Coronary care unit
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Overview
A coronary care unit (CCU) is an area of a hospital specialized in the care of patients who are critically ill with heart disease. The CCU is a subset or subtype of intensive care unit (ICU) care. The role of the coronary care unit (CCU) varies tremendously between hospital centers. In small rural centers, any patient who is being “ruled out” for a myocardial infarction (MI) may be placed in a CCU. In contrast, in large urban teaching hospitals, only those patients requiring invasive hemodynamic monitoring with a pulmonary artery catheter, mechanical ventilation, and intraaortic balloon pump (IABP) counterpulsation may be placed in the CCU. 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. In those hopsitals who provide cardiothoracic surgery services, there is often a coronary care unit dedicated to the management of patients following coronary artery bypss grafting (CABG), aortic valve surgery or other thoracic surgery.
History of the CCU
Coronary care units developed in the 1960s when it became clear that close monitoring by specially trained staff, cardiopulmonary resuscitation and medical measures could reduce the mortality from complications of cardiovascular disease. The first description of a CCU was given in 1961 to the British Thoracic Society, and early CCUs were located in Sydney, Kansas and Philadelphia. Studies published in 1967 revealed that those observed in a coronary care setting had consistently better outcomes (Mehta & Khan 2002).[1]
Characteristics
The main feature of coronary care is the availability of telemetry or the continuous monitoring of the cardiac rhythm by electrocardiography. This allows early intervention with medication, cardioversion or defibrillation, improving the prognosis. As arrhythmias are relatively common in this group, patients with myocardial infarction or unstable angina are routinely admitted to the coronary care unit. For other indications, such as atrial fibrillation, a specific indication is generally necessary, while for others, such as heart block, coronary care unit admission is standard.
Management of the Patient on Arrival to the CCU
The arrival in the CCU marks a critical point in the transition of a patient's care. The focus of initial efforts should be to assure that the transition from the emergency room or cardiac catheterization laboratory is seamless. Nurses caring for the patient should assure the following when giving "report" to each other:
- 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.
- The infusion rate of all parenteral agents should be reviewed.
- The compatability of parenteral agents being infused should be reviewed. (e.g. UFH may cause the precipitation of a fibrinolytic agent such as rPA).
- The timing of the last dose of all medications should be recorded.
- The timing of all planned doses of drugs should be recorded.
- Allergies should be recorded
- Contact information for the next of kin and a health proxy should be recorded.
- Know lab values should be recorded. Lab values that are pending should be noted.
ACC / AHA Guidelines (Do Not Edit)
Class I
1. STEMI patients should be admitted to a quiet and comfortable environment that provides for continuous monitoring of the ECG and pulse oximetry and has ready access to facilities for hemodynamic monitoring and defibrillation. (Level of Evidence: C)
2. The patient’s medication regimen should be reviewed to confirm the administration of aspirin and betablockers in an adequate dose to control heart rate and to assess the need for intravenous nitroglycerin for control of angina, hypertension, or heart failure. (Level of Evidence: A)
3. The ongoing need for supplemental oxygen should be assessed by monitoring arterial oxygen saturation. When stable for 6 hours, the patient should be reassessed for oxygen need (i.e., O2 saturation of less than 90%), and discontinuation of supplemental oxygen should be considered. (Level of Evidence: C)
4. Nursing care should be provided by individuals certified in critical care, with staffing based on the specific needs of patients and provider competencies, as well as organizational priorities. (Level of Evidence: C)
5. Care of STEMI patients in the coronary care unit (CCU) should be structured around protocols derived from practice guidelines. (Level of Evidence: C)
6. Electrocardiographic monitoring leads should be based on the location and rhythm to optimize detection of ST deviation, axis shift, conduction defects, and dysrhythmias. (Level of Evidence: B)
Class III
It is not an effective use of the CCU environment to admit terminally ill, “do not resuscitate” patients with STEMI, because clinical and comfort needs can be provided outside of a critical care environment. (Level of Evidence: C)
Reference