Cardiac Step-down Unit Research Articles

Stepping out: Education for cardiac recovery

ABSTRACTThis paper reports on the conduct of study that investigated the experience of nurses working in a Cardiac Step Down Unit (CSDU). The study was undertaken in order to identify factors that inhibit the smooth running of the unit and impact upon patient care.Case study design was used to explore practices in the CSDU. Data collection strategies included focus groups, semi structured interviews, surveys, self-report, and observation of nursing activity. The case study approach enabled generation of data sets that illuminate the context, culture and working environment of the unit. It was found that the nursing care provided in the unit focussed on the provision of technology oriented rather than patient oriented care and that nurses experienced lack of role clarity about the care they provided. A number of recommendations that emerged from the study have since been implemented in practice and the effect of these changes are being evaluated in a follow up study.

Waiting together: translating the principles of therapeutic relationships one step further.

Inconsistent nursing practices created nurse-patient boundary issues on a cardiac step-down unit related to confidentiality, limit setting, and professionalism with patients and families awaiting organ transplantation. A staff work group designed and implemented a plan to translate the principles of therapeutic relationships into daily practice. A work plan developed for nursing staff outlined concrete solutions and resources available within the hospital. This framework can be used to empower staff in the ongoing effort to manage relationships with chronically ill patients and their families.

To have and have not: Health and health care disparities in chronic kidney disease

A 50-year-old African American man came to the emergency room complaining of substernal chest discomfort over the past 2 months, as well as anorexia, general malaise, and decreased urinary frequency over the past 2 weeks. The patient stated that his chest pain lasted 2 to 3 minutes; did not radiate to the neck, jaw, or shoulder; was precipitated by lifting heavy objects; and did not occur at rest. He admitted to mild shortness of breath when walking up the stairs at home. He noted that for 2 weeks, he had been feeling exhausted and had had poor appetite, weight loss, and less frequent urination than usual. The patient had last seen a physician 4 years ago at an urgent care facility for a pilonidal cyst abscess. Five years prior to that, he had been told by a primary care physician that he had hypertension. He was treated with an unknown medication and, after a follow-up visit, was told that his blood pressure was normal. He has no other known history of cardiovascular or renal disease. He takes no medications. He lost his job as a cook and the health insurance that the job provided; he now says that he is unable to continue seeing the physician. He completed high school, is married, and works as a taxi driver as well as at a local farmers market on weekends. His father had hypertension and died suddenly at age 55. His mother is 71 and has diabetes. He has one older brother who

Keep Pace With Step-Down Care

High-Performance Care Teams The PCU care delivery team comprises a mixed level of caregivers. PCU nurse managers vary in background and expertise from critical to general care. Staff nurses may often be graduates with minimal experience. Licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) can efficiently administer medications. Under nurse supervision, LPNs also can provide direct care, give treatments, and make observations, but not clinically assess patients. Unlicensed assistive personnel (UAPs) provide support services including direct care, technical procedures (phlebotomy, ECG, monitor set-up, and surveillance), and equipment and environmental maintenance. These team members also work under RN supervision. Because of high acuity and changing patient conditions, it’s imperative to develop a highperformance team with a clear communication structure and appropriate delegation. RNs with minimal clinical experience may be challenged to learn assessment skills in addition to supervisory skills for LPNs/LVNs and UAPs. Unit leaders, such as nurse managers or advanced Fifty-year-old Marvin Smith, an African American male with no significant history of heart disease, presented to the ED with 6/10 chest pain and diaphoresis. His heart monitor showed normal sinus rhythm, and ECG showed ST segment depression in the anterior leads. His troponin was positive, indicating an acute non-ST-segment elevation myocardial infarction (MI). Five to 15 years ago, the ED nurse manager would have assigned Smith to a CCU bed. Today, as advanced technology supports higher-acuity stable patients in lessintensive environments, managers have other options. Since Smith is hemodynamically stable, he’s more likely to receive ongoing monitoring and therapy on the cardiac stepdown unit. Progressive care units (PCUs)— also called step-down, telemetry, intermediate care, and transitional care units—continue to grow in number as the patient acuity gap between critical care and medical/surgical care narrows. Optimally, patients should be transferred to where they can get the best care, without limiting their placement by traditional unit boundaries. Thus, patients’ care needs define acute and critical care, not the hospital’s geography. Patients admitted to PCUs span a range of diagnoses and care demands. Typically, they need highfrequency monitoring interventions and are at risk for rapid status ProgressiveCare

Marginal cost of liberating ventilator-dependent patients after cardiac surgery in a stepdown unit

