SITE INFORMATION SURVEY: FOCUS INITIATIVE


SITE CONTACT INFORMATION

Institution Name
Institution Address
Institution City  Postal Code 
State or Province  Country 
Institution Phone Number () -
Institution Web Site Address

Is your hospital for profit not for profit

Is your hospital primarily:
Community Non-Teaching practice (no anesthesiology or surgical residency)
Community Teaching practice (residency program but no cardiac anesthesia or cardiac surgery fellowship)
Community Teaching Hospital (residency program with a cardiac anesthesiology or cardiac surgery fellowship
Academic (affiliated with a medical school, residency program and fellowship)
Veterans Administration

Rank your hospitals IRB process in terms of difficulty (1 is easy and 5 is extremely difficult)

SITE PERSONNEL – MAIN PROJECT CONTACTS

Please provide the names of the main contacts that would be involved in the FOCUS project from each discipline.

  First Name MI Last Name Suffix
/Prof. Suffix		 Phone Email Address
(if different than above)		 Primary Contact
Cardiovascular Anesthesiologist 
Surgeon 
Operating Room
Nurse 
Perfusionist 
ICU Physician 
ICU Nurse 
CEO/Hospital Exec 
Press Contact 

PERSONNEL STATISTICS

Personnel Type Number Dedicated Team
Yes      No
Attendings
Cardiovascular Anesthesiologists
Cardiac Surgeons
Surgeon Groups in Cardiac Area
Surgeon Groups in Hospital
Fellows
Cardiovascular Anesthesiology Fellows
Cardiac Surgical Fellows
Critical Care Fellows
Perfusionists
Perfusion groups on hospital staff
Perfusion groups outside of hospital staff
Perfusion training program
   
Personnel Type Number Dedicated Team
Yes      No
OR Personnel
Cardiac OR Nurses
OR Scrub Technologists
Anesthesia Technologists
Nurse Practitioners
Nurse Practitioners in OR patient care
Nurse Practitioners in ICU patient care
Nurse Practitioners in patient care on floor
Physician Assistants
Physician Assistants in OR patient care
Physician Assistants in ICU patient care
Physician Assistants in patient care on floor
Research Coordinators

SUBJECT POPULATION & TREATMENT

Data Number
Number of staffed Cardiac ICU beds (average)
On bypass CABG
Off Pump CABG
Valve Surgery
Cardiac Transplants
Aortic Surgery
Other

What percentages of cardiac anesthetics are primarily administered by:
CRNA%
Cardiac anesthesia fellow %
Resident%
Faculty attending%

Does your hospital and surgical program participate in the STS database? Yes No

What percentage of surgeons participate in the STS? %

How is infection surveillance handled at your institution?
External
Internal
Hospital Epidemiology Infection Control Dept (HEIC)
Unit Level

Do you track postoperative infections that are managed in the outpatient setting:? Yes No

What percentage of patients are seen at 30 days?

For cardiac cases in year , what is the total number?

For those cases, what is the percentage breakdown by gender? % male % female
 
For those cases, what is the percentage breakdown by race? %Caucasian
%Black
%Hispanic
%Asian
%Nat. Amer.
%Other

ICU INFORMATION

Number of staffed Cardiac ICU beds (Average)

Who covers/manages the ICU (check all that apply):
Cardiac surgeon manages his/her own patient
A dedicated team of physicians with critical care
experience
Cardiac anesthesiologists are member of ICU team
Cardiologists are members of the ICU team
Other ICU Provider (state)
What types of patients are typically cared for in the ICU (not overflow)?:
Cardiac
Thoracic
Surgery other than cardiac or thoracic
Medicine

Is the ICU open or closed

Do patients get admitted to a recovery room area for a set period of time prior to going to the main cardiac ICU? Yes No

With regards to the patients who are discharged from ICU level care:
The step down unit located within the same physical area
Patients get transferred to another physical area

INFORMATION SYSTEMS

What type of records are kept for:

  Paper  Electronic  Electronic System Number of Years
Anesthesia
ICU

SAFETY INITIATIVES

What percentage of your surgical, nursing, and perfusion colleagues know about the FOCUS project? %

Among personal other than yourself what is the level of enthusiasm for FOCUS at your site?
High
Moderate
Low

What safety initiatives are currently employed during CV surgery at your institution?


PARTICIPATION IN FOCUS

Based upon the data generated from Phase I of the FOCUS project, subsequent phases will concentrate on three (3) critical areas in need of scientific discovery. Please rank the following based upon your desire to participate:

Learning collaborative on infection prevention
Peer to peer evaluation tool
OR equipment and design
Other

Additional Comments: