زنجیره امید

NICU

Mortality reduction of the Newborns and Children with congenital heart disease, before and after heart surgery with support of Zanjireh Omid Charity Institute

Place of implementation
The Medical Center for Children. Department of Pediatric Cardiology
Address: Dr. Gharib St, Keshavarz Boulevard

Necessity of the project
Development of medical sciences and the modern technology save the children with heart disease by treatment actions and surgery in childhood. These patients could not be treated in the past. Treatment and care before, during and after heart surgery require a professional treatment team with deep knowledge of the treatment and general care principles of the Newborns and children. This team should also be professional in treatment and children care principles in critical situations. In establishing and developing of special hospital units for heart surgery of the Newborns and children despite providing the possibility of performing surgeries should also consider reducing mortality and other side effects in newborns and children based on the international standards. Understanding the specific requirements of newborns and children and ability to control the conditions of these patients is not possible without precise prediction of the combination of the care team, number of its members, their knowledge and the required equipment for continuing a safe treatment.
It should be noted that the heart surgery section of the Medical Center for Children has started its activities since 2011 with 4 pediatric cardiac surgeons, 5 pediatric cardiologists, 2 cardiac anesthesia specialists and 7 ICU beds for post-operation care, 10 pre-operation ICU beds for patients with complicated heart problems and 10 beds in pediatric cardiac section. The successful treatment and surgery experience of complicated cardiac diseases of newborns and children in this section resulted in the busy waiting list of the patients who need cardiac surgery. The waiting duration for surgery in this section is 2 to 3 years. There are lots of continuous daily requests from different parts of the country and also other treatment centers of Tehran. On time reception of most of them due to the limited facilities and space of the cardiac section is not possible and these services could not be improved.

Furthermore, deficit of the specialized personnel for pre and post operation care resulted in 10% to 15% mortality in newborns and children. Implementation of this project will reduce the mortality of newborns and children with cardiac disease near to the standards of the developed countries.

Project objectives:

Treatment objectives

1.  Mortality reduction of the newborns and children with congenital heart disease before, during and after heart surgery
2.  Reduction  of  side  effects  and  disabilities  after  heart  surgery  of  newborns  and children
3.  Improving the quality level of care before, during and after newborns and children’s
heart surgery
4.  Reducing waiting duration of the patients for heart surgery and as a result reduction of the side effects cause by delay in performing children heart surgery
5.   Reduction of the hospitalization period through quality and quantity improvement of the personnel
6.  Reduction  of  the  hospital-acquired  infections  by  acting  based  on  personnel standards and using the standard equipment

Social objectives
1.  Improve the quality of life of the children with congenital heart diseases
2.   Parents relief and positive mental impact on the patient and his family by good treatments and on time reception of the emergent cases
3.  Giving instructions to the parents and families on how to take care of the patients with cardiac disease

Project description
1)  Reception method of the patients
There are two categories of received patients in this center:
A)  Patients who are covered by Zanjireh Omid. These patients are referred by legal entities and individuals or the Welfare centers to the institute and after file completion join the institute by the social worker department and their treatment cost will be paid by Zanjireh Omid according to the type of deprivation from 50% to 100%.
B)  Patients who independently come to the Medical Center for Children and their treatment costs will be covered by family or some part of it by insurance.

The implementation process
A)  Allocation of the required space
Although the heart section of the Medical Center for Children is active with two ICU units, this space is not enough to improve the services. The space of heart ICU unit could be increased if the required space is allocated in this center. Number of ICU beds could be increased to 10 beds and 15 beds in heart section.

B)  Personnel recruitment
There are 3 aspects in recruitment of the personnel of the pediatric heart surgery ICU:
1.  Combination of the personnel
2.  Recruitment and retaining the required personnel
3.  Improving abilities and knowledge of the personnel
1)  Combination and structure of the personnel
-    ICU specialist
Lack of ICU specialists is one of the difficulties of the heart ICU of the Medical Center for Children. So instead of ICU specialists, cardiac surgeons and cardiologists take care of the hospitalized patients in this section before and after surgery.  Due to the necessity of using the abilities of surgeons and cardiologists in their specialized fields and their busy working schedule, ICU specialists should be recruited in this section in order to reduce the hospitalization time in ICU, improve the treatment results and on time control of the post-operation side effects.

2)  Recruitment and retaining the required personnel:
-    Professional nurse
Considerable deficit of professional nurses is a constraint to increasing the hospitalization beds. Based on the heart surgery standards, one nurse is required per patients immediately after surgery and one nurse for two patients after the first hours in each shift. Therefore, 4 professional nurses are necessary for each heart surgery ICU bed and 4 professional nurses for each ICU bed after the first hours and also 2 nurses are required for improvement of the pediatric cardiac section. The heavy workload of cardiac intensive care section and the low wage in comparison with the other sections have reduced the professional nurses’ motivations to work in this section.

3)  Improving abilities and knowledge of the personnel

All the staffs dealing with treatment and care of the newborns and children with heart diseases should continuously participate in training courses of new cardiology findings. Using the educational services of the reputable institutes in this field will be fruitful in updating knowledge of the pediatric heart surgery team. According to the lack of ICU specialists on the heart surgery team of the Medical Center for Children, educating and preparing 2-3 persons in this field is necessary. These training courses are held since the spring of 2013 with cooperation of Zanjireh Omid Institute with the heart surgery section of Necker hospital, specialized group of Prof. Pascal Vouhe and support the French Embassy in Iran and will continue in the future. It should be mentioned that the dispatch and training costs are provided by La Chaine de l’Espoir- France and the Embassy of France in Iran.

The performance report and the annual ongoing costs of pediatric cardiac ICU project to continue reducing mortality of children before and after surgery











Report of the Mortality reduction of the Newborns and Children before and after heart surgery

The operational beginning of the project: January 2014
The operational ending of the project: November 2014

The operational location of the project: Children's Hospital Medical Center, Building No. 2 on the fourth floor next to the pediatric heart ICU
The project area: 300 M2

Partners and Donors financing the project:
1- Mashiz Financial and Credit Institute
2- TOSHIBA Co.
3- PARS Engineering Co.
4- Technology and laboratory Co.
5- FARSAN TEJARAT Co.
6- The company of Medical Equipment Management of Iran
7- RAYMAND RAD Co.
8- SHALCHILAR Relative Brothers Co.
9- MEHRAN Medicine Company

Project Beneficiaries:
All children or infants suffering from heart diseases who come from all over the country are the beneficiaries

Implementation of the project:
Demolition, reconstruction and repair of the ICU section, to Change interior design and Retrofit roof to fix the roof console and modification of mechanical equipment

A) Changing the interior design
1- The ceiling height was increased up to 0.5m to improve air flow and indoor environment for the staff.
2- All lightings were equipped with water and air proof and washable fixture.
3- Stand medical gases councils – 10 times more expensive that wall capsule, which are easier to    monitor were used. Through this, the staff has more space to work.
4- To provide uniform air in all parts of the section, all air channels recalculated, design and was replaced

B) To create electrical safety
1- In order to create electrical safety, in case of power failure at the hospital, the section was equipped with USP system.
2- In order to create electrical safety, in case of a short-circuit electrical wires, the section was equipped with Isolated Transformer, all equipment continue to operate without any interruption.
c) Infection control
1- In order to control the infection, the entrance of the section was equipped with SCRUB system.
2- In order to infection control and traffic management, the entrance doors in two phases were equipped with intelligent automatic sliding glass doors.
3- In order to control and prevent infections from entering the patient's relatives, all beds are equipped with a closed circuit camera and the ability to view the patient's entourage was provided.
4- In order to control the infection, the floorings are provided from the finest brand and replaced completely. They could be washed and disinfected easily as well

5- In order to control the infection, the isolated air circulation channels of patient's room were repaired or changed.
6- In order to control the infection and air infiltration from the ceiling to the ICU
unit, the architecture of the ceiling was redesigned and it was modified.
7- In order to control the infection, the working room was equipped with cabinets, sinks and other equipment entirely from stainless steel and equipped in accordance with the valid standards.

