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

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 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

6. 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 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 )

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

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

9. Standard precaution CASS (continuous aspiration of subglottic secretions) Tracheal suction manual Achievement test of suction practice Certified 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 10 4 pieces) ( year ) Introduction of Infection control patient

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

11. Pressure ulcer de novo Total Patients Air mattress Ventilated Patients ‘04‘07‘08‘06‘05 80 0 50 8080 0 5050 ‘09 5 0 1010 Pressure ulcer treatment Specialist Doctor Nurse Pharmacist Care worker Pressure ulcer treatment team

12. 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 Respiratory failure 42% 26% 16% 6% 10% weaned 31% ventilator-dependent 40% dead 29% April 2004 – March 2009 1 bed-bound 2 head-up 3 wheel chair 4 sitting 5 standing 6 walking admission discharge Change of ADL

13. (%) 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 condition Bed occupancy rate Revenue Ordinary profit rate

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.

15. Het Concertgebouw Amsterdam Sapporo Concert Hall Kitara Thank you for your attention !