Background. With the recent changes in Medicare reimbursement for ventilator-dependent patients at skilled nursing facilities, hospitals may, by necessity, be required to liberate these patients from mechanical ventilation before discharge. This study sought to determine the marginal cost of liberating ventilator-dependent patients in a cardiac stepdown unit. Methods. By retrospective analysis, the complete billing records of all 15 ventilator-dependent patients were obtained and abstracted for each item used. The drug or supply acquisition cost and direct variable cost of other items and labor were used to compute the daily and total marginal cost for each patient. Results. Of 15 patients, 13 were discharged alive and liberated from mechanical ventilation. Length of stay was 28 ± 23 days. Average per diem cost was $438.77 ± 152.34. Costs were significantly higher in patients who required hemodialysis: $555.31 ± 491.04 versus $380.54 ± 272.25 ( p < 0.01). Conclusions. Ventilator-dependent patients can be inexpensively liberated from mechanical ventilation in a stepdown unit.

Cost-effectiveness of amiodarone for prophylaxis of atrial fibrillation in coronary artery bypass surgery.

The cost-effectiveness of amiodarone prophylaxis of atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) was determined. A decision analysis using current hospital data and values from the literature was conducted. Under the base-case scenario, CABG patients received usual care (no prophylaxis) or 2 g of oral amiodarone hydrochloride over one to three days before surgery and 400 mg daily for seven days after surgery. Costs of hospitalization in the intensive care unit (ICU) and the cardiac step-down unit (SDU), cardioversion costs, electrocardiogram costs, drug costs, nursing administration charges, and pharmacy i.v. admixture charges were included. A sensitivity analysis using a Monte Carlo simulation and a one-way sensitivity analysis were performed. The mean cost per AF event avoided was lower in the amiodarone group ($15,750, 95% confidence interval [CI]: $15,591-$15,999) than the control group ($17,426,95% CI: $17,252-$17,600). A majority of the cost difference was due to the cost of hospitalization for patients without AF, the frequency of AF, and the cost of hospitalization in the SDU for patients with AF. For patients treated with amiodarone who did not develop AF, the cost difference was sensitive to changes in the cost of hospitalization and the efficacy of amiodarone. For patients who did develop AF, the cost difference was robust. Prophylaxis of AF with amiodarone in CABG patients was more cost-effective than usual care in the short term from a hospital perspective; the results were sensitive to changes in the cost of hospitalization of patients who did not develop AF and the efficacy of amiodarone.

Hepatitis C

Hepatitis C virus infection is responsible for significant morbidity and mortality worldwide. Advances in detection and monitoring of hepatitis C virus infection, as well as treatment protocols, have contributed to the medical focus on this high profile disease. Presence of risk factors should increase the clinicians index of suspicion for this symptomatically nonspecific disease.

Polymicrobial gram-negative bacteremia associated with saline solution flush used with a needleless intravenous system

Background: During a 2-week period, seven cases of nosocomial polymicrobial gram-negative rod bacteremia occurred on a 39-bed medical and cardiac step-down unit. Combinations of Enterobacter cloacae (seven isolates), Klebsiella pneumoniae (five isolates), and Citrobacter freundii (two isolates) were isolated from blood cultures. Methods: Concurrent and retrospective chart reviews were used to look for further cases and common exposures. Epidemiologic methods were used to refine determination of common exposure. Restriction enzyme DNA analysis was performed on the isolates. Results: Concurrent and retrospective chart reviews revealed four additional possible cases during the same period. All case patients were exposed, through peripheral saline solution locks or central venous catheters, to saline solution “flush” from a central 0.9% saline solution bag and a needleless dispensing pin. Epidemiologic methods implicated probable extrinsic contamination of a single bag and pin used during a 24- 48-hour period (Fisher's Exact Test, p < 0.002). There were no other common exposures. Restriction enzyme DNA analysis of the isolates further supported a common source for the outbreak. Conclusions: The introduction of needleless intravascular systems has been embraced for employee protection. Our report is the first to raise the question of patient safety with such systems. This outbreak highlights the inherent risks in rapid introduction of new technologies and points out the delicate balance among patient health, employee safety, and cost containment.

Inhalation Injury: Carbon Monoxide Poisoning

JANICE BRANDEBURG, R.N., M.N.ED., has worked in various critical care settings, including coronary care and a cardiac stepdown unit. Currently, Ms. Brandeburg is an instructor at the University of Pittsburgh School of Nursing in Pennsylvania. The author wishes to recognize Patricia Bohachik, R.N., clinical assistant professor, for her assistance in preparing this article. the victim of carbon monoxide poisoning. Since symptoms resemble those of respiratory, cardiac, or neurological insult, the diagnosis may not be immediately evident from the clinical picture alone. Suspicion of carbon monoxide poisoning should be aroused when he patient's history reveals an association between a source of carbon