Equipping the cardiac ICU included (12 ICU beds, 2 isolated bed, and 1 bed for special operations)
Items in this section are as follows:

1- Rehabilitation beds bought from the best brands of the world with the FBA quality certification from United States. They are the most expensive and most equipped devices in the country and were chosen to reduce the infant's mortality.
2- The portable digital X-ray machine, In addition to excellent picture quality and efficiency of radiology and medicine film processing, it is provided to convert all analog devices in hospitals to digital images.
Therefore, in addition to this section, for all parts of the hospital, digital photographs is provided.
3- In order to shoot with less energy and high quality picture and improving the imaging system of the other sections of the hospital from analogue to digital, Portable X-ray machine has been prepared and it is digital.
4- In order to provide work space for doctors and nurses due to giving services to the patient of medical gases consoles, the section is selected from ceiling or column styles and all the medical equipment was installed on the consoles.
5- All the medical equipment was provided from the best and most quality brands existed in the world and mostly they have the CE certificate from Europe and also the FDA certificate from the United States.
6- The Sono/Echo device is one of the most important equipment of surgical ICU. The device is made of the highest quality and have been imported for the first time. It has also the European CE and American FDA certificates.
7- All this equipment are bought from ATOM (Japan), FUKUDA (Japan), TOSHIBA (Japan), SIMENS (Germany), PHILIPS (America), BENETT (America) and also domestic famous introducer.

Destruction, reconstruction of central compressed air
The actions in this section are as follows:

1- Compressed air system due to being disabled, low air quality of hospital and the lack of filtration and water and oil pipes consumer, made us to replace the compressed air system. New advanced systems and oil-free compressors made in America of the Atlas Copco brand.

2- Central compressed air systems of hospital by two independent compressors and with 20 percent more capacity than current need hospital, was calculated. All incoming and outgoing air is equipped with filtration.

3- In addition, the floor is covered by stone and the walls are covered by ceramic. (70 m ceramic and 30m stone)

Equipping heart surgery room

In order to carry out more operations, the existence of backup devices and avoid the interruption in the operation of hospitals, all the equipment of the operating room include of Heart pumps, pump accessories, surgical instruments and digital suction have been provided from the best brands in the world and most of them, in addition to have the CE certificate from Europe, they have the FDA from America.

Creating educational programs and teamwork for operating room personnel, nursing and medical care of the patient before and after the surgery.

Given the need to create a group and improve the quality of pediatric cardiac care for patients before and after surgery, Zanjireh Omid in coordination and agreement with Tehran University of Medical Sciences, has carried out actions since 2013 which has achieved good results in order to reduction the children mortality:

1- Dispatch pediatric cardiac surgeons (Cardiologist), pediatric cardiac interior, special care (Institute), nurses as short term training (Observer) and long term training (Clinical) to Necker Hospital, Paris, for enhancing knowledge and exchange of health information that had lasted since 2013 and it will be continued to completion specialized staff.
2- The 40 new nurse training in both theory and practical courses that is taking place from June 2013. 20 nurses selected by experts and were working in the sector. 20 other recruits were needed, for that reason 20 nurses are already have started their training. They will be active on all the bed capacity in the center and obviously with the skillful personals, the medical cares will be completed and the children mortality will be reduced.
3- Due to the high volume of work in the children cardiac section and the need to enhance the quality of medical care, Zanjireh Omid over the agreement with the Department of University of Tehran to undertake a five-year pay raise for 60 nurses and 20 operating room staff. This causes a bit of hard work and persistence of trained personnel will be made up and they will work for long time in that section.
The result of this project:
During the 117 days of active operating room over the past few months a total of
44 surgeries have been transferred to the NICUOH. The pediatric cardiac mortality rate in the medical center hospital was 23.6% before, but after equipping and treating the children it is reduced to 9%.

The future plan for this project

The plans of 2015:

1- To increase the NICU OH active bed in 2015, the attraction of the nurses is being done gradually by informing to the Department of Nursing and other private hospitals, showing the infants cardiac surgery film (which has been produced by the cardiac surgery team), taking exams and clinical training 
2- Publication and distribution of educational classes of infant's cardiac surgery nursing in six packages with a total of 24 DVD.
3- Create a complete database for recording and maintaining all patient information including (demographics, medical history, information about anesthesia - described pump cardiac surgery, the patient's length of stay in ICU, discharge conditions and record the all further information and follow-up visits).
4- All ICU cardiac surgery procedures and protocols developed by the research committee of hospital.
5- Providing educational video to inform parents about the process of admission and hospitalization, cardiac surgery and care in the operating room and ICU and also the caring after discharge.

The estimated required additional equipment to the ICU of the project
(5000 million Rials) as follows:

1- Thromboelastogram device
2- Cell saver device
3. Drug nebulizer machine
4. The hole pacemaker device
5. The ultrasonic device for washing sets

Two years have been passed since the launch of “Reduction of Children Mortality” project founded by “Zanjireh Omid” charity at Children Medical Center hospital. Through God’s mercy and donors’ efforts, medical teams and nursing staff have managed to decrease mortality of children suffering from congenital heart defect (CHD) from 23% to 3.5%. Below you can find a short report of services being carried out at the charity.
Performance report of NICUOH at Children Medical Center
According to a joint agreement between Tehran University of Medical Sciences and Health Services and “Zanjireh Omid” charity a project titled “Reduction of Children mortality” suffering from Congenital heart defect (CHD) funded by “Zanjireh Omid Charity” were launched in 2013.
After selection of a suitable location for establishment of the ward in an unutilized space between two ICUs on 4th floor of Bldg. No. 2 of “Medical Center” by medical center and Zanjireh Omid experts, the project begun in following phases:
Destruction, reconstruction and repair of ICU ward, Interior design and retrofitting of ceiling console and restoration of the mechanical devices which resulted in:
a) Interior design
b) Electric safety
c) Monitoring infection

Equipment of cardiac ICU including: 12 ICU beds, 2 isolated beds, special operations and outpatient surgery room beds as detailed below:
All equipment is selected from the following brands: Alton from Japan, Fukuda from Japan, Toshiba from Japan, Siemens from Germany, Philips from USA, Benet from USA and also from domestic products, holding quality certificates from FDA of USA and CE of Europe to decrease mortality.
Portable digital Radiology instrument make taking digital photos more accessible in the entire wards of the hospital.
To make use of space more efficiently for doctors and nurses, all medical instruments have been installed on ceiling consoles.

Destruction, reconstruction of Central compressed air system of hospital with oil free high-tech systems, which made compressed air move in entrance and exit paths with full filtration.
Equipment of Cardiac Surgery Room

In order to perform more operations after NICU opening, following Instruments were purchased:
Heart pump machine
Pump accessories
Surgery instruments and digital suction device

Selection and instruction of nurses to work in cardiac surgery ICU of medical center: 60 nurses including: nurses employed at cardiac wards of medical center, 18 senior nursing students of Tehran and Iran universities attended theoretical and clinical apprenticeship classes since 2014. The trained personnel started working at Cardiac ICU since its opening.
 Six-month advanced training course of “nursing cardiac surgery” for was held for nurse supervisors: The course was evaluated and instructed by two expert nurses in Children’s cardiac surgery ICU from London. The total expenses of the course including the travel expenses of non-Iranian instructors were covered by Zanjireh Omid charity. The course started on September 18th of 2016 after obtaining license from Health and Medical Education Ministry
Protocols of all cardiac surgery ICU procedures were developed by cardiac ward research committee supervised by hospital research department. Major part of protocols is documented and a book about pediatric cardiac surgery is being written at the moment. 
Creation of a video tutorial to inform parents of admission process, hospitalization, cardiac surgery, intraoperative care, ICU and postoperative care.
Travels of doctors and cardiac surgery nurses to Necker Hospital in Paris (a referral center for pediatric cardiac patients) planned, coordinated and financially supported by Zanjireh Omid Charity.
Dispatch of nurses and Internal and pediatric cardiac surgery doctors to Necker hospital in Paris to pass complementary courses.
 Conducting a research project studying stress and tension level among nurses working at ICU and holding group therapy sessions to instruct how to overcome tension 
Holding Yoga courses at children medical center in 2013 which were financially supported by Zanjireh Omid Charity
Making Monthly incentive payment to all nurses, nursing assistants and service staff of pediatric cardiac surgery ICU and cardiac surgery room of medical center who numbered 130 in total.

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