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 RNs 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
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:
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
+ 1 ml/hr
6 hours
50 - 75
no change
next AM
76 - 85
- 1 ml/hr
next AM
86 - 100
30 minutes
- 1 ml/hr
6 hours
101 - 150
60 minutes
- 2 ml/hr
6 hours
> 150
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
al
Pa
tie
nt
Re
so
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eM
an
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er
Attending
Physicians
Pharmacists
on
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t
pa
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c
Oc ists
l & rap
a
sic The
y
Ph
Chaplain
Patient
llow
e
F
ogy
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o
i
d
Car
nts
e
sid
e
R
&
ns
r
e
Int
Res
pir
Nursing
Die
tic
ian
ator
y
The
rapi
st s
Team Collaboration at Duke
Its 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
% of Time Needs Met
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.
r.
M
e
Can g h av
in
s
?
u
Cla isitors
v
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!
