ORIENTATION TO THE CARDIAC INTENSIVE CARE UNIT
for Internal Medicine Housestaff
Welcome to the CCU. We have prepared some general information to acquaint you with our unit,
the patient population and the staff. Our goal is to make the CCU rotation a successful and
satisfying learning experience for you, and a comfortable, safe environment for the patients.
The CCU is an 8-bed unit with room # 618-625.
Telephone (617) 632-7600.
Fax (617) 632-7610
Key Contacts:
CCU Medical Director:
CCU Nurse Manager:
CCU Clinical Advisor:
Resource:
Peter Zimetbaum, MD b 32115
Cindy Phelan, MS, RN b 36501
Pam Browall, RN
Anne Settino, RN 7am-7pm M-F
The role of the resource nurse is to manage, direct and provide leadership for unit-based patient care delivery, oversee resource
utilization and the admission, discharge and transfer of all patients. During the 7pm-7am shift and weekends please ask for the
assigned resource nurse if there are bed needs or patient issues.
Clinical Nurse Specialist:
Unit Coordinator:
Case Manager:
Social Worker:
Bed Facilitator:
Donna Williams, MS, RN, CCRN b 93324
Clinical Educators:
Colleen Donahue, RN, CCRN,
Lynn Mackinson BS, RN,
Stacey Smith BS, RN, CCRN
Jeri Willner 7am-3pm
Kameela Coleman 3pm-11pm
Rachelle Chenard b 91336
Tim Williams b 91621
on-call staff, b 92466
There is 24-hour coverage for all pat ient s requiring admission int o t he CCU. Please page t he bed facilit at or
first for
patients requiring a bed in the CCU. This includes transfers from OSH, ED, floor and cardiac/EP catheterization lab
patients. The BIDMC is committed to accepting all cardiology admissions/transfers as a priority.
CareVue Key:
IS Support Service extension 48080
Call if your password has expired
Important points while in the CCU
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Hand Washing: you must use CalStat prior to entering a patient room and upon
leaving, as well as before using a computerCareVue: is the computerized documentation
system that requires a key and password. You will find patients VS, I and O, hemodynamic
numbers and the nursing notes. In the fall of 2007 the Critical Care ICU’s will change this
system over to the IMDsoft or Medivision. This means all documentation will be online,
including progress notes, consent and attending notes.
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Green Medical record: progress notes, ECG, consents, outside medical records.
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Blue Chart: The patient Medical Administration Record, including blood glucose
documentation. Many critical care protocols for sepsis and organ donation, insulin
infusion algorithm, ventilator weaning protocol, guidelines for sedation and analgesia,
neuromuscular blockade, and management of heparin-induced thrombocytopenia
•
King of Hearts Monitor-The CCU Nurse is responsible for answering calls on this
line during the time that the Holter lab is closed; 5pm to 7am. If the patient calls with
symptoms, the nurse takes a very brief history and downloads a rhythm strip. CHECK The
resident on the CCU team along with the RN is then responsible for the evaluation of the
patient to determine if the patient should seek further medical care. The EP fellow on
call should be notified if any patient is advised to go to the Emergency Department.
Strips will be placed with the patients King of Hearts record.
•
FYI-No food or drink is allowed in patient care area. Please no peanuts, staff
member with a peanut allergy
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Communication- Communicate directly with the RN caring for the patient
regarding urgent orders, any change in the plan of care, procedures and call outs.
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Consents/Orders-Every patient will need a Consent for Intensive Care obtained
within the first 24hr. of admission. Every patient that requires restraints needs an order
placed in POE every 24hours. Every patient that requires central access, an order must be
placed in POE for tracking purposes.
CARDIAC CARE UNIT – INTERN ORIENTATION
INTRODUCTION – The CCU is a demanding rotation for interns for several reasons. Patients in the
CCU may generate enormous amounts of data. These data need to be carefully analyzed and
rapidly integrated into a thoughtful, comprehensive plan. In addition, our patients might require
devices, previously unfamiliar to you, such as: intraaortic balloon pumps, mechanical ventilators,
vasoactive medications, and/or invasive monitoring, each associated with protocols,
terminology, and adverse effects. Finally, the rotation introduces many interns to new invasive
procedural skills, each associated with its own frustrations, learning curves, and complications.
Despite these potential frustrations, the CCU is a place where learning and patient care are top
priorities, and most interns find this rotation a valuable and rewarding part of their training.
The high actuity of our patient population requires a proactive, team-based approach to roundthe-clock medical care. Frequently, patient survival depends not only on whether the correct
intervention occurs, but also on how quickly it is implemented. Thus, we depend on constant
vigilance and a collaborative approach, which requires diligent communication among all
physicians on the team, as well as with nurses, respiratory therapists, consultants, primary care
providers, patients, and families. We have developed the following guidelines to clarify your role
during this rotation.
