Transcript ICU Cardiac Rehab: Heading ‘em Up and Moving ‘em Out

Welcome to
Duke Hospital
Teaching
Technology
Teamwork
Rebecca Johnson, RN, Lupino Washington, BSN
Duke University Health System, Durham, NC
CCU Description
• 16 bed cardiac intensive care unit
• Major Diagnoses include
• Cardiogenic shock
• Acute myocardial infarctions
• Cardiomyopathy
• Unstable angina
• Life threatening arrhythmias
• Overflow of patients other than cardiac
CCU Staffing
• Charge Nurses - act as resources to
nurses and physicians
• Charge Nurses do not take patients
• The staff is 90% Registered Nurses
• There are 60 RN’s in the CCU
• Nurse patient ratio is 1:1 to 1:2
CCU Staffing
Nurse Clinician
• Liaison between the patient,
family and healthcare team
• Assists in end-of-life issues
Patient Resource Manager
• Manages discharge planning
and insurance issues
CCU Staffing
Attending physicians
• Round morning and evening
• Available 24 hours a day
Cardiology fellow, resident, and intern
• On the unit 24 hours a day
Pharmacists
• Available on the unit for rounds and
consultation from 7:00AM to 11:00PM
Patient Room
Cardiac Care Unit
Progressive Care Unit
Description
• Two 31 bed medical cardiology progressive care
units
• All beds have telemetry
• Patient populations consist of
• Unstable angina and post acute MI
• Cardiomyopathy
• Pre-heart transplants
• Dysrhythmias
• These units offer opportunities to use innovative
technologies, participate in research based
practice, and facilitate patient education
Progressive Care Unit
Patient Room
Progressive Care Unit
Typical Day on the CCU
Nurse-to-nurse report using
computerized charting
Daily Rounds
using computerized physician order entry
• The entire team rounds daily on each patient
• Every team member has input in creating the plan of
care:
Attending
Fellows
House staff
Care nurse
Clinical pharmacist
Patient Resource Manager
Respiratory therapist
Nursing Contribution
to Rounds
• Update
team on vital signs and hemodynamics
• Relate patient response to medication
(vasopressors and oral agents that have been
titrated by nurse)
• General changes in patient status
• Input into the decision whether or not the patient is
able to transfer to another unit or rehab facility
• Identify patient and family concerns and questions
Education, Leadership and
Responsibility
Nurses are responsible for monitoring patients
and interpretation of information as well as
operating a wide variety of equipment such as:
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•
•
Intra aortic balloon pumps
Pulmonary artery catheters
Continuous venous-venous hemodialysis
Temporary transvenous pacemakers
Ventilators
Defibrillators/cardioversion
Pericardial drains
Routine Care
Responsibilities and
Nurse Driven Protocols
• Titration of vasopressors to patient
hemodynamics
• Phase I Cardiac Rehab
• Nurse Driven protocols
• Heparin – titrate according to nomogram
• Potassium – supplement according
patient lab value
• Magnesium - supplement according
patient lab value
• Tube feedings
Staff Nurse using critical thinking
skills to titrate vasopressor to
patient hemodynamics
HEPARIN ADJUSTMENT CHART
CARDIAC CARE UNIT --- 7200
Goal of Therapy --- therapeutic aPTT of 50 - 75 seconds.
aPTT
(seconds)
Bolus
Dose
(units)
Stop
Infusion
(minutes)
Rate
Repeat
Change
aPTT
(ml/hour)
< 40
3,000 units 0
+ 1 ml/hr
6 hours
40 - 49
0
0
+ 1 ml/hr
6 hours
50 - 75
0
0
no change
next AM
76 - 85
0
0
- 1 ml/hr
next AM
86 - 100
0
30 minutes
- 1 ml/hr
6 hours
101 - 150
0
60 minutes
- 2 ml/hr
6 hours
> 150
0
60 minutes
- 3 ml/hr
6 hours
*** Rate change is based on Heparin infusion of 100 units/ml. ***
Instructions for Heparin Nomogram
For patients who received thrombolytic therapy: (ie, tPA, TNK, rPA)
From 6 - 12 hours after start of thrombolytic agent ---1. Do NOT discontinue or decrease the infusion unless significant
bleeding occurs or the aPTT is > 120.
2. Adjust the infusion upward if aPTT is < 50.
12 or more hours after start of thrombolytic agent ---Adjust Heparin using the entire chart. Deliver the bolus, stop the
infusion and/or change the rate of infusion based on aPTT result.
