Welcome to Duke Hospital

1. Welcome to Duke Hospital

2. Nursing at Duke Hospital Teaching TechnologyTeamwork Rebecca Johnson, RN, Lupino Washington, BSN Duke University Health System, Durham, NC

3. 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

4. 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

5. 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

6. 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

7. Patient Room Cardiac Care Unit

8. 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

9. Progressive Care Unit

10. Patient Room Progressive Care Unit

11. Typical Day on the CCU Nurse-to-nurse report using computerized charting

12. Daily Roundsusing computerized physician order entry Attending Fellows House staff Care nurse Clinical pharmacist Patient Resource Manager Respiratory therapist The entire team rounds daily on each patient Every team member has input in creating the plan of care:

13. 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

14. 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

15. Routine Care

16. 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

17. Staff Nurse using critical thinking skills to titrate vasopressor to patient hemodynamics

18. HEPARIN ADJUSTMENT CHARTCARDIAC CARE UNIT --- 7200Goal of Therapy --- therapeutic aPTT of 50 - 75 seconds. *** Rate change is based on Heparin infusion of 100 units/ml. ***

19. Instructions for Heparin Nomogram For patients who received thrombolytic therapy: (ie, tPA, TNK, rPA) From 6 - 12 hours after startof 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.

20. Nurse Physician Collaboration

21. 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

22. How are our nurses prepared to practice ?

23. 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

24. Men in Nursing

25. Nursing Education Ph.D. – Doctorate in Nursing • Researchers • Administrators of practice • Educators Dr. Bradi Granger Heart Center Nurse Researcher

26. 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 Nursing Assistants Staff Nurses Nursing Assistants Staff Nurses Nursing Assistants * 7100 and 7300 are Progressive Care medical cardiology units ** 7200 is the Cardiac Care Unit

27. Orientation New staff members begin their work experience on the CCU with a thorough orientation

28. Beginning the Clinical Ladder Orienting New Staff Nurses ( Clinical Nurse I )

29. Clinical Ladder ProgramAdvancement for the Staff Nurse

30. 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

31. 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

32. 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

33. Nurses Presenting at National Critical Care Conference

34. Teamwork Education, experience, autonomy and responsibility prepare nurses to be competent and respected members of the healthcare team.

35. Nursing Is an Integral Component of the Healthcare Team Physical & Occupational Therapists Attending Physicians Patient Resource Manager Pharmacists Chaplain Patient Cardiology Fellow Respiratory Therapists Interns & Residents Nursing Dietician

36. Team Collaboration at Duke It’s More than just the doctors and nurses . . . . .

37. In addition to the healthcare team, we value families Family presence is important for the well-being of our patients

38. % of Time Needs Met Needs of Family Members (2003) J Clinical Nursing, 12(4) 490-500

39. Physicians speak with families dailyFamily Conference with Physician, Care Nurse and Charge Nurse

40. 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.

41. If life support has been withdrawn, we encourage families to be present as much as they wish - 24 hours per day

42. There are times when children are allowed to visit

43. 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.

44. 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

45. Teamwork!

46. COLLABORATION SUCCESS !