Month

Apr
2015

May
2015

June
2015
July
2015
Aug
2015

Sep
2015

Oct
2015

Parameter

1. 100% patients on warfarin after valve

replacement (mechanical) have INR in
acceptable range (2.5 3.5)
2. 100% patients of open heart surgery have
hemoglobin >=10 g/- at the time of discharge
3. 100% of planned PCI should be on Dual Ant
platelets
4. 100% of planned PCI should receive ACEi/ARB
5. 100% of planned PCI should receive Statins
(LMT)
1. Reassessment of patients on warfarin after valve
replacement (mechanical) have INR in
acceptable range (2.5 3.5)
2. CVTS patients having Cardiac arrhythmias
during peri-operative period are controlled within
24 hours.
3. All IPD patients are screened for DM (if status
is unknown)
1. Cardiac Surgery patients have duration of
ventilation within 6-8 hours
2. PCI patients with access site complications
1. In CORONARY ARTERY BYPASS GRAFT
SURGERY LIMA is used as GRAFT
2. POST PCI patients are given ATORVASTTIN in
40 mg dose
1. LENGTH OF STAY in patients undergoing CVT
Surgery.
2. Duration between consent and intervention in
patients undergoing Primary PCI (For the months
June, July, August
1. Re-assessment of parameter LENGTH of STAY
in patients undergoing CVT Surgery
2. 80 % of the hospitalised cardiac patients undergo
lipid profile assessment (if it has not been done
earlier).
3. 80% of the patients undergone CABG surgery do
not require inotrops for more than 48 hours, post
surgery
1. Assessment of the benchmark Swan Ganz
should not be used in more than 25% of the

Presentati
on done
in the
meeting
on
15 May
15

CAPA prepared
and Submitted
on

15 Jun 15

15 Jun 15

15 May 15

15 Jul 15

15 Jul 15

15 Aug 15

15 Aug 15

15 Sep 15

15Sep 15

17 Oct 15

17 Oct 15

27 Nov 15

27 Nov 15

CABG patient.
2. Assessment of the benchmark glycoprotein
IIb/IIIa inhibitors should not be used in more
than 15% of angioplasty patients.
Nov
2015

1. Antibiotics are not administered for

more than 3 days in 70 % of the
patients undergoing CVTS Surgery

Dec
2015

1. Reassessment of the benchmark Swan Ganz

should not be used in more than 25% of the
CABG patient.

Jan
2016

1. Page of Primary consultants is

completed in all aspects in 100 percent
of the hospitalized patients.
2. Less than 10 percent patients
(excluding planned surgery) are
transfused single unit of blood/blood
product.
1. Antibiotics are not administered for
more than 5 days in 90 % of the
patients undergoing CVTS Surgery
2. Less than 5 percent patients developed
hematoma post PCI.
1. Family Education in given on daily
basis and as and when required (during
change of patients status) in 100 %
patients.

Feb
2016

Mar
2016

Apr
2016

2. OPD Staff is aware about the admission

criteria and has identified the patients
on the basis of category on more than
90 % of the occasions.