1

THORACIC SURGERY Division Service Charter

Strada di Fiume 447 – 34149 Trieste - www.aots.sanita.fvg.it

2

Division of THORACIC SURGERY CATTINARA HOSPITAL

15th FLOOR SURGERY TOWER

PLEASE READ CAREFULLY This booklet contains vital information for your hospital stay. If you wish, you may write your comments using the form at the end of the booklet; then cut it and drop it into the special box located in the physicians’ room at the end of the corridor.

3

INTEGRATED ACTIVITY DEPARTMENT GENERAL AND THORACIC SURGERY

THORACIC SURGERY Division

Director: Maurizio Cortale, MD

Telephone.: 040 - 399 4088; 040 - 399 4298 – Fax.: 040 - 399 4373 e-mail: maurizio.cortale@aots.sanita.fvg.it

Nurse Coordinator: Lara Camassa

Telephone: 040 – 399 4276; Fax: 040 –910 332 e-mail: lara.camassa@aots.sanita.fvg.it

USEFUL NUMBERS

TELEPHONE

FAX

ADMINISTRATIVE OFFICE

040 - 399 4591

040 – 399 4996

XV th floor Surgery Tower

INPATIENT WARD Nursing Staff Barbara Urbani Carmen Pascutto

040 - 399 4591

XV th floor Surgery Tower

OUTPATIENT CLINIC Valentina Adamic

040 - 399 4757

Outpatient Clinic Building Room 80 First Floor Mondays, Wednesdays and Fridays 9.00 – 1.00 p.m.

Enrico Arbore, MD Stefano Lovadina, MD

040 - 399 4298 040 - 399 4088 040 – 399 4298 040 – 399 4088

Elisabetta Benci, MD

040 - 399 4298

4

INTRODUCTION In 2004 Trieste University Hospital embarked upon a process of accreditation for clinical excellence in compliance with the standards set by JOINT COMMISSION INTERNATIONAL (JCI). Accreditation for clinical excellence is a voluntary process of systematic and periodic assessment, mainly involving health care professionals, with a view to continuous quality improvement. Accreditation is an effective and exhaustive tool for assessing quality in health care. There are different quality assessment schemes with a common set of specific criteria and standards aiming to improve quality management while providing an external assessment approach to avoid self-referencing. Among these, the JOINT COMMISSION INTERNATIONAL methodology was chosen as best suited to a hospital setting. In fact, the JCI standards are reviewed on a continuous basis and offer a high level of detail on key health service delivery processes. They take a systems approach to quality improvement, while involving all health care professionals, i.e. medical, nursing , administrative and technical staff. CLINICAL ACTIVITY The Division of Thoracic Surgery in Trieste focuses on lung cancer surgery, with specific regard to advanced disease, on surgical resection and reconstruction of the tracheo-bronchial tree and vessels, and the surgical treatment of mediastinal and esophageal, as well as thyroid and parathyroid disease. It also specializes in minimally invasive and/or video-assisted thoracopulmonary surgery; it provides treatment for pleural disease in general, including chest-wall surgical resection and reconstruction and emergency thoracic surgery. In particular, it focuses on the diagnosis and advanced surgical treatment of pleural mesothelioma, hyperhidrosis, pneumothorax and diffuse infiltrative lung disease with undefined diagnosis, on infectious disease requiring surgical treatment, as well as surgery for chronic pulmonary hypertension or the thoracic outlet syndrome.

5

ASSESSMENT OF THORACIC PATIENTS IN THE OUTPATIENT CLINIC Patients’ first visits are performed on an outpatient basis (Outpatient Clinic, Room 80, located on the First Floor of the Outpatient Clinic Building opposite the Hospital, Telephone number 040 -3994757) and must be booked in advance at the Centralised Booking Office (CUP). The Outpatient Clinic is open on Mondays, Wednesdays and Fridays from 11.00 a.m. to 01.00 p.m. The clinical picture is then discussed with the patient and diagnostic and therapeutic strategies are proposed. The patient may wish to have family members or trustworthy people involved in the discussion. If the patient agrees with the Surgeon’s proposals, he/she is taken in the Outpatient Clinic’s charge. The Clinic will contact him/her at home or on the mobile phone and will inform him/her about the dates of diagnostic and/or therapeutic procedures. The patient’s medical records will be kept in Room 80 throughout the diagnostic workup. Before undergoing any preoperative diagnostic testing (bronchoscopy, specialist visits or preoperative anesthesiology visits), the patient will go to Room 80 to pick up his/her medical records, which will be returned upon completion of the diagnostic procedure. After the preoperative testing has been completed, all papers are taken by the staff to the Physicians’ Room in the ward (Surgery Tower, 15th Floor, Thoracic Surgery, room at the end of the corridor, Telephone number 040 – 399 4298). The likely date of surgery is set by the Outpatient Clinic Physician based on the waiting list. The patient will generally be informed about the exact date of surgery during the week preceding admission. Any patient can ask for the likely date of surgery. The term ‘likely’ is used here to point out that long-term surgical scheduling is subject to changes to cater for unexpected needs (emergencies, ICU bed unavailability, etc.). During the preoperative testing phase, medical certificates needed to obtain sick leave from employers shall be issued upon the patient’s request.