GENERAL EXPECTATIONS – The CCU intern has a well-defined and important role in the CCU. A
few general points to remember:
 The specific responsibilities of the intern in the CCU include:
 Record and report data – this includes data derived from direct examination of the
patient, as well as information from CareVue, bedside monitors, green medical
chart, blue notebook containing the medication list (called the MAR),
electrocardiograms, radiographic studies, microbiology reports, and lab values from
the hospital computer system.
 Write an assessment and plan for each admission – the intern should write an A+P
for each patient admitted while on call, even if the resident has written a complete
note including the history and physical examination.
 Generate and maintain the problem list, which must be reviewed by the resident
and placed in front of the MAR (the blue notebook) at the time of admission. Every
patient in the CCU must have a problem list. The problem list should be reviewed
prior to rounds and updated on a daily basis. The problem list will help you organize
your presentation and notes, and it will also enable the entire team to provide
coordinated care.
 Communicate your ideas on rounds in a clear and succinct manner.
 Write well-organized daily progress notes that outline the plan in detail.
 Obtain the CONSENT FOR INTENSIVE CARE within the first 24hrs, and place in the
patients green record book.
 You will never be criticized for asking for help or for saying you do not know. Please ask
the resident, fellow, nurse, respiratory therapist, or attending if you feel unsure about the
appropriate response to any situation. The nurse manager, resource nurses and the CCU
director are also available to help resolve any problems or conflicts that may arise.
Specifically, you are not expected to:
 Perform unsupervised procedures
 Implement a treatment plan without consultation with your resident, fellow,
and/or attending.
 Lead family meetings regarding the direction of care.
 Make triage decisions about transferring patients into or out of the ICU.
 It is also important to know when to call the attending. We expect the attending to be
called for the following events:
 New admission
CPR of any duration
Defibrillation or Cardioversion
Emergent need for transvenous temporary pacemaker or transcutaneous pacing
Chest pain requiring emergent heart catheterization
Intubation / reintubation
Accidental or patient-initiated extubation
Initiation of nonivasive mechanical ventilation
Initiation of vasopressor therapy or addition of a second vasopressor in a pressordependent patient
 Need for urgent / emergent consultation with other services (especially EP,
pulmonary, surgery, neurosurgery, neurology, GI, or interventional radiology)
 An angry family member, or family request for a meeting with the attending
 Death of a patient on the service (expected or unexpected)
Although you will have “primary” patients (specifically, those whom you admitted on call
and see before work rounds), all patients are the shared responsibility of the entire
team. Please don’t say: “That’s not my patient”. If the admitting team is out of the
hospital and you are on call, you need to know what’s going on. Paying attention on
rounds, and making sure that every patient has an up-to-date problem list, allows this to
happen.
The work-hours rules make sense for a variety of reasons and must be observed. It is
admirable when you want to stay past noon post-call to finish up work you have started,
but it is the responsibility of the entire team to get you out of the hospital on time.
Interns should not arrive before 0700 to pre-round. Post-call interns should be excused
from rounds by 1200 and must be out of the hospital before 1300. Interns are not required
to stay for sign-out rounds on swing days, and should therefore be out of the hospital by
4:00 PM. We need to work together as a team to conform to the work-hours rules, which
are designed to assure quality care for all our patients.
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PRE-ROUNDING – Teaching rounds start at 8:00 AM. Please examine your patients, review the
green and blue charts, update the problem list, and note the most recent labs prior to teaching
rounds. In general, too much time in pre-rounding is spent in gathering CareVue data that will be
out of date by the middle of rounds; the corollary is that too little time is spent processing
information. Use some of your pre-rounding to seek advice from the resident, fellow, nurses, or
therapists.
If you are having trouble pre-rounding between 7:00 and 8:00 AM, please talk to the residents
and see if they are able to help you gather some of the necessary information, or redistribute
patients more equally among interns. The residents may also have suggestions that allow you to
organize your time more effectively. If you are seeing three or more patients, the physical
examination of stable patients may be deferred until work rounds.
WORK ROUNDS – The efficient transfer of information on the rounds is the most important and
difficult job of the intern in the CCU. Presentations need to convey a large amount of
information in an organized and succinct fashion. Please do not read your presentations; it is fine
to have your work-up in hand, but reading the presentation slows rounds. Presenting without
reading means that you need to take time before rounds to think about what you want to say.
Work with your resident and spend a few minutes practicing your presentation. Look over the
problem list to make sure you aren’t missing any problems.
If you are having trouble presenting in this manner, ask the resident or fellow to help you
organize your thoughts prior to rounds; the attending is also available for feedback on how to
approach these presentations. The CCU rotation is a great place to learn and practice this
important skill. This training is essential for you to be an effective intern now, and an even
better resident next year.
