Buchanan, 1996; Knaus, Felton, Burton, Fobes, & Davis 1997, J. of Nsg Administration

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1 Can Patients with Moderate to High Risk Acute Coronary Syndromes Be Cared For safely in a Cardiac Acute Care Unit (ACU)

2 Introduction Several studies have evaluated the safety of managing g patient with low to moderate risk acute coronary syndromes in an intermediate cardiac care setting The purpose of this presentation is to describe our one-year experience with an acute care nurse practitioner managed and physician supervised acute cardiac care unit in a large university-affiliated, tertiary/quaternary care teaching hospital

3 Introduction Acute Cardiac Care Unit was developed to care for patients who have a higher acuity than can be managed on cardiology ward or who need medications that cannot be administered without close nursing supervision The majority of these patient had acute coronary syndromes (ACS), or heart failure Arrhythmias, Post laser lead extractions and post alcohol ablation

4 Introduction Individuals such as ACNPs who are readily available and prepared to participate in the diagnosis i and management of health-care h problems in collaborative professional relationships with physicians can potentially extend the efficacy of medical management. Buchanan, 1996; Knaus, Felton, Burton, Fobes, & Davis 1997, J. of Nsg Administration

5 ACNP Model Of Practice ACNP PHYSICIAN PRACTICE MODEL NURSING PRACTICE MODEL JOINT PRACTICE MODEL Parinello. Crit. Care. Nsg Clinics of N. America 1995

6 Brief Overview of UHN Heart and Circulation Program UHN Heart & Circulation Program TGH-TWH-PMH-MSH Cardiovascular ICU 22 Beds Full service Cath-Lab Short Stay Unit 28 Beds Vascular Surgery 14 Beds Cardiology Inpatient 34 Beds CV Inpatient 56 Beds CCU 14 Beds

7 Brief Overview of UHN Heart and Circulation Program TGH CCU ( Beds) Total admissions i for the year patient t Missing data 132 patient Acute Coronary Syndromes 366 patient (66.4%) Congestive Heart Failure 126 patient ( %) Aortic Dissection 20 patient (2.3%) Arrhythmias 56 patients (6.6%) Intubated patient 122 patient ( %) Patients required inotropes 210 patient ( %) Cardiac catheterization 295 patient (35 35%) Angioplasty 199 patients ( %)

8 ACS Brief Overview of UHN Heart and Circulation Program CHF C. Shock Aortic Dissections Arrhythmias TGH CCU (10-14 Beds CCU Pericardial disease Majority of these patients have a higher Acuity illness that cannot be managed on the regular ward yet are stable enough To be managed in ACU unit on the ward ER Periphery Hospitals In-patient Home transplant

9 Purpose The Process of Developing The ACU To decrease the demands on the Coronary Intensive Care Unit To provide a seamless approach hf for patients requiring a defined set of interventions from within UHN and other institutions

10 The Process of Developing The ACU Aortic Dissection CCU Very High Risk ACS Cardiogenic Unstable Shock Arrhythmia Unstable CHF High Risk ACS ACU CHF Laser Lead Arrhythmia Extraction Post Alcohol l Ablation D iti ti f ACS d Decrease waiting time for ACS procedures Increase CCU referrals for very high risk groups Increase volume for PCI patient population

11 Criteria of Admissions INCLUSION EXCLUSION ACUTE CORONARY SYNDROME HEART FAILURE OTHER VERY HIGH RISK GROUPS ALL ACS Patient Population except Unstable ST Elevation Myocardial Infarction Pt. with known Heart Failure who Require Low dose Dopamine and /or Dobutamine HF Patient with low SBP <90 mmhg requiring Inotrope support Pt s who require either increased NSG care or Medical care Post alcohol ablation Post laser lead extraction EP Patient with frequent Ventricular arrhythmias ACS patient ST elevation MI Symptomatic S t ti hypotension Unstable rhythms Need for invasive hemodynamic monitoring

12 The Process of Developing The ACU Medications: Dopamine maximum 5ug/kg/minute (maximum) Dobutamine 10ug/kg/minute (maximum) Milrinone 0.5 mcgs/km/minute (maximum) Nitroglycerin IV no maximum Lasix IV infusion 10 mg/hr Integrillin, Aggrastat and Reopro Procedures: Post femoral sheath removal care Care patient with arterial line Exclusion Swan Ganz, Ventilation and IABP

13 Source of Admission & Discharges ADMISSIONS DISCHARGES OTHER ER SENDING CCU HOSPITALS DEPARTMENT FACILITY CATH-LAB CCU WARD DEATH WARD OTHER HOME OR

14 The Process of developing the ACU Multidisciplinary Approach Nurse Manager Pharmacy ACNP & Physicians Social Worker Nurse Educator Staff Nurses

15 The Process of developing the ACU Cardiology Inpatient Ward Teaching Team ACNP Team EP Team 14 Beds 12 Beds 6 Beds Staff Cardiologist 3-4 medical resident Staff Cardiologist 4 ACNP Staff Cardiologist 3 Nurse Clinicians 44 ACU Beds 1 ACNP

16 The Process of Developing the ACU The ACU was opened successfully November 2001 in a 4 bed capacity

17 Role of the ACNP UHN APN Total 55 APN TGH 29 APN TWH 14 PMH 12 Cardiology- TGH CHF Congenital Inpatient C 1 6 ACNP

18 Role of the ACNP Wendy Linda Dr. Ross Abdiqani Kaye

19 ACNP Role Component CLINICAL (39 to 70%) ADMINISTRATION ACNP RESEARCH (6 to 13%) (3 to 5%) EDUCATION (3 to 12%) Buchanan, 1996; Knaus, Felton, Burton, Fobes, & Davis 1997, J. of Nsg Administration

20 Role of the Educator Coronary Care Unit Inpatient Cardiology Acute Care Unit

21 Role of Staff RN Role Change from being a nurse on inpatient unit to working in a more acute care setting with a complex patient population

22 395 Admissions Data 69 Acute Myocardial Infarction ( %) 160 High risk UAP ( %) 60 Arrhythmia (15.1%) 33 Laser lead extractions (8.3%) 35 CHF (8.8%) 13 Post septal alcohol ablation (3.2

23 Data 25 other (6.3%) Mortality 1% (4/395 admissions) Mean LOS 2.5 Days Of patients with ACS 54% angiograms, 34% PCI From High risk ACS group 37.5% on IV NTG, 45.6% on GP2B3A inhibitors, (47/160) 37.0% CK positive MI, 74/160 had a CK positive ii MI

24 Summary We demonstrated that the management of patients moderate to high risk ACS, CHF and other complex cardiac conditions can be safely accomplished in an ACNP managed and physician supervised cardiac acute care unit patient populations can

25 Conclusion On the basis of our one year experience, it appears that it is save to provide an intermediate care options with a moderate to high risk ACS patient (excluding unstable ST-Elevation MI These prospects are particularly attractive because such populations might otherwise occupy a limited number of beds that could be better serve high-risk patients