6

PLEASE REMEMBER: Patient participation in the healthcare process also includes his/her right to know by name or in person the physician responsible for coordinating his/her care - i.e. his/her Referent Physician - and the qualifications of the healthcare providers involved in his/her care. The Referent Physician here is Maurizio Cortale, M.D., who is the physician in charge of the ward, or, in his absence, Enrico Arbore, M.D., or, in his absence, Stefano Lovadina, M.D., or the physician on duty present in the ward. TYPE OF SURGERY The type of surgery to be performed is described in the Informed Consent Form and in the Care Plan provided by the Outpatient Clinic, Room 80, or by the ward. The Informed Consent Form is generally given to the patient during his/her preparation in the Outpatient Clinic, to make sure that he/she has enough time to read it thoroughly, sign it and return it to the Outpatient Clinic. If you need clarification on any point, please contact the Outpatient Clinic. ELECTIVE ADMISSION TO THE THORACIC SURGERY DIVISION During the week preceding admission, the patient is called on the phone by the staff of the pre-admission Outpatient Clinic (Room 80), and sometimes by the physicians of the ward. On the telephone the patient agrees on the date of admission, that is usually the day preceding surgery. As a rule, surgery is performed on Tuesdays and Thursdays, therefore admissions will be on Mondays and Wednesdays at 11.30 a.m. respectively. 11.30 has been chosen to give the staff enough time to prepare the patients’ rooms.

7

Patients do not need any admission form in advance. They will collect the form on the 15th Floor from the physician on duty and then they will submit it at the Registration Office (3rd Floor) together with an identity document. Here each patient will receive his/her Thoracic Surgery clinical record, and will then carry it up to the ward, where he/she will announce his/her arrival to the head nurse or any other registered nurse. As a rule, fasting on the day of admission is not required. Should it be necessary, patients will be informed in advance on the phone. REQUIREMENTS BEFORE ADMISSION

ANY BLEEDING-PROMOTING DRUG, such as:

Aspirin - Aspirinetta, Cardioaspirin, Clopidrogel etc. Non-steroidal anti-inflammatory drugs - Brufen, Voltaren, etc. Platelet antiaggregant drugs – Tiklid, etc. Anticoagulants – COUMADIN, SINTROM

MUST BE DISCONTINUED 5-10 DAYS BEFORE SURGERY AND REPLACED WITH SELEPARIN (at appropriate doses) that will be provided to the patient by the Outpatient Clinic, Room 80, or by the ward.. The Outpatient Clinic staff will show the patient how to inject the drug. Please remember that, when Selaparin is administered with a subcutaneous injection, the shot must be given in the anterolateral or posterolateral abdominal region, rotating the injection site (left and right). Pinch a fold of skin between your thumb and index finger; insert the needle fully at a 90 degree angle to the pinched-up skin. Keep the fold pinched until the end of the injection; finally, do not rub the skin, but apply gentle pressure on the injection site.

8

NB: Seleparin must not be administered by intramuscular injection.

Stop smoking. Smoking irritates your lungs, reduces their capacity and the likelihood of a successful surgery. The pre-admission Outpatient Clinic can book for you an appointment with a stop smoking specialist. Patients are kindly recommended to leave valuables (money, gold items, jewellery) at home.

Exercise

Exercise before surgery will keep you fit and will make you feel better. If you have an exercise programme or you take part in a rehabilitation scheme, please continue to do so. Increasing your daily activities can also be helpful. Breathing exercises will be very important after surgery and provide a good relaxation technique. If you notice cough secretion before surgery, deep breathing and expectoration exercises will be particularly useful.

Contact us.

In case of temperature or persistent cough, if you are in doubt or if you have any special requirements before surgery, get in touch with the pre-admission Outpatient Clinic (until 01.00 p.m.) or with the ward. Otherwise, you can get in touch with the physician on call. Dial 040-399 4298 or 040-399 4522.

SAME DAY ADMISSION This is an exceptional event in the planning of thoracic surgery; yet, if you are admitted on the same day of surgery, you will have to comply with the rules described in the following paragraphs: ‘On the day before surgery’ and ‘On the day of surgery’. You will have to arrive at 7.00 a.m. at the Thoracic Surgery Division, on the 15th Floor of the Surgery Tower and talk to the Head Nurse. The time of your transport to the operating theatre will depend on the duration of previous surgery, that cannot always be foreseen.

9

AT THE TIME OF ADMISSION What to bring with you:

1) Healthcare card 2) An identity document (if available), or a residence permit and passport for foreigners 3) Clinical records concerning previous hospital admissions or chronic diseases, and all recent radiological records either on disk or films (e. g. CT scans, PET/CT scans.X-rays) 4) Current therapy plan.

In the Ward, the therapy will be recorded and /or updated by the physician on duty and written on the chart. From then on, the Ward will take care of your therapy to prevent overlapping or mistakes in drugs administration. Please hand in all your drugs. On admission, the patient’s specific needs will be assessed to provide individualized care. The patient will receive from the nursing staff a set of rules on fall prevention in hospitals and instructions on an appropriate diet regime based on the patient’s condition. ON THE DAY BEFORE SURGERY

Try to have a relaxing evening and to sleep well. Patients usually find it useful to listen to quiet music, to take a hot shower, to read or to engage in other relaxing activities.

Don’t eat anything after midnight (including candies or chewing gums).

ON THE DAY OF SURGERY

Do not eat anything; you can take only the medications prescribed by the ward with a sip of water.

10

Diabetics should not take insulin unless instructed otherwise by

the physicians.

If you have removable dentures, give them to the menbers of the staff who prepare you for surgery.

You will be asked to take off all your clothes and to change into a

hospital gown provided by a nurse together with antiembolism stockings

Leave all your valuables with a family member or the Head Nurse,

who will keep them in a safe.

The time of your transport to the operating theatre will depend on the duration of previous surgery, that cannot always be foreseen.

IMMEDIATELY AFTER SURGERY After surgery you will wake up in the ward or, if required by the Anesthetist, in the Anaesthesia and Resuscitation Ward. A nurse will be around and will try to help you. You will be wearing an oxygen mask and some intravenous lines will be inserted. In case of thoracic surgery, there will also be 1 or 2 drainage tubes. The bladder catheter is used for longer surgery. . In some cases, an endotracheal breathing tube will still be inserted, therefore you will not be able to speak. The group of nurses in charge of your surgery will help you, anticipating your needs and helping you to communicate otherwise. Usually, analgesic coverage is effective; should you be in pain, inform the nurse or the physician on duty.

11

Controlling pain is of major importance to favour coughing and expectoration and thus your wellbeing. Every day you will be asked to assess the severity of pain (if any) in a 0 (minimum) to 10 (maximum) rating scale. On the first day after surgery, you will be asked to stand up and then sit on an armchair next to your bed. Such procedure is fundamental to help you breathe better, and to reduce the likelihood of a pulmonary embolism or bronchial pneumonia. For the same reason, in the following days, we ask you to remain seated in the armchair as long as possible, and, where possible, to walk about the ward if permitted to do so by the physician. Furthermore, in the days following surgery, you will be assisted by a physical therapy specialist who - where necessary – will teach you how to execute the correct, desirable manoeuvres for ensuring pulmonary expansion and hygiene. During the first days after surgery, a slightly increased temperature together with the expectoration of a small quantity of blood can be normal, but do not hesitate to ask for explanations; the medical team doing the ward round, the referent physician or, in his absence, the physician on duty will be happy to help. Chest X-ray monitoring will be carried out, first in bed and then in the Radiology Department, where you will be taken by a healthcare assistant. The aim of x-rays is that of assessing the outcome of surgery and securing a proper lung re-expansion. Drainage is removed if there is no air leak, with a modest serous fluid secretion and a suitable lung re-

12

expansion. For further details on your hospital stay, please read your Care Plan.

Patients must not leave the hospital during their stay. In case of absolute necessity, a ward physician written consent will be required.

The doctor and other healthcare providers perform their duties mainly in the morning: for this reason, visiting is restricted to visiting hours. To respect the right to private and confidential care of all our patients, visitors must leave the room when patients are being given treatment or even monitored by physicians or nurses. Please provide the ward staff with family members’ phone numbers, so that the nurses or the physician on duty can inform them at any time about any transfer or sudden change in the patient’s conditions. If the patient’s valuables are given to his/her relatives, they are kindly required to check them before signing the receipt. VISITING TIMES Patients can be visted every day, Sundays and holidays included, from 12.00 noon to 8.00 p.m . For Anaesthesia and Resuscitation patients, visiting time is from 6.00 p.m. to 7.00 p.m. Patients need quiet: Please speak softly, limit the number of visitors in the room and the duration of the visit.. INFORMATION ON THE PATIENTS’ HEALTH STATUS We are aware that the visitors’ personal engagements at work prevent them from getting information on the patient at the preferred time. For this reason, even though the Referent Physician is the doctor in charge of the ward, information can be provided also by the physicians on duty, who can be found in the ward from 8.00 a.m. to 8.00 p.m. Please remember that, to respect the right to private and confidential care of all our patients, each patient should provide the name of the person (or people) who can inquire about his/her health conditions.

