

weaned

31%

ventilator-dependent

40%

dead

29%

April 2004 – March 2009

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6

1 bed-bound2 head-up3 wheel chair4 sitting5 standing6 walking

admissiondischarge

Change of ADL

80

84

88

92

96

100

104

0

0.4

0.8

1.2

1.6

1系列2系列

(%)

30

20

10

0

(billion yen)

ordinary profit rate

Revenue (fiscal year)

(%)

04 05 06 07 08 09 (year)04 05 06 07 08 09

Financial conditionFinancial condition

Bed occupancy rate Bed occupancy rate RevenueRevenue Ordinary profit rate Ordinary profit rate

ConclusionConclusionThe 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.

Het Concertgebouw Amsterdam Sapporo Concert Hall Kitara

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