|Year : 2020 | Volume
| Issue : 2 | Page : 27-30
Case study: Optimal utilization of mechanical ventilator at tertiary care hospital during COVID-19 pandemic
Deepak Venkatesh Agarkhed1, Anand Bandachar Mamdapur2, R Madhusudan2, Sreekanth Shetty3, Bevin D'Silva4, Moirangthem BIken Singh2
1 Department of Clinical Engineering and Quality, Sakra World Hospital, Deverabisanahalli, Outer Ring Road; Ex-Technical Committee Member-National Accreditation Board for Hospitals and Healthcare providers (NABH), Bengaluru, Karnataka, India
2 Department of Intensive Care Medicine, Sakra World Hospital, Deverabisanahalli, Outer Ring Road, Bengaluru, Karnataka, India
3 Department of Cardiology, Sakra World Hospital, Deverabisanahalli, Outer Ring Road, Bengaluru, Karnataka, India
4 Department of Emergency Medicine, Sakra World Hospital, Deverabisanahalli, Outer Ring Road; Vice President, Society of Emergency Medicine, Karnataka Chapter, Examiner for Royal College of Emergency Medicine, Bengaluru, Karnataka, India
|Date of Submission||03-Sep-2021|
|Date of Decision||09-Sep-2021|
|Date of Acceptance||17-Sep-2021|
|Date of Web Publication||01-Apr-2022|
Dr. Deepak Venkatesh Agarkhed
Sakra World Hospital, Deverabisanahalli, Outer Ring Road, Bengaluru - 560 103, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Agarkhed DV, Mamdapur AB, Madhusudan R, Shetty S, D'Silva B, Singh MB. Case study: Optimal utilization of mechanical ventilator at tertiary care hospital during COVID-19 pandemic. QAI J Healthc Qual Patient Saf 2020;2:27-30
|How to cite this URL:|
Agarkhed DV, Mamdapur AB, Madhusudan R, Shetty S, D'Silva B, Singh MB. Case study: Optimal utilization of mechanical ventilator at tertiary care hospital during COVID-19 pandemic. QAI J Healthc Qual Patient Saf [serial online] 2020 [cited 2022 Aug 11];2:27-30. Available from: https://www.QAIJ.org/text.asp?2020/2/2/27/343314
India is one of the top countries having more deaths so far due to the COVID pandemic. Bangalore city too witnessed an average of 12 COVID-19 deaths a day in the first wave and 96 COVID-19 fatalities a day in the second wave. Indian health-care system was under severe challenges including bed availability, oxygen consumption, and medical equipment due to unprecedented surge of COVID patients.
Sakra World Hospital, Bangalore is tertiary care hospital has 300 bed capacity. During the mid of April 21 to the first week of June 21, COVID-19 cases increased drastically as shown in the [Figure 1] graph. The average length of patient too increased from 4 to 7.1 days on account of COVID-19 patients, thereby the creating shortage of bed availability for needy patient. The resources required to serve increased COVID-19 patient load was challenging, especially materials and equipment.
|Figure 1: Graph showing pattern of inpatient COVID-19 patient at hospital|
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The COVID-19 pandemic mainly affects patient lungs. The necessary of oxygen and usage of mechanical ventilator, computed tomography scanner becomes need of hour during this pandemic. The medical equipment management had become major focus during COVID-19 time, especially for patient treatment and recovery such as mechanical ventilator and BIPAP units. This article is highlighting how in peak COVID-19 pandemic situation hospital team has tried to tackle shortage of intensive care beds wherein patient required mechanical ventilator.
Waiting for ventilator for needy patient, unnecessary motion of staff, rework of staff to connect patient circuit on ventilator, and delayed transportation are MUDA (waste) which compromised or delayed patient who needed ventilator in hospital. The location of intensive care is scattered across the high rise building and managing timely usage of ventilators in required intensive care unit (ICU) was real challenge to hospital COVID-19 task force.
Although hospital had 50% ICUs beds having mechanical ventilator, with surge in COVID-19, especially in May and June 21, there was suboptimal utilization of ventilators at the start of second wave of COVID-19 pandemic. Before the start of COVID pandemic medical equipment in general and ventilator, BIPAP in particular were allotted to various ICU and ward based on user requirement. To make transfer equipment from one area to another, there was undue delay since approval at various level were needed. The time to shift from one ICU to another ICU was involving lot of paper work and time-consuming. Due to possibility of essential elective surgery, there was a need to keep few ventilators on standby mode. Unfortunately, no team either nursing, medical administration or clinical engineering was owning the responsibility to this critical process of timely resource sharing and quickly utilizing on needy patient.
The repeated delay in ventilator shifting and undue escalation of this problem at various levels led to discussion at COVID-19 task force meeting. After analyzing root cause of lack of ownership for medical equipment transfer and tracking process, the management has given both authority and responsibility to associate vice president (AVP) to take lead and quickly adopt workable solution for best utilization of equipment especially ventilator.