13

Please remember that the physician providing inform ation has other duties to fulfil. RELATIVES’ WAITING AREAS There are a number of relatives’ waiting areas, such as the room on the 15th Floor where corridors cross, the space in the entrance hall in front of the lifts and on the 4th floor, just in front of the operating theatre. In these areas, a coin-operated public phone can be found.. On the 3rd and 4th Floors, just in front of the operating theatre, or on the 5th Floor in the stair hall, visitors can find coin-operated vendors dispensing hot drinks and snacks. On the ground floor there is a coffee bar and a self-service restaurant (press button 2 in the lift) open from 7.00 a.m. to 7 p.m.; on the same floor there is a newsagent’s, a hairdresser’s and a phone card distributor. A money change machine is located on the 5th floor. FOOD, DRINKS, SMOKING AND FLOWERS Breakfast is served at around 9.00 a.m., lunch after 12.00 noon and dinner after 6.00 p.m.. There is a limited choice of food, in compliance with the appropriate diet regime prescribed according to the patient’s disease. Under special circumstances, patients can avail themselves of a personalized diet. Please contact the Hospital’s Dietary Service. Bringing in of food and beverages for patients is d iscouraged; if brought in, please ask for a special authorization. ALCOHOL and SMOKING are FORBIDDEN . Presence of flower arrangements in the proximity of patients’ beds could esacerbate the conditions of allergic pa tients: relatives and friends are advised not to bring flow ers.

14

DISCHARGE The day of discharge can be foreseen, after the first few days of hospitalization, based on the care plan, as long as the latter is complied with. On the day of discharge, the patient receives a letter (Discharge Summary) to be given to his/her Treating Physician, with the diagnosis, treatment indications and the reports of the main tests carried out. In the morning you will be informed about the time of discharge by the referent physician or the physician on duty. Sometimes, to favour admission of new patients, you will be asked to get dressed and wait for the Discharge Summary in the lounge. Should the patient require a continuation treatment before going home, the Continuity of Care Procedure will be undertaken, i.e. the Local Nurses Home Care Service will be contacted; a social-healthcare supporting network will be set up, in order to help both patients and family members to carry on the treatment in the most efficient way. If the patient wants a copy of his/her clinical record, the latter can be asked for at the time of discharge. A fee will have to be paid for this service. If the patient needs to be escorted home by ambulance, this should be pointed out in due time to the nursing staff, and a contribution to the service is expected. In case of suspected or ascertained tumour diagnosis, a temporary Discharge Summary will be issued, pending the definite histological test. As soon as the histology results are known (the current waiting time is about 10-15 days after surgery) the patient will be called by the

15

referent physician or by the physician on duty who will deliver the definite Summary. Should an oncologic assessment be necessary, the physician on duty will book a visit at the Oncology Outpatient Clinic of the Maggiore Hospital (via della Pietà 19, phone number 040 – 399 2413) and will send the patient’s clinical record. THE “ FAST TRACK” PROGRAMME The term ‘Fast Track’ refers to an algorithm for scheduling a set of procedures that will allow accelerated healing while reducing complications and the postoperative recovery period. It was codified for the first time in the late 1990’s by a Danish surgeon ( Henrik Kehlet ) who applied it only to general surgery. Early discharge experience in Thoracic Surgery dates back to the early 2000s, with studies by Cerfolio et al, showing that thoracic surgery can be performed with limited use of drains, and the latter can be removed on the first and second postoperative days. In 2007, McKenna et al. published the results of a study involving 282 patients in whom lobectomies had been performed with VATS (video-assisted thoracoscopic surgery), with a median hospital stay of three days.

These authors seem to show that the ‘Fast Track’ approach does not increase morbidity, mortality and hospital readmissions in the period following discharge and for thoracic surgery the Length of Stay should be equal to or less than 4 days in 80% of patients treated. In order to implement the ‘Fast Track’ Programme in our unit we have identified five key objectives:

A. Patient and Family Education B. Modification of Surgical Technique C. Pain Reduction D. Early Mobilization E. Telephone Follow-up Care

