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Editorial Establishing a new cardiac surgical
unit: Challenges and solutions
Yatin Mehta, Yash Paul Bhatia1
Chairman, Medanta Institute of Critical Care and Anesthesiology, Sector 38, Gurgaon, 1Principal Consultant, Medanta
The Medicity, Managing Director, ASTRON Hospital Consultants, Haryana, India
PMID: ******** DOI: 10.4103/0971-9784.69039
With the healthcare delivery system going
through a major transition to ensure quality
healthcare delivery at all levels a new paradigm
appears to be emerging for establishment of
tertiary care centers for the biggest killers of
the future, namely, heart disease and cancer.
The author of this editorial and his group has
been involved in planning and operationalizing
several tertiary care hospitals, both in India and
overseas, over two decades, which were the
results of conceptualization and execution by
their surgical chief, Dr. Naresh Trehan. During
these endeavors, the anesthesiologists in the
cardiothoracic unit have had important role
in planning, supervising and commissioning
of operating rooms (ORs), intensive care
units (ICU)/recovery rooms (RR) and cardiac
catheterization laboratory. They have also been
instrumental in suggesting and incorporating
several useful inputs during the formation and
layout of radiology departments.
The administrators of the hospitals frequently
consult the senior members of the team to
gain input about the requirements from the
perspective of doctors seeking to create a
“beautiful” hospital. It is an eternal dilemma
whether one chooses technically sound
hospital or aesthetically sound one. Therefore,
one should look for creating a unit which gets
nominated not as the most beautiful unit but
as a functionally perfect unit housed in most
aesthetic surroundings.
The basic principle one should observe is that
the newly established center should be able to
Address for correspondence: Dr. Yatin Mehta, Medanta Institute of Critical Care and Anaesthesia, Sector 38, Gurgaon, Haryana, India. E-mail: yatinmehta@
hotmail.com
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fulfill the basic definition of quality as given
by Institute of Quality - “The degree to which
health services for individuals and populations
increases the likelihood of desired outcomes
and are consistent with current professional
knowledge.”[1]
Following the dictum of Avedis Bonadenian
on three basic components of delivering
health care quality, viz., Structure (stable
characteristics for the providers of care and
tools and resources available at their disposal),
Process (activities that go on between and
within the practitioners and patients) and
Outcome (changes in health status attributable
to antecedent health care), quality assurance
in our cardiac units is also essential – this
also allows us to measure the quality of the
healthcare delivery at all times.
The structures include the civil infrastructure,
the equipment plan and the machinery.
Designing of the facility is the first challenge,
wherein a definite need for sizing of the facility
and the level of care needs to be decided to
ensure that the unit is optimally poised to cater
to the current load, with an option to upgrade
to meet the likely increase in demand for more
beds. Financial support for the project is the
key for making such decisions; ultimately, the
center so created has to be not only viable in
the long run, but also profit making. Often
because of lack of foresight, there is a mismatch
in the requirement to availability ratio. One
needs to constantly remind oneself – “Are we
creating monuments or hospitals?” On the
other hand, an underplanned and executed
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Mehta and Bhatia: New cardiac unit
facility will compromise the basic functions and will
adversely impact the quality of healthcare delivery. At
this stage, it is worthwhile to refer to the local as well as
international accreditation norms, relevant guidelines
(e.g. American Institute of Architects guidelines (AIA))
and the available building codes.[2]
The space planning of each of the units such as the
emergency room, the ambulatory units, non-invasive
cardiac lab, invasive cardiac catheterization laboratory,
OR, postoperative Areas e.g. ICU, in-patient units,
preventive and rehabilitative cardiology has to be
optimized, integrated and synergized. This assures a
smooth flow without causing choking or functional
obstruction in healthcare delivery. At the same time,
one has to keep in mind the staff fatigue which could
result if the units are too spread out. Ensuring staff
adequacy is probably one of the biggest challenges
in hospital design. Selecting the correct requirement
will decide the performance of the facility. Having
ensured the functional adequacy, compliance to the
accreditation norms of certain bodies such as Joint
Commission International and National accreditation
board for hospitals becomes necessary in order to get
the accreditations rapidly.
The equipment planning for a cardiac unit needs to be
carried out thoughtfully after a proper need analysis
(which takes into account the future trends). We need
to remember that the technology is changing faster
than what we can imagine. In fact it is said in lighter
vain that by the time we spell the word “technology”,
the new order has already moved in! This is true for
cardiac sciences as well; therefore, we need to plan the
equipment technically adequate to meet the projections
of the proposed center while keeping pace with
emerging technologic needs. Opinions from colleagues
who have recently contributed to the development of
facilities of good standing may be sought while taking
decisions.
Considering the rapid growth in the field of hybrid
procedures (cardiac surgical and interventional
cardiologic procedures under the same roof), one
needs to plan for these expensive but mandatory
suites. A state of the art cardiac operation theater with
cardiac catheterization laboratory may be relevant.
Such operating suites permit carrying out advanced
procedures like transapical/percutaneous aortic valve
replacement. Positron emitting tomography scanner or
64 slice computerized tomography scanner for cardiac
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imaging may become relevant in the days to come.
Also, with centralization of operating department it
is possible to ensure flexibility of allocation of theater
time, nonduplication and greater economy in the use of
common facilities, better supervision and availability
of OR in emergency.[3]
Having created the infrastructure, the establishment of
processes and protocols need a lot of emphasis. This
includes staffing norms, training, and an environment
to create an assurance that the systems and processes
would work when required. The moment of truth is
when the patient requires to use the facilities at the
hospital (a mobile coronary care unit in the event of
an acute coronary event); that is when the challenge
meter starts ticking. The assurance of availability of
an adequately equipped and staffed ambulance on
24/7 basis is itself a huge challenge. Accepting to
provide advanced transport mechanisms such as an air
ambulance with the same above mentioned conditions
will stretch the hospital resources to the maximum.
Well-designed protocols with adequate training and
re-training of staff and use of modern communication
technology can be handy in assuring the excellence
of this practice; this is also a requirement as per the
accreditation norms of most of the accreditation bodies.
A well-equipped emergency with a focus on the
needs of cardiac patients is vital. In order to convert
the “usual” emergency areas to those with focus on
cardiac care, a special holding area with well-equipped
cardiology services and trained staff may be created to
overcome this challenge. Many of the hospitals are now
putting up a “Heart Command Center”, which focuses
on specialized infrastructure, medical equipment
(e.g. echocardiography machine, intra-aortic balloon
counterpulsation, ventilators, pacemakers, etc.),
monitoring equipment and manpower to specially cater
to cardiac emergencies in the emergency department to
meet this need.
The out-patient services should be planned, keeping
in mind a multidisciplinary approach, such that cross
reference between cardiology, cardio-thoracic surgery,
nutritional services and diagnostics is made available
in the same geographic area, saving steps and time for
the patient and the family.
The adequacy and optimization of diagnostic services
based upon work load and its flexibility to accommodate
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Mehta and Bhatia: New cardiac unit
newer technologies need to be considered. It is necessary
to assure availability of services in the shortest time so
that timely reports may be made available within a
short time [i.e. pneumatic tubes, Hospital Information
System (HIS), (Picture Archiving and Communication
System (PACS)], causing least discomfort to the patients
and their attendants. The non-invasive cardiology
services ideally should be available in the out-patient
department itself while invasive cardiology services
could be suitably located with easy access to recovery
area (where patients are nursed after undergoing cardiac
catheterization), ORs and day care with integration
to electro-physiology and other specialized units.
Strong, Standard operating procedures (SOPs) need
to be developed to ensure safe and smooth activity for
patients as well as for health care providers.
The ORs for cardiac services are required to cater
to various types of surgeries and such multitasking
requires more space than the conventional ORs. An
adequate zoning, proper air conditioning controls as
per the American Society of Heating, Refrigeration
and Airconditioning Engineers’ guidelines along
with support areas with adequate sterility assurance
are the core requirements. However, the success of
the cardiac surgery services is highly dependent
upon the practices being followed in the ORs. The
fundamental requirement recommended by AIA
for cardiac OR are large size (>600 square feet),
seamless, washable walls preferably painted with
antibacterial paint, laminar flow with preferably
separate ducting and positive air pressure in each
OR, and high-intensity three Light Emitting Diodes
operating lights. There should at least be two mobile
pendants with additional O2 and CO2 flow meter for
off pump coronary artery bypass graft surgery and
scavenging for anesthetic gases and nitric oxide and
temperature control within the OR.
The ICUs should be close to the ORs with facilities
for isolation (positive/negative pressure cubicles [4]
with windows), hand washing facilities in each
cubicle, easy access to head end, e.g. pendants/power
columns, pneumatic tubes and support areas like store,
pantry, counsiling room, stat lab, duty doctor and ICU
consultant room, etc.
The authors suggest the following points to young
colleagues involved in establishing a new cardiac
surgical hospital:
1. Spend quality time with the architects and
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project team.
2. There are a large number of contractors/
subcontractors involved in creating the facility.
All of them have their own pace, time tables and
agendas. Bigger projects cause bigger delays! It is
rare that projects are completed in the stipulated
time and budget.
3. One has to be meticulous with the workers and
follow up their performance on a daily basis.
4. All prices are negotiable! At times it is shocking to
learn how high the dealers’ profit margins are and
how much cheaper one can buy equipment/services
than the rack rate!
5. Get your elbows dirty!
It has been mentioned in the last few paragraphs
about systems, processes, protocols, SOPs, while
it is well understood that the outcomes of cardiac
services are highly dependent on these factors; yet
there is one common factor which impacts all these
and that common factor is the Human Resources.
Availability of adequately trained multidisciplinary
team consisting of doctors, nursing and paramedical
staff in addition to adequate administrative support
is the real challenge. The adequacy in numbers as per
the staffing norms for different sections of the cardiac
unit is a challenge by itself in view of global shortage of
trained medical manpower. More so, is the availability
of specialized nursing and paramedical staff. A strong
credentialing and privileging mechanism needs to be
put in place to ensure that only adequately qualified
and trained people are authorized to undertake any
activity within the system. The identification of training
needs of each individual and organizing in-house or
specialized training at defined regularity could be
the key to meet this challenge. So, the answer here
lies in ensuring proper need-based human resource
planning with proper selection mechanism, followed
by training.
Having established the infrastructure and the protocols,
one should concentrate on the outcome. As we said
in our definition of Quality “The Quality has to result
in increasing probability of achieving the desired
outcome.” Recording of the outcomes and putting a
trend analysis in place to ensure continuous quality
improvement has to be a part of the whole process. All
the investment in terms of infrastructure, effort, time
and money needs to converge in getting the desired
results.
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Mehta and Bhatia: New cardiac unit

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