For all patients who did NOT have thrombolytic therapy:
Adjust Heparin using the entire chart. Deliver the bolus, stop the infusion,
and/or change the rate of infusion based on aPTT result.
HO should weight, age and gender adjust the initial infusion rate to the
patient.
If patient has not reached therapeutic range after 2 adjustments are made
using the chart, ask HO to write order for additional bolus or additional
increase in drip rate, if appropriate.
Nurse Physician Collaboration
Responding to Emergencies
Nurses use critical thinking to pull together the patient
assessment data, effects of medications and
hemodynamic numbers to respond to emergency
situations
How are our
nurses
prepared to
practice ?
Nursing Education
AD – Associate degree – 2 years
Diploma in Nursing – 3 years
BSN – Bachelor of Science in Nursing – 4 years
MSN – Master or Science in nursing –2 -3 years
NP – Nurse Practitioner
CRNA – Certified Nurse Anesthetist
CNS - Clinical Nurse Specialist
MHA – Masters in Hospital Administration
Men in Nursing
Nursing Education
Ph.D. – Doctorate in Nursing
• Researchers
• Administrators of practice
• Educators
Dr. Bradi Granger
Heart Center Nurse Researcher
Nursing Structure
Medical Cardiology
Clinical Operations
Director
Nurse
Manager
Operations
7100*
Nurse
Manager
Education
71 / 73
Nurse
Manager
Operations
7300*
Nurse
Manager
Operations
7200**
Nurse
Manager
Education
7200
Staff Nurses
Staff Nurses
Staff Nurses
Nursing
Assistants
Nursing
Assistants
Nursing
Assistants
* 7100 and 7300 are Progressive Care medical cardiology units
** 7200 is the Cardiac Care Unit
Orientation
Unit Orientation
Coordinator
RN
Facilitates
Orientation
Classes:
•IABP
•Hemodynamics
•Shock
•Pacers, etc.
Preceptor,
Experienced RN
Coaches new nurse
In developing critical
thinking skills
Mentoring
Experienced RN
Continues to coach
and support after
formal orientation
New staff members begin their work experience
on the CCU with a thorough orientation
Beginning the Clinical Ladder
Orienting New Staff Nurses
( Clinical Nurse I )
Clinical Ladder Program
Advancement for the Staff Nurse
Education, Leadership and
Responsibility
Nurses are responsible for many
areas of their own practice:
• Scheduling
• Interviewing potential staff members
• Create policies and procedures
• Conduct yearly skills validation
• Ongoing inservices and education
• Evaluate new product for hospital use
Teamwork
Nurses have the additional responsibility
to participate in hospital wide
multidisciplinary committees
• Mortality and Morbidity
• Cardiovascular Medicine Performance
Improvement
• Cardiovascular Serviceline Council
• Medical Directors meeting
• Heart Center Discharge meeting
How do nurses maintain their
proficiency as well as learn new
competencies?
• Yearly skills revalidation on the unit
• Unit inservices of new equipment and
techniques
• Hospital wide programs
• Local Conferences – present as well as participate
• National Conferences – present as well as
participate
Nurses Presenting at National
Critical Care Conference
Teamwork
Education, experience,
autonomy and responsibility
prepare nurses to be
competent and respected
members of the healthcare
team.
Nursing Is an Integral Component of
the Healthcare Team
Attending
Physicians
Pharmacists
Patient
Nursing
Team Collaboration at Duke
It’s More than just the doctors and nurses . . . . .
In addition to the healthcare
team, we value families
Family presence is important for the
well-being of our patients
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% of Time Needs Met
100
90
80
70
60
50
40
30
20
10
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Needs of Family Members (2003)
J Clinical Nursing, 12(4) 490-500
Physicians speak with families daily
Family Conference with Physician, Care Nurse
and Charge Nurse
Family Visitation
• Visiting hours are daily from morning until
bedtime and are open, but not unlimited
• Visitors are requested to use an intercom
system to call back before entering the unit
• Staff members have the right to ask family to
wait before coming
Yes, He is in
room 7214.
If life support has been withdrawn, we
encourage families to be present as much
as they wish - 24 hours per day
There are times when
children are allowed to visit
Teaching, Technology,
Teamwork
Teaching, technology and team work
have allowed Duke to successfully
achieve extraordinary care for our
patients and their families.
and
Through education, responsibility and
autonomy, nurses have a strong impact
on patient care and outcomes.
Duke Hospital
achieved Magnet
Status for
excellence in
Nursing Services
in 2006
First Critical Care Unit in
North Carolina to receive
the Beacon Award for
Excellence in Nursing
practice
Teamwork!