CATHOLIC HEALTH SYSTEM MERCY HOSPITAL OF BUFFALO

POLICY AND PROCEDURE

TITLE: Scope of Services- Open Heart Unit PREPARED BY: Julie LaManna, Director of Cardiac Services

RESPONSIBLE DEPARTMENT: Cardiac Services

POLICY #:

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APPROVED BY: Kathleen Guarino Vice President Nursing, REVIEWED BY: Julie LaManna, Senior Director of Cardiac Services

PURPOSE: 1. Define the services provided. 2. Describe the type of patients served. 3. Maintain consistency with the Mercy Hospital Mission. CLINICAL AREA FOR USE: Open Heart Unit (OHU) SCOPE: The Open Heart Unit (OHU) provides intensive high quality nursing care to acutely ill young adult, adult, and geriatric patients. In the Open Heart Unit (OHU) the range of services includes comprehensive nursing care to the status post open heart patient. Specific services include: 1. Continuous 24 hour EKG monitoring. 2. Invasive hemodynamic monitoring with arterial lines. 3. Pulmonary Artery Catheter. 4. Counter Pulsation Therapy (IABP). 5. Initiation and/or maintenance of mechanical ventilatory support. 6. Cardioversion 7. Defibrillation 8. Initiation and/or maintenance of anti-arrhythmic, inotropic, and vasoactive medications. 9. Transvenous and epicardial pacing. 10. Nutrition 11. Hydration 12. Patient and family education and emotional support. 13. Discharge Planning 14. Continuous Renal Replacement Therapy (CRRT) 15. Ventricular Assist Devices MISSION/VALUES: 1. Provide high quality, cost effective, compassionate, state-of-the-art health care services to the young adult, adult, and geriatric patient. 2. Support an environment, which promotes continuous quality improvement. 3. Offer a wide spectrum of innovative health services that best meet the physical, emotional, and spiritual needs of the critical care population. 4. Develop and promote a collaborative, multi disciplinary team approach to patient care. 5. Provide considerate and respectful care. 6. Provide nursing care without discrimination as to race, color, religion, gender, national origin, disability, sexual orientation, or source of payment.

Title: Scope of Services- Open Heart Unit DEPARTMENT GOALS:

Responsible Department: Cardiac Services

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Expected clinical outcomes. Maintain standards of practice as defined by AACN (American Association of Critical Care Nurses). Nursing staff will maintain appropriate competencies. Accurate, ongoing, detailed head-to-toe assessment to allow for early detection and treatment of any changes in patient condition. Early identification of patients with high risk discharge factors and implementation of actions to overcome risk factors. (i.e., referrals to appropriate agencies) Patient is transferred/discharged with an appropriate length of stay. Use of appropriate resources.

OPERATIONAL POLICY: 1. Location: OHU is located on the second floor of the McAuley Building. 2. Capacity: Variable capacity of patients as they move through the continuum of care.. The following guidelines will be used for structuring assignments with OHU: Consideration is given to; Patient condition complexity and required nursing care. Dynamics of the patients status, including knowledge and skills required to provide comprehensive assessment. Required technologic support and Registered Nurse demonstrated advanced skill competency and demonstrated nursing staff skill and competence level and supervision required. Complexity of patients assessment, including knowledge and skills required. Relevant safety and infection control issues. Patient care requirements will be assessed and scored per OHU acuity system. Acuity Score of 40 or greater may be achieved by any or all of the following and equates 1:1 nursing care. Maximum care Medication via IV Medication effect assessment required IV titration/push IV flush line Vital signs q 1 hour plus I&O q 1 hour 29 plus treatments in 24 hours (Nurse/Patient interactions) Complex monitoring requirements Ventilator/Oxygen adjustment required Sensory/Cognitive Impairment An example of patients who may fall into the 1:1 patient: nurse category are : Immediate post-op patient that has undergone CABG, valve repair, or any other procedure requiring cardiopulmonary bypass. Any patient requiring IABP therapy for hemodynamic instability. Any patient requiring ventricular assist device. Continuous Renal Replacement Therapy Any patient requiring re-exploration in OHU. Any patient deemed to be hemodynamically unstable to the point that it would be deemed unsafe to have another additional patient assigned (Determined by charge nurse or nurse caring for patient).

Title: Scope of Services- Open Heart Unit

Responsible Department: Cardiac Services

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Acuity Score of 25 to 40 may be achieved by any or all of the following and equates 1:2 nursing care. Moderate assistance. Medications via IV. Medication effect assessment required. Vital signs q 2-3 hours. 19 to 28 treatments in 24 hours (Nurse/Patient Interactions). Basic monitoring requirements. Oxygen adjustments, pulmonary requirements. Sensory/Cognitive Impairment.

