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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Many hospitals contain both a CCU for critically ill patients and units called either an "intermediate care unit", "progressive care unit", "telemetry floor" or "step down unit" for patients who are not as crtically ill. These units provide a level of care that is intermediate to that of the intensive care unit and that of the general medical floor. These units typically serve patients who require cardiac telemetry such as those with unstable angina.

An increasing number of lower risk STEMI patients are now being initially admitted to an intermediate care unit. This is particularly true of patients undergoing primary angioplasty. Those patients who are stable for the first 12 to 24 hours in the CCU are now being transferred to an intermediate care unit. In addition, patients originally admitted.

Characteristics

Modern intermediate care units are staffed by highly trained individuals who practice evidence based medicine to improve clinical outcomes. Guidelines are often in place to assure access to updated evidence based data regarding the optimal managment of patients. Equipment is available for continuous monitoring of the ECG is available so that arrhythmias are immediately recognized and cardioversion or defibrillation can be performed promptly. A intermediate care unit does not support mechanical ventilation, intraaortic balloon pump counterpulsation, invasive hemodynamic monitoring nor the use of temporary pacemakers.

CCU Staffing and Personnel

Credentials

Requirements regarding the level of certification for nurses varies internationally. In the United States, policies will vary between institutions, but the following are often recommended for nurses staffing both the CCU and an intermediate care unit::

• Certification in critical care nursing (CCRN, Critical Care Registered Nurse) through the American Association of Critical-Care
• Advanced cardiac life support certification (ACLS)

Staffing Ratios

Higher nurse-to-patient ratios have been associated with improved clinical outcomes in the intensive care setting. There is ongoing debate regarding the optimal nurse-to-patient ratio. Some states such as California have attempted to mandate staffing ratios for spcific intensive care areas such as 1:2 in the intesive care unit setting, 1:4 in a telemetry setting, and 1:5 in a telemetry unit. Despite such mandates, variability in staffing ratios remains. Rather than mandating a fixed staffing ratio, it is reasonable to recommend a variable staffing ratio based upon the acuity of a group of patients and the competency of a group of providers.

Management of the Patient on Arrival to the Intermediate Care Unit

Initial efforts on arrival to the intermediate care unit should assure that there is a seamless transition from the emergency room or cardiac catheterization laboratory. Nurses and physicians caring for the patient should assure the following when giving "report" to each other:

1. A complete accounting of all medications administered should be undertaken. While it may be clear what parenteral agents are actively infusing, it may not be clear what oral (e.g. aspirin, clopidogrel, metoprolol) and subcutaneous agents (e.g. unfractioned heparin, enoxaparin) have been administered. Notes can be illegible.
2. The infusion rate of all parenteral agents should be reviewed.
3. The compatability of parenteral agents being infused should be reviewed. (e.g. UFH may cause the precipitation of a fibrinolytic agent such as rPA).
4. The timing of the last dose of all medications should be recorded.
5. The timing of all planned doses of drugs should be recorded.
6. Allergies should be recorded.
7. Contact information for the next of kin and a health proxy should be recorded.
8. Known lab values should be recorded. Lab values that are pending should be noted.
9. The hemodynamic status of the patient must be reviewed.

Standing Orders on Admission to the Intermediate Care Unit

It is reasonable to have a standard set of standing orders for an intermediate care unit. Elements of a set of standing orders might include the following:

• Aspirin 325 mg PO qd
• Dosing of an antithrombin including titration as needed
• Dosing of a beta-blocker.

• Acutely and during the first 24 hours: 5 mg IV metoprolol over one to two minutes, which should be repeated every five minutes for a total initial dose of 15 mg. If this is tolerated, then administer the first dose of 50 mg of PO lopressor 15 minutes after the third IV dose. Repeat this 50 mg dose q 6 hours.
• After the first 24 hours: Metoprolol 50 mg PO every 6 hours. If this dose is tolerated, then administer 200 mg of controlled release oral metoprolol q day

• Analgesic agent
• Stool softener
• Anxiolytic agent
• Daily weight
• Height on admission
• Specify vital signs
• Specify laboratory checks
• Monitor oxygen saturation and administer 2 li per minute in the absence of COPD
• Monitor ECG continuously, specify 12 lead q 8 hours for 24 hours and then daily thereafter
• Bedrest and advancement of activity levels

Electrocardiographic Monitoring in the Intermediate Care Unit

Ongoing monitoring of the electrocardiogram in the intermediate care unit allows for early detection and treatment of arrhythmias. Intermediate care unit nurses and physicians must be competent in the following:

1. Placement of leads appropriate to the infarct location
2. Placement and interpretation of right sided leads
3. Recognition of arrhythmias and conduction disturbances
4. Calculation of the corrected QT interval

Unless the telemetry unit is designed electrically to detect ischemic changes in the ST segment, it should be realized that the ST segments may shift in the absence of ischemia when standard telemetry units are used. 12 lead ECGs are therefore necessary to evaluate the patient for ischemic changes.

In some setting, such as cryptogenic stroke, telemetry during hospitalization may not be adequate and need supplementation by ambulatory monitoring after discharge from the hospital.

Indications

Clinical practice guidelines by the American Heart Association address the use of telemetry.

The Choosing Wisely campaign by the Society of Hospital Medicine included as one of their five recommendations:

• "Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation".

Hemodynamic Monitoring in the Intermediate Care Unit

Unless a patient is hypotenisve and requiring pressors, non-invasive cuff measurements should be sufficient and should be measured at a frequency that matches the acuity of the patient.

2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT)

Class I

"1. It is a useful triage strategy to admit low-risk STEMI patients who have undergone successful PCI directly to the stepdown unit for post-PCI care rather than to the CCU. (Level of Evidence: C) "

"2. STEMI patients originally admitted to the CCU who demonstrate 12 to 24 hours of clinical stability (absence of recurrent ischemia, heart failure, or hemodynamically compromising dysrhythmias)should be transferred to the stepdown unit. (Level of Evidence: C) "

Class IIa

"1. It is reasonable for patients recovering from STEMI who have clinically symptomatic heart failure to be managed on the stepdown unit, provided that facilities for continuous monitoring of pulse oximetry and appropriately skilled nurses are available. (Level of Evidence: C) "

"2. It is reasonable for patients recovering from STEMI who have arrhythmias that are hemodynamically well tolerated (e.g., AF with a controlled ventricular response; paroxysms of nonsustained VT lasting less than 30 seconds) to be managed on the stepdown unit, provided that facilities for continuous monitoring of the ECG, defibrillators, and appropriately skilled nurses are available. (Level of Evidence: C) "

Class IIb

"1. Patients recovering from STEMI who have clinically significant pulmonary disease requiring high-flow supplemental oxygen or noninvasive mask ventilation/bilevel positive airway pressure/continuous positive airway pressure may be considered for care on a stepdown unit provided that facilities for continuous monitoring of pulse oximetry and appropriately skilled nurses with a sufficient nurse:patient ratio are available. (Level of Evidence: C) "

Sources

• The 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction