patient room, at each work station, the nurse s station, and in each medication/suppl y room.

3 drip management. e. Suspected pacemaker malfunction or defibrillator discharge. f. Observation for post pacemaker or defibrillator placement or post ablation. g. Hemodynamically stable new onset supraventricular arrhythmias (atrial fibrillation or flutter, PSVT) when patient is likely to undergo a planned electro physiology study or cardioversion as an inpatient. Patients requiring 2:1 nursing care for moderate sedation for Trans- Esophageal Echocardiogram and planned Cardioversion. h. Syncope when an arrhythmia or cardiac disorder is a suspected cause. 2. Cardiac Surgery a. Post cardiothoracic surgery patients, i.e., CABG and high risk CABG, valve replacement and repair, aortic root repairs, thoracic fluctuating hemodynamic and/or mental status. DVT prophylaxis. Psych/social interventions. Oxygen requirement monitoring. Continuous IV medication infusions requiring frequent monitoring. I.e. heparin, insulin, vasoactive meds. b. Cardiology - Post Catheterization Lab Post angiopatients require arterial line setup, continuous vital sign and EKG monitoring, hourly anticoagulation monitoring, neuro-assessment patient room, at each work station, the nurse s station, and in each medication/suppl y room. Call light system differentiates types of calls including bed alarm, bathroom alarm, staff assist alarm, and code alarm. In order to overcome our geographically large unit, the Vocera system provides two-way communication between staff members and patient rooms. Each room is equipped with a call light which planned procedures (such as cardioversions, arterial monitoring and sheath removal, and TEEs) unforeseen events (rapid responses and codes) ADT rates (week)daily rounds with PT/OT, mds, and case managers to determine expected discharges and acuities Charge RNs and bedside RNs communicate floor acuity throughout all shifts and may affect the ability to admit high acuity patients. If

4 AAA repairs, who are hemodynamically stable but may require fluid resuscitation and transfusion due to fluid shifts. b. Patients with a Ventricular Assist Device. All nurses receive special training and yearly review of skill. c. Hemodynamically stable patients who have received a heart transplant during the current admission. d. Patients who have previously received a heart transplant and are being admitted for rejection, infection, etc. e. Patients with Transcatheter Aortic Valve Replacement. All nurses receive special training and yearly review of skill. 3. Thoracic Surgery a. Patients with lung cancer who have had thoracotomy, lobectomy, and/or Video Assisted Thoracic and site assessments. Sheath pull requires 1:1 nursing for one hour, with a second nurse to stand by during certain periods. Post-sheath pull requires q15 minute vital sign, site check, and CMS checks for one hour, q30 minute checks for one hour, and then hourly until patient is off total bed rest. Bed rest is typically four to eight hours post sheath pull. c. Cardiology CHF management Heart failure education in compliance with communicates with a central monitor, individual RN s vocera, and intercom at each pod. High ADT rate contributes to fluctuating staffing needs and increased RN work load. There are two code carts and two EKG machines available on the floor. has a centralized Telemetry Monitor Room. Telemetry Technicians provide on 11K remote telemetry monitoring for adult and pediatric acute the charge RN or floor RN finds that The Grid does not safely represent the floor acuity at any time, decisions can be made with the assistance of the following chain of command: RN charge RN Manager/AOD/Staffin g Office Divisional Director CNE. Ineffective staffing situations can also be reported via a Staffing Variance Form, which is sent to the hospital staffing committee. Unsafe staffing situations can also be reported via an Unsafe Staffing form which is processed by the ONA. Staff Experience: As is a progressive care unit, staff receives training in addition to acute care RN

6 2. Amputations / Below knee, above knee, total metatarsal, and toes. 3. Venous disease. (DVTs, etc.) 4. Vascular Access ( Dialysis fistula revision, venous thrombectomy, new grafts). 5. Post arterial stent patients who need overnight monitoring usually bleeding, ischemia or blood pressure issues. 5. Direct Telemetry monitoring for patients from other services. administering medications per MD instruction. Pre- and postprocedure care involves 1:1 nursing care. All nurses receive annual skills training in moderate sedation procedure. Cardiology EPS Electrophysiolog y services involving site evaluation, patient education for mobility restrictions of shoulder/arm, continuous EKG monitoring, and pacer lead verifications, at times with adjustments needing frequent Generally, has a lower ratio of CNAs to RNs than an acute care floor. has one telemetry technician on duty at all times. HUC coverage varies, but generally consists of one HUC on duty from 07-2300. Insufficient staffing is managed by the charge RN, Unit Manager, and Nursing Resource Management (the float pool). All RNs work 12 hour shifts. CNAs work either 8 or 12 hour shifts, Tele Techs and HUCs alternate between these roles and work 8 hour shifts. Assignments and Daily Management of Patient Care: Assignments are made by the previous shift charge RN. Acuity, skill mix, continuity of

8 Frequent safety checks due to fluctuating hemodynamic and/or mental status. DVT prophylaxis. Psych/social interventions. Oxygen requirement monitoring. Continuous IV medication infusions requiring frequent monitoring. I.e. heparin, insulin, vasoactive meds. Cardiac surgery patients may be on pathways, requiring additional education and RN managed physical therapy. Thursday. The Resource Nurse serves to assist with procedures (such as arterial sheath removal and moderate sedation), manages patient education, and assists with ADTs. On days without a Resource RN (Fri- Sun) the charge RN will staff up four additional RN hours for 4+ procedures on day shift or 3+ procedures on night shift. Charge nurse may staff up eight additional RN hours during night shift for 6 or more VAD patients (if at least 4 or more of them are unstable). Day staffing: Staff RN 3-4 patients CNAs 2-1 per shift Night staffing: Staff RN 4 patients CNA 1-0 per shift Depending on patient

census and acuity. RNs taking care of TAVR patients will have a 3 patient assignment only. 9