An example of a patient who may fall into the 2:1 patient/nurse category care: A hemodynamically stable post-op day one patient that has undergone CABG, valve repair , or any procedure requiring cardiopulmonary bypass. A patient requiring mechanical ventilation. A patient receiving IABP therapy that is not balloon dependant and is extubated. Acuity Score of less than 25 may be achieved by any or all of the following and equates 1:3 nursing care. Minimal assistance. Medication effect assessment required. Vital signs q 4 hours. 10 to 18 treatments in 24 hours. (Nurse/Patient Interactions.) Basic monitoring requirements. Sensory/Cognitive Impairment.

An example of a patient who may fall into the 3:1 patient/nurse category care: Patients considered hemodynamically stable for a minimum of twenty-four (24) hours. (These patients should not be on IV infusions requiring active titration, nor should be dependant on temporary pacemakers.) Patients in this category will not require vital signs or neurological assessment more frequently than every four (4) hours. 3. Hours of Operation: 24 hours a day, seven days a week. 4. Visiting Hours: To provide maximum care and rest, visiting is limited to two family members at a time for specific time frames. 5. Private duty nurses are not permitted. 6. Flowers are not permitted. 7. Two defibrillators in the unit- one must remain in OHU at all times. ORGANIZATION: 1. Medical Director of OHU Care Unit: The Medical Director of the OHU has the overall function to direct the medical activities of the unit so that optimal care is given at all times. 2. Nurse Manager and the Clinical Director of Cardiac Services, with the Medical Director of the OHU regarding operational policies with medical implications. 3. The Nurse Manager of the OHU is responsible for the day to day nursing activities on the OHU. The Clinical Director of Cardiac Services has the overall function to direct nursing activities so that optimal care is given. EQUIPMENT AVAILABLITY: 1. One emergency open chest cart. 2. Two defibrillators with pacer capabilities. 3. Suction, oxygen, and compressed air with means of administrating. 4. Hardwire cardiac monitors in all rooms. Six telemetry channels will be available for ambulating patients.

Title: Scope of Services- Open Heart Unit 5. 6. 7. 8. 9. 10. 11. 12.

Responsible Department: Cardiac Services

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One emergency Code 9 Cart. One free standing intubation tray. Combined line and thoracotomy cart Additional equipment for oxygen administration. Trays: Pacemaker- Pericardiocentesis- a TLCVP Tray. Intra Aortic Balloon Pump. IV pumps. Programmers for permanent pacemakers.

The most frequent types of diagnoses seen in the patients include: 1. Cardiac Surgery 2. Thoracic Aorta Cases The Critical Care Nurse is expected to assist with the following procedures: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Central line insertion. Pulmonary artery catheter insertion. Thoracentesis/Pericardiocentesis. Cardioversion. Chest tube insertion. Arterial line insertion. Transvenous pacemaker insertion. Extubation/Intubation Acute renal dialysis. Insertion of Intra Aortic Balloon Pump. Emergency open chest resuscitation.

The Critical Care Nurse is expect to perform the following procedures: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Defibrillation Extubation Maintenance of invasive lines for hemodynamic Management of Intra Aortic Balloon Pump Epicardial pacing. Management of patients on mechanical ventilation. Insertion of NG tubes. Drawing arterial blood gases. Assists with other procedures as necessary. Continuous Renal Replacement Therapy Manage patient with Ventricular Assist Devices

Medications Frequently Used: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Antihypertensives Anticoagulants Insulin Antibiotics Diuretics Analgesics Sedatives Steroids Bronchodilators Antiarrhythmic Agents Vasoactive Medication

Title: Scope of Services- Open Heart Unit Personnel Providing Services: 1. 2. 3. 4. 5. 6. 7.

Responsible Department: Cardiac Services

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Attending Physicians/Physician Assistant Registered Professional Nurses Intermediate Treatment Assistants Nurse Manager Clinical Nurse Specialist Cardiac Nurse Practitioner Unit Clerk

Support Services Available: Cardiology Diagnostic imaging Dialysis services Nutritional services Spiritual care Pharmacy Quality management: Performance Improvement Case Management- Discharge Planning and Social Services Infection Control 8. Rehabilitative Services- Physical Therapy, Occupational Therapy, and Speech Therapy 9. Respiratory Therapy 10. Volunteer Services 1. 2. 3. 4. 5. 6. 7.

ORIGINATION/EFFECTIVE DATE: 1/17/02 Date/ Initials REVIEWED: REVISED: REFERENCES: March.04 JL 12/200 4 JL 1/08 JL Date/ Initials Date/ Initials Date/ Initials 6/09 JA Date/ Initials Date/ Initials Date/ Initials Date/ Initials Date/ Initials

FEDERAL LAW: NYS LAW: JCAHO STANDARD: LD 1.7