It is important that the nurse for each patient be present for rounds. You can check the nursing
assignment board for the nurse caring for the pt next to the patient’s name.
New and established patients are presented in a very similar fashion. A template outlining CCU
presentations is included at the end of this handout.
NEW PATIENTS –Please adhere to the following structure when you present new patients
to the team:
•
Start with the chief complaint, including the specific reason why the patient
requires CCU admission. For example: “Mr. B is a 47 yr old male with new onset chest
pain, found to have anterior ST elevations on the ECG, transferred to the BIDMC from
OSH for PCI, now s/p stent to proximal LAD”.
•
The next step is the history of present illness, which reviews the events
leading up to the patient’s admission to the CCU. This part of the presentation should
be structured in the following fashion, and modified based upon the patient being
admitted from home, a nursing home, a rehab hospital, or the floor.
o
Events leading up to medical evaluation.
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Evaluation by paramedics, physicians, or other nonmedical responders,
including the description of the patient and their surroundings, initial vital signs,
HR/rhythm and events in the field (intubation, defibrillation or cardioversion and
administration of medications).
o
ED course, floor or cath lab prior to transfer, including vital signs,
diagnostic and therapeutic procedures performed, and medications administered.
o
When events that occurred outside of the CCU are poorly documented in
the record, simply present the facts as well as they can be discerned.
o
Do not “editorialize” until you are done presenting the data. In other
words, don’t offer your assessment and plan before you are ready to present it
in its entirety at the end of your presentation.
•
Provide a detailed past medical history. Although care in the CCU is often
directed towards acute problems, we depend on thorough and accurate details of all
aspects of the patient’s past history. You don’t need to take much time to present this
information, but it does require preparation before rounds. Please take the time to
review the available details from the OMR, including old discharge summaries and
outpatient notes. Old paper charts should be obtained from medical records and
outside hospitals to supplement these online sources.
•
Use the same format for presentations that you were taught in medical
school. Please include outpatient medications, allergies, social history, family history,
and a concise review of systems. In addition to the usual aspects of the patient’s social
history (work-related exposures, use of illegal drugs, tobacco and/or alcohol), we care
a great deal about whether there is a family member closely involved in the patient’s
care, since this will help determine who should take part in a family meeting if the
patient is unable to communicate. Try to identify at least one contact person, and
include the phone number in your note.
•
After you have provided the above information, the rest of your presentation
follows the structure outlined below (and on the template provided at the end of this
handout).
ESTABLISHED PATIENTS –Each presentation of the established patients on the service
should begin with a review of the events from the preceding 24-hour period. A cardiac or
respiratory arrest is an event. A consult is an event. Diagnostic and therapeutic
procedures that required the patient to leave the unit (head or chest CT, MRI, lung
biopsy, IR embolization) are events. Any invasive procedures performed in the unit by the
CCU team. Any procedures performed by a consulting service (temporary pacemaker,
bronchoscopy, thoracentesis, endoscopy, chest tube placement, tracheostomy) or results
of TTE, TEE should be mentioned as events.
During this time, we should also hear about specific issues central to the patient’s major
problems. For example, if the patient has sepsis and has been on vasopressors, a brief
comment about their pressor requirement (rising or falling) is appropriate. In contrast, an
increase in the creatinine from 1.0 to 1.3 is not an event; it is a lab value, and should be
mentioned later in the presentation. In general, a new physical finding noted incidentally
during pre-rounds is not an event. However, if the patient has just had a stroke and has
new hemiplegia, you should include this as an event.
ALL PATIENTS – The remainder of the presentation is the same for both new and
established patients:
Flow Sheet – In general, presentations of the flow sheet should be made using the most
recent data recorded on the CareVue system. Report the temperature (current, maximum
or minimum), heart rate, BP, detailed ins-and-outs, and weight (all of the beds have builtin scales). The 24-hour output from drains, including chest tubes and surgical drains,
should be mentioned. Patients with invasive monitors will have additional information to
present, including central venous pressure, cardiac output, and pulmonary capillary
wedge pressure. For patients with continuous oximetry catheters (MUST protocol
patients), mixed venous oxygen saturation, which is recorded on a stand-alone bedside
monitor, should be noted. The patient on the IABP (intra aortic balloon pump) should be
presented as: IABP 1:2
Maps 65-75, good augmentation, systolic unloading is 2-10 points. The ventilator settings
should be presented in detail, including mode of ventilation, respiratory rate, FiO2,
airway pressures, rapid shallow breathing index (RSBI) and arterial blood gas results.
Exam – Limit this part of the presentation to pertinent findings from the exam performed
before rounds. For example: “On exam this morning, I found that the patient’s murmur
was diminished, and her S3 has disappeared.” Any invasive monitoring devices need to be
noted on physical examination – this includes central venous catheters and arterial lines.