16

The patient, usually with his/her family, have already been informed in the Outpatient Clinic about the diagnostic work-up needed for his/her disease and the characteristics of his/her surgery until discharge home. The surgeon will make sure that the patient and family understand the information they have been given and that they accept the treatment proposed. He/She will also ensure that the patient is supported by his/her family and check whether postoperative logistical support is needed. Special emphasis is given to the post-operative period. The literature shows that with a modified surgical approach called ‘fissureless’ the surgeon can proceed to lobe dissection after preparing the artery from the hilum toward the lung periphery. Thus a dramatic air leakage reduction is obtained with shorter hospital stay. This organizational model requires active intervention by the nursing staff who receive special training on the importance of early patient mobilization in reducing morbidity. The patient is seated in a chair, sometimes in the immediate postoperative period or most often on the first postoperative day. He/She is then invited to relax, to expectorate, and to eat. Walking is also encouraged on postoperative day 1. In order to increase the patient’s physical and psychological comfort, we have decided to set up a Telephone Follow-up Care Service. These checks are performed by the same nurses as cared for the patient in hospital 24 hours, 3 days, one week and one month after discharge. Entries on possible problems are logged into a special Record Book. The nurse will discuss with the patient any issue or doubt that emerged at home. Of course the patient is told very clearly that he/she may at any time contact the ward to receive further explanations.

Clear benefits for the patient include

Early recovery of motor activity and autonomy. Rapid access to a more comfortable environment. In this

regard, it should be pointed out that, with only few exceptions, all patients are discharged straight to their homes.

17

URGENT ADMISSION This kind of admission usually concerns trauma patients coming from the Emergency Department. The decision to admit the patient is made by the Emergency Department physician, in agreement with the physician on duty or the physician on call in the Thoracic Surgery Division. Emergency Department at Cattinara Hospital, Phone number: 040- 399 4566; 040 – 399 4567.

RETURNING HOME How will my surgical wound feel? You may feel discomfort, tension, or swelling in the area subject to surgery, which should be considered normal after a surgical procedure. Additionally, during the surgical procedure some nerve bundles may become irritated, possibly leading to tingling, numbness, or altered sensibility in the thorax, shoulder, or arm, which may last for several months. What should I do if I am in pain? Pain should not be “endured”, but adequately soothed through analgesics; commonly used pain relievers such as paracetamol, or other NSAIDs and/or combinations thereof (paracetamol + codeine; tramadol) taken for a few weeks are usually effective at controlling pain caused by thoracic surgery. (NB: several doses of analgesics will be given to the patient upon discharge). When should sutures be removed? The surgical wound is sutured internally with absorbable sutures which do not require removal, while the skin and the drainage incisions are sutured with metal staples or non-absorbable sutures that must be removed after about ten days. In this regard, upon discharge the

18

patient will receive an appointment for the removal of the sutures in the outpatient clinic (Room 80). How many times shall I dress the wound? Upon discharge, a surgeon from the surgical team will check your wound and indicate the date for the next wound dressing in the discharge summary. During this wound dressing the surgeon will decide if and when another wound dressing is in order. In the meantime, should you notice significant changes such as increased swelling and redness, or a high fever, please contact us. When will I be able to shower or bathe? Unless instructed otherwise by the physician, you can remove the wound dressing and wash the wound with neutral soap 7 days after surgery. What kind of clothes should I wear? You are free to choose your clothes; we suggest items that do not constrict your chest and leave you freedom of movement. Are there any movements or activities that I am fre e to do and/or that I should avoid? For about 15-20 days, you should perform the kinetic physical therapy breathing exercises you were taught in the Hospital, and avoid intense physical effort and thoracic trauma. For about three months, you should avoid airplane flights, underwater immersions, and sojourns at high altitude. Will I have to undergo treatment after surgery? The decision to administer any complementary treatment will be made in a multidisciplinary manner, on the basis of the final histologic examination, by the surgeons, oncologists, and radiation therapists. In all cases, the patient will be subject to an oncological evaluation even in the follow-up phase to the disease itself. When will I be able to return to work? Keep in mind that any surgical procedure, of any type and for whatever reason, is always a stressful event for the body, which needs time to recover. Together with your Treating Physician, you can set the

19

length of your recovery period, in light of your general health conditions. What about exposure to sunlight? Exposure to sunlight after surgery is not a problem, except for the wound area. You should wait at least two months before exposing the surgical wound to the sun, due to the risk of skin blemishes. Will I be able to drive after surgery? There are no particular medical contraindications to driving; nevertheless, it is advisable not to drive for 3-4 weeks following surgery, since some driving manoeuvres and the use of certain pain relievers may lead to reduced personal safety. Will I be exempt from co-payment? Once the final histologic results are available, we will be able to issue the form for exemption from co-payment, which you will have to submit to the relevant District Health Authority (ASL) for the release of a certificate of exemption from co-payment of the individual portion of health care costs. If we are unable to provide this form upon discharge, we will provide it in the following weeks during outpatient visits. Where can I ask for a certificate of hospitalizatio n for my employer? Upon discharge, you can apply for a certificate of hospitalization at the Administrative Registration Office on the third floor.

