Problems in evaluating coronary care units: Their responsibilities and their relation to the community

Abstract

As a consequence of our experience in the coronary care unit of the Royal Infirmary of Edinburgh, we have examined certain unresolved problems of intensive coronary care and attempted to appraise the responsibilities and future of coronary care units. While intensive coronary care has now accomplished its initial goal of reducing mortality from serious ventricular arrhythmias and yielded many long term survivors of ventricular fibrillation, it is difficult to judge the full extent of its achievements. This is partly because of striking differences in policy among coronary care units, particularly with regard to admission and discharge of patients, and partly because the lack of comparability between patients in coronary care units and those in general medical wards makes it impossible to contrast the benefits of intensive with conventional care. Since the future development of these units depends on accurate and objective reporting of results, we have proposed a scheme to aid their uniform presentation. Established coronary care units must accept the responsibility of providing training courses for doctors, nurses and technicians who will be concerned with the development of other intensive care areas, and special provisions may be needed to enable them to do so. At the present stage in our knowledge of the cause, prevention and treatment of arrhythmias and of the mechanism of cardiogenic shock or failure, there should be some component of research in most coronary care units, particularly those in major university hospitals, for several years to come. Indeed it is likely that the academic units will become increasingly elaborate and have, for example, continuous on-line computer analysis of arrhythmias and facilities for assisted circulation. Well run service units can be expected to reduce over-all mortality when situated in large general hospitals. Certain minimal requirements for these have been described; the chief is adequately trained medical and nursing staff. The widespread establishment of intensive coronary care areas is unlikely to be accomplished without depletion of doctors and nurses from other medical services. Experience from existing units is not sufficiently advanced to justify their development in every busy general hospital. Although this will restrict temporarily application of the most up-to-date treatment, it is hoped that knowledge now being accumulated will soon lead to selective application of intensive coronary care to those most vulnerable.