Welcome to Duke Hospital

Teaching Teaching

TechnologyTechnology

TeamworkTeamworkRebecca 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 Roundsusing 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 Nursing Contribution to Roundsto 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:

• 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 CHARTCARDIAC CARE UNIT --- 7200

Goal of Therapy --- therapeutic aPTT of 50 - 75 seconds.

aPTT(seconds)

Bolus Dose

(units)

Stop Infusion

(minutes)

Rate Change

(ml/hour)

Repeat aPTT

< 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. ***

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.

Instructions for Heparin Nomogram

Nurse Physician Collaboration

Nurses use critical thinking to pull together the patient assessment data, effects of medications and hemodynamic numbers to respond to emergency situations

Responding to Emergencies

How are our nurses prepared

to practice ?

Nursing EducationNursing 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

Clinical Operations Director

Nurse Manager

Operations 7100*

Nurse Manager

Operations 7200**

Nurse Manager

Education 71 / 73

Nurse Manager

Operations 7300*

Nurse Manager

Education 7200

Staff Nurses

Nursing Assistants

Staff Nurses

Nursing Assistants

Staff Nurses

Nursing Assistants

Nursing Structure Nursing Structure Medical CardiologyMedical Cardiology

* 7100 and 7300 are Progressive Care medical cardiology units ** 7200 is the Cardiac Care Unit

OrientationOrientation

Unit Orientation Coordinator

RNFacilitates Orientation

Classes:•IABP•Hemodynamics•Shock•Pacers, etc.

Preceptor, Experienced RNCoaches new nurse In developing critical thinking skills

MentoringExperienced 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 ProgramAdvancement 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

• Mortality and Morbidity• Cardiovascular Medicine Performance

Improvement • Cardiovascular Serviceline Council• Medical Directors meeting • Heart Center Discharge meeting

Nurses have the additional responsibility to participate in hospital wide multidisciplinary committees

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

Nursing

Respiratory Therapists

Pharmacists

Interns & R

esidents

Patient Resource Manager

Physical & O

ccupational

Therapists

Chaplain

Dietician

Cardiology Fellow

Patient

Team Collaboration at Duke

It’s More than just the doctors and nurses . . . . .

Family presence is important for the well-being of our patients

In addition to the healthcare team, we value families

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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

Can Mr.

Clausing have

visitors?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.

First Critical Care Unit in North Carolina to receive

the Beacon Award for Excellence in Nursing

practice

Duke Hospital achieved Magnet Status for excellence in Nursing Services in 2006

Teamwork!