It is not necessary (and usually not helpful) to repeat all of the previously noted normal
findings. Let us know if you did not have time to examine the patient during pre-rounds
and we will conduct the exam together during work rounds. Do not assume that the exam
is unchanged from admission, and do not assume that any physical findings you did not
check specifically are normal.
Labs – New diagnostic studies (mainly chest radiographs and electrocardiograms) should
be mentioned here, if they were not described in the events section. Include the chem-7
and CBC results, in addition to any other labs that have changed significantly over the
past 24 hours. In general, we order too many “routine” labs on our patients; please take
some time to consider whether you need to check daily LFTs and coags, if your patient
had normal values initially and is improving clinically. Serum glucose levels, which are
reported via both the lab (chem-7) and CareVue (bedside finger stick) systems, all need to
be reported. Daily ECG’s after 3 days post STEMI are not necessary, only if the patient is
having ongoing ischemia or rhythm issues. Daily CXR to check position of ETT or IABP are
not necessary unless there is a question or they have been repositioned. We also need to
hear about any new microbiology studies, particularly any positive or pending results. The
swing intern’s responsibility should be to load all of the radiological studies onto the
Centricity Online Radiology system for each of the patients, so that the team may looks at
them during rounds.
Meds – These should be read by the nurse directly from the MAR (the blue notebook), not
from the POE system. All the meds on the med sheet need to be mentioned, and should be
checked against the POE list. It is crucial that we know exactly what medications the
patient has received. An order in the computer system is not the same as tablet or
infusion actually given to the patient. Please tell us the drip rates for any continuous IV
meds; for antibiotics, mention how long the medication has been given, and the planned
total course of therapy (i.e., vancomycin day 9 of 14).
Examining patients – After the presentation, the team goes in to see each patient. Some
specific points to keep in mind:
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Greet the patient when you go in the room. Always assume the patient is
aware of your presence and can hear you. An endotracheal tube by itself does not
interfere with cognition; many of our sickest patients are aware of what is happening
around them.
•
Uncover the patient and perform a directed, respectful examination; make
sure the drape is drawn across the door to assure appropriate privacy.
•
Address the patient before you leave the room. Exchange pleasantries even if
the patient is unresponsive or sedated. If the patient or a family member wants to
have an extended conversation, let them know when you will be back to finish the
discussion.
Making a plan – After seeing the patient, you will have a chance to present your
assessment and plan. To prevent being interrupted by the more senior physicians
participating in rounds, you need to spend time before rounds thinking about what you
want to say. Please don’t be offended if your plan undergoes some major revisions. Use
the problem list to organize your presentation. A few suggestions:
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An organ system is not a problem. Respiratory failure is common in our
patient population, but “respiratory” is not a problem. (Also, “musculoskeletal-wise”
is not an English word). For many of these patients “ARDS” or “Pneumonia” or even
“Acute respiratory failure” more accurately describes the clinical situation.
Remember, one system may have many problems; for example, cardiovascular
problems may include CHF, atrial fibrillation, and MI.
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Discuss every problem on the list; update the list as new problems are
identified and other problems resolve. For example: “Acute respiratory failure” should
be changed to “Pneumococcal pneumonia” if the patient has positive blood cultures.
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The “housekeeping” problems at the end of the list (prophylaxis, glucose
control, communication, nutrition, analgesia, sedation, weaning, head-of-bed
elevation, code status, and disposition) need to be reviewed each day. All central
venous catheters and arterial lines (including the number of days they have been
present) must be mentioned explicitly during rounds. This is a shared responsibility of
the entire team. There is increasing recognition that these details are the key to
successfully managing critical illness.
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Orders are to be written during work rounds as the plan is being made. While
in the ICU, there should be NO verbal orders given. All orders need to written in POE.
If there is anything being ordered STAT you must notify the nurse also.
NOTES – Interns write admission notes on each admission. If the resident has documented a full
H+P you need not duplicate all the details, but we expect you to document your own assessment
and plan. Each patient gets a progress note every day. Progress notes should include:
 Current meds (including planned duration of therapy [“day 10 of a 12 day course”] for
antibiotics)
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Important labs
Your physical exam
A problem-by-problem discussion of the plan. Please use the problem list, including the
“housekeeping” details mentioned above, to organize your note.
PROCEDURES – Before the procedure begins make sure that you have the check sheet called
“CENTRAL CATHETER INSERTION OR REPLACEMENT PROCEDURE NOTE” present in the room. This
will be part of the patient record so please make sure this is completed.
All procedures should be performed with maximum attention to sterile technique, including the
use of gowns, gloves, half sheets, masks, eye protection, and chlorhexidine prep. Please take
the time to make sure the established protocols are followed. Iatrogenic infection adds
enormously