The Hospital quality assurance team understood root causes for suboptimal ventilator utilization with help of all strake holders through fish bone chart [Figure 1], [Figure 2], [Figure 3], 5 WHY analysis tool as shown in [Table 1] and recommended to have senior management member as process owner for Ventilator management.
|Figure 2: Cause and effect diagram for suboptimal ventilator utilisation|
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|Table 1: 5 Why analysis conducted by hospital quality team to understand root causes for sub optimal ventilator utilization|
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The following improvement ideas were adopted by AVP with help of COVID-19 task force for better, quick change over of ventilator without compromising on uptime of equipment.
- Total productive maintenance (TPM) concept was adopted through training all clinical engineers on troubleshooting on COVID-19-related critical equipment
- The critical spare parts and accessories needed for equipment were procured extra and kept in hospital without waiting for supply chain lead time
- User group was trained on identifying error code and communicating to clinical engineer through phone or video call
- The cleaning and disinfection of equipment based on original equipment manufacturer (OEM) protocol was strengthened to reduce risk of spread of COVID-19 through ventilator and its accessories. Maximum disposable items were being used like patient circuit and special precautions were taken to disinfect parts which come in contact with patient like flow sensor
- Most of the troubleshoots were resolved by clinical engineering team remotely and only for absolute need, engineer used to enter COVID-19 area with proper protection kit
- The instruction manual, service manual, and video on operation of equipment were uploaded in hospital Intranet for ready reference
- Single Minute Exchange of Dies concept of LEAN manufacturing method adopted to reduces the time required to change over equipment like ventilator from one patient to another
- The biggest challenge was ensuring that unused equipment is quickly moved to required area without delay as there was tendency of holding equipment in specific area in anticipation of its need for any patient. This is also more pertaining to those area wherein they expected surgeries may happen resulting in possible ventilator needs
- The closed social media group was created which included intensivist, surgeon, nursing, and clinical engineering team. Twice in day, the status of areawide ventilators physically present, on use on patient and in stand by mode for patient besides ventilator needing maintenance was shared in closed group
- On daily basis the location wise equipment availability, its usage was closely monitored by AVP with help of biomedical engineer and nursing staff
- The care was taken to avoid mixing of ventilator in COVID-19 area from noncovid area although disinfection protocol was followed as per OEM norms
- With still elective surgeries and emergency surgeries performed at hospital, few ventilators were standby mode. This issue was addressed with clinical team through sharing stand by ventilators among various clinical specialties
- Based on ventilator patient surge in number, additional set of ventilators were quickly procured and installed. Mix of ventilators turbine based (without compressor gas input) and other one taken for flexibility in usage across hospital as few ward beds were converted to ICU capabilities but without central compressed air lines
- The ventilator modes of application were refined based on patient critical condition.The monitoring also involved is ventilator used as invasive or non-invasive mode to ascertain possible replacement of BIPAP exchange of ventilator based on advice of intensivist
- The decision to shift ventilator from one area to another was purely based on patient clinical requirement
- During last few weeks of the 2nd wave of COVID-19, there was increase in the need for patient who have recovered from COVID-19 but still needing assistance of mechanical ventilation in non-COVID area
- After due diligence with anesthesia team and service providers, anesthesia ventilator was used for few patients to address shortfall of mechanical ventilator.
The staff got training on basic troubleshooting and quick changeover as part of TPM and SMED training. The result was evident as there were only two breakdowns on ventilators with 0.1% downtime and needless to say that there was maximum 100% utilization of equipment with quick changeover from one patient to another. The change over time has reduced from 20 to 5 min after adoption of SMED. The process got ownership from senior member of management who could take quick decision on speedy transfer ventilator. The patient mortality had many contributing factors but timely availability of ventilator has improved clinical care of patient. Turbine-based ventilator procurement resulted in flexibility of mechanical ventilator usage across hospital. The transparency in usage of ventilators resulted in no unnecessary row among stakeholder. Needless to say, precious lives of patient were saved through Lean concept to tackle MUDA, i.e., waste of rework, motion, transportation, and waiting.
The following lessors were learned during this 2nd COVID-19 wave pandemic with respect to asset management.
- The equipment management process cannot be viewed in isolation by clinical engineering, nursing, and clinician. The crossfunctional coordination is necessary as hospital processes curt across barriers of functional departments
- The asset sharing at shortest time is mandatory. The hospital is decided to adopt centralized medical equipment storage and distribution
- The hospital had noticed that since their existing ventilators needed Air 4 bar for its function, in quick time interval it was difficult to commission existing area to ICU as pipeline for Air 4 need to be laid. It is better to have combination of turbine-based ventilators along with current set of ventilators
- The virtual training and maintenance is way forward for user group and clinical engineers
- Systematic planning and procuring of inventory and strict infection control practice gives dividend of improving uptime and safety to patient and staff.
The experience of best usage of life-saving ventilator with minimum downtime and quick transfer and connection to required patient by trained staff taught hospital team that Kaizen, i.e., continuous improvement in process based on demand is the best way to improve quality of patient care and improve. The Kaizen can be only achieved through the application of thinking hat from various stake holders and executed under able process owner.
The preparedness of hospital toward similar pandemic situation has improved postimplementation of optimal utilization of mechanical ventilator. The overall intra-hospital asset quick transfer, its visibility, and utilization have improved by adoption of best practices learned from ventilator case study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3]