20

COLOUR OF UNIFORM PROFESSIONAL RANK

white

Physicians, biologists, chemists, physicists, pharmacists

green with dark

green collar

Nurse coordinators

green

Registered nurses

yellow

General nurses

blue with white

collar

OTA, OSS (technical and healthcare assistants)

blue

Auxiliary staff

pale blue with white

collar

Head technicians

pale blue with dark

blue collar

Physical therapists

pale blue

Technicians (radiology, laboratory …)

white with orange

pocket trim

Administrative staff

21

DAY CARE The Thoracic Surgery Division has 1 bed available for day care, which is usually reserved for patients who require an invasive diagnostic procedure (CT-guided needle biopsy, etc). Patients are discharged on the same day, upon assessing, generally by means of a chest x-ray, the absence of complications. The Day Care Service is open Mondays to Fridays, from 7.00 a.m. to 2.00 p.m.. PRIVATE PRACTICE For any information about private practice affiliated with the hospital and carried out in the ward, contact the pre-admission Outpatient Clinic, Room 80, Mondays, Wednesdays and Fridays, from 8.00 a.m. to 1.00 p.m. Phone: 040- 399 4757..

As a patient of

“Ospedali Riuniti di Trieste” University Hospital

You are entitled to:

TRUST All hospital patients are entitled to be treated as trustworthy individuals. QUALITY This University Hospital, a Centre of National Relevance and High Specialization, has the purpose of carrying out its healthcare, teaching and research functions in a joint and coordinated way, so as to improve public health provision, enhance the quality of educational processes, develop biomedical knowledge and technological innovation, in the effort of enhancing the functions and activities of both hospital and university staff.

22

The Hospital provides professional healthcare services on a continuous basis, focusing on patients, ensuring a multidisciplinary and integrated organizational approach, as well as understanding and respecting patients and their families. SAFETY All patients are entitled to the necessary healthcare services without having to suffer any further damage due to malfunctioning facilities or services. In order to guarantee such rights, the Hospital is constantly committed to controlling the risk factors and ensuring maintenance for both facilities and hospital medical equipment. The Hospital is also committed to providing continuous training to all healthcare professionals (Law n°338 of 23 December, 2000). PROTECTION Because of their health conditions, all patients are vulnerable and have the right to be protected and taken care of. The same right to receive special protection also applies to the children who may be admitted to our Hospital. By way of exception, the competent offices of the University Hospital can only take into their custody the personal belongings of patients admitted in emergency or unable to keep their valuables safe. Patients are recommended not to bring any valuables to the hospital (money, gold items, jewellery) during their period of stay. NORMALITY All patients are entitled to receive treatment at our University Hospital without any of their habits or social and family relationships having to change more than needed. CERTAINTY All patients are entitled to certainty of treatment, without becoming victims of professional or organisational conflicts nor of favouritism on the basis of their economic and social status.

23

The Hospital has the duty to determine the waiting times for the provision of services, according to specific standards and depending on the level of urgency of each case. Patients who so request are entitled to see the waiting lists, provided privacy is respected.

PARTICIPATION All patients, their families, the safeguarding bodies and volunteer associations can contribute to improving the quality of the healthcare services and activities of the University Hospital through:

Civic Audit surveys perceived quality surveys joint working groups on specific issues reports and complaints.

Participation in the healthcare process also includes the patient’s right to know the name of the physician in charge of his/her care as well as the qualifications of the professionals involved in the treatment process. DIFFERENCE All patients are entitled to receiving customized treatment according to their needs, and having their individuality respected, without any discrimination based on age, gender, nationality, race, language, political opinions, professed religion, or culture. The Hospital is committed to satisfying, as far as possible, the requests for religious or spiritual assistance, by contacting ministers of the different religions. TIME All patients are entitled to having their time respected. Whenever it is not possible to comply with the agreed waiting times, patients shall be informed of the length of the delay and the reasons for it. If the Hospital is unable to provide a service within the maximum time expected, it shall make available an alternative service of comparable quality.

24

PRIVACY AND CONFIDENTIALITY All patients are entitled to the confidentiality of personal data, including information concerning their health conditions and the possible diagnostic and/or therapeutic procedures to undergo, as well as the right to the protection of their privacy during diagnostic examinations, specialist visits and medical-surgical treatments in general. The healthcare professionals of the University Hospital are committed to supplying patients and their families with communications on the patients’ admission and health conditions, except in cases of explicit dissent. Updated information will be supplied throughout the care process and will be documented in the patients’ records. A copy of the clinical records can be requested by patients or any other person provided with the delegating person’s identification document (or a copy of it) or a self-certification. The application for a copy of the clinical records can be submitted either upon discharge or in the days immediately following (before the record is sent to the archive). The application has to be filed at the Centralized Booking Office (CUP) desks of the “Maggiore” and “Cattinara” Hospitals. As from 1/6/2005 applying for a copy of the clinical records from the CUP will require a minimum down payment of € 5.00. The difference shall be settled on collecting the document. Please note that the Medical Record Archive is open Mondays to Fridays, from 7 a.m. to 2 p.m. and can be contacted by dialling 040 - 3994031 for any enquiry, especially if concerning clinical records preceding 1977. DIGNITY All patients, even if affected by incurable diseases, are entitled to receive respect for their personal dignity, by suffering as little as possible and receiving all the necessary care. Our Hospital recognizes and respects the needs of the terminally-ill patients by treating the primary and secondary symptoms, by managing pain, by responding to the emotional, religious, cultural problems of patients and their families.

25

RIGHT TO INFORMATION AND CONSENT All patients are entitled to receive, within reasonable time, exhaustive information on their diagnosis, therapy and prognosis, especially in the case of risky procedures requiring the patients’ explicit consent. Patients have the right to give or deny their consent to the proposed treatments or tests. During their hospital stay, patients are asked to give a general and a specific consent, in compliance with the regulations in force, for all invasive and/or complex procedures. If the informed consent is not signed, the physician will not be allowed to carry out any diagnostic and therapeutic activity, with the exception of the cases provided for by the law and the situations of necessity and urgency, when the patient’s life is in imminent danger. Patients will receive clear and exhaustive information on clinical experimentation and will be able to participate only after signing the relevant informed consent. HEALTHCARE INFORMATION AND DOCUMENTATION Physicians and healthcare professionals ensure that patients receive clear, simple, essential, thorough and comprehensible information. Patients are entitled to participate in the definition of their care plan, to be informed on what impact a disease can have on their quality of life as well as the therapies and healthcare solutions capable of resolving or at least relieving suffering and pain. They are entitled to see their clinical record and to request a copy of it. The Clinical Record shall be clear, legible and complete with all information regarding the diagnosis, treatments and procedures carried out. Patients are entitled to receive a discharge summary at the end of their hospital stay. If the diagnosis is not yet complete, patients have the right to receive a discharge summary with the provisional conclusions. All patients can discontinue their therapy at any stage of the clinical-therapeutic process or reject a particular treatment. Healthcare

26

providers have the obligation to inform patients of the possible consequences of such behaviour. COMPLAINTS AND REDRESS Patients can file complaints with the Customer Relations Office (U.R.P.) when their rights are violated. The University Hospital has the duty to give a reply on the subject matter of the complaint. Patients and their families can exercise this right in person or over the phone during the office opening hours or by mail, fax, e-mail or by filling out the forms available at the info points and dropping them into the appropriate complaint boxes. In the case of easily solvable issues, the Customer Relations Office (U.R.P.) will guarantee a reply in real time or, at the latest, within 15 days. For the most complex cases, requiring a certain amount of investigation, the reply will be given within 30 days. This notwithstanding, patients have the right to take legal action in order to receive compensation for the damage suffered. ORGAN DONATION As provided for by Law 91/99, Patients can consent to become organ donors by making a declaration of will at the Info Point of the Customer Relations Office (U.R.P.) of “Cattinara” Hospital. The staff of the above-mentioned office is at patients’ disposal for any further information on this matter. .

As a patient of “Ospedali Riuniti di Trieste”

University Hospital

It is your duty to:

Respect the hospital staff’s work and professionalism as a prerequisite to implement an appropriate therapy and care program. Behave responsibly and respectfully towards other users .

27

Be respectful of the rooms, equipment, furniture and fittings of the Hospital facilities. Observe the established deadlines and times so that the hospital activity can be carried out normally. Smoking is prohibited throughout the hospital facilities. The use of mobile phones is forbidden as they can interfere with the operation of the electromedical equipment (infusion pumps, automatic respirators, etc.) Animals are not allowed inside the perimeter of the University Hospital. With the aim of safeguarding the health of minors, their access to the inpatient wards should be limited. In particular circumstances, exceptions may be agreed with the ward staff. BOOKING, OUTPATIENT SERVICES, X-RAYS AND LAB TESTS Telephone booking Ring the Call Center; dial 040 – 67 02 011 Mondays to Fridays, from 8.00 a.m. to 1.00 p.m. Booking in person Go to the Centralized Booking Office (CUP), located at :

Cattinara Hospital: Strada di Fiume 447,ground floor, services area.

To book at the CUP desks, one should get a ticket from the turn-o-matic (take-a-number dispenser). CUP desks are also to be found:

In the Local Health Districts At the provincial chemists’

What is necessary You will be asked to provide:

28

Your General Practitioner’s referral (including the diagnosis

and any exemption) Your healthcare card

Fee-for-service payment The payment is usually made at the CUP desks before the service is provided. Under certain circumstances, the payment can be made after the service has been provided, according to the instructions received at the time of booking. HOW TO APPLY FOR CLINICAL RECORDS A copy of the clinical records can be requested by the Patient or by any other person person provided with the delegating subject’s identity document ( a copy is accepted) or self-certification. The application for a copy of the clinical records must be filed with the Centralised Booking Office (CUP) desks of either “Cattinara” or “Maggiore” hospitals. Starting from 1st June 2005, the applications for copies of clinical records submitted at the CUP desks will be accepted only upon advance payment of a minimum fee of € 5.00. On picking up the documents, the patient will be asked to cover the unpaid balance. Please remember that the personnel of the Clinical Record Archives work Mondays to Fridays, from 7.00 a.m. to 2.00 p.m., and can be reached on the phone (dial 040- 399 4031) for any information, especially if concerning clinical records dating back to the period preceding 1977. Payment (*) A copy of the clinical record will be issued upon payment of a fee, proportional to the number of pages to be photocopied.

€ 5.00 up to 30 sheets

29

€ 0.10 each sheet exceeding 30 € 3.00 medical records and reports

(*)These fees apply unless there have been changes between the printing of the booklet and today. Collection The copy of the clinical record can be

Collected at the CUP desks Delivered by mail, by paying postage to the mail carrier

Delivery time The average delivery time is 10 days. The ward has to send the clinical record to the archives at the end of the diagnostic process. Delivery time can be longer if, at the time of discharge, the diagnostic process has not been completed yet. . FIRE In case of fire or if you suspect fire, call immediately a member of the staff, who will ring 4444 and coordinate the rescue operations.

30

HOW TO REACH THE HOSPITAL BY BUS

Bus Services

22 Central Railway Station – Cattinara 25 Piazza Borsa – Cattinara 26/ Largo Osoppo – Cattinara (only on

Sundays and holidays) 39/ 37

Aurisina – Cattinara Largo Barriera - Cattinara

48 Largo Barriera – Cattinara 49/ Muggia – Cattinara A AFTER 9.00 p.m.

For the full bus routes and timetables, visit the website at http://www.triestetrasporti.it

31

HOW TO REACH THE HOSPITAL BY CAR

Leave the A23 Venice – Trieste motorway at the Lisert toll station, and follow the ‘Italy-Slovenia Border’ direction; after the Padriciano exit, continue towards Rabuiese and follow the road signs. HOW TO REACH THE HOSPITAL BY TAXI Radiotaxi: Phone: 040 – 307 730; fax 040 – 305 035 Website: www.radiotaxitrieste.it Alabarda Taxi: Phone: 040 - 390 039; fax 040 – 946 363 e-mail: taxialabarda@tiscalinet.it

32

LEGEND

Church

Emergency Department

Bus stops

Visitors’ entry

Taxi

Parking for disabled people

Forbidden Hospital areas

Parking for disabled people

Green areas and gardens

Access for accompanied disabled People

Outside areas

Parking lots

Info Point

33

COMMENTS AND SUGGESTIONS

Dear Madam /Sir, Please fill in this form at the end of your hospital stay. The information you provide will be very important to improve the quality of our service.

Pain control was:

� poor � fair

� good

� excellent

The information I was provided with was :

� poor � fair

� good

� excellent

Please write in this space your favourable and unfavourable comments about our ward, and your suggestions as to how we can improve.

Servizio Sanitario RegionaleAZIENDA OSPEDALIERO – UNIVERSITARIA

Ospedale di rilievo nazionale e di alta specializzazione( D.P.C.M. 8 aprile 1993)

OSPEDALI RIUNITI DI TRIESTE FACOLTA' DI MEDICINA E CHIRURGIA

DAI CHIRURGIA GENERALE e TORACICA - Direttore: pro f. Gennaro LiguoriSC Chirurgia toracica - Direttore: prof. Maurizio Cortale

34

If unfortunately a relative or a friend of yours we re to face your same health problems, would you recommend our Hospital?

�yes �no, because_________________________________ ______________________________________________ ______________________________________________ ______________________________________________

35

NOTE This booklet contains information valid at time of printing and is periodically updated. Among the other issue, however, may intervene in the operation changes.

36

Drafted by the Communication Office in collaboration with the Customer Relations Office, on the basis of texts provided by the Thoracic Surgery Division in compliance with the Joint Commission International accreditation standards . tel. 040 – 399 6301; 040 – 399 6300; fax 040 399 6298 e-mail: comunicazione@aots.sanita.fvg.it Strada di Fiume 447 – 34 149 Trieste

Revision 002 of 2012

ACCREDITED FOR ORGANIZATION BY

JOINT COMMISSION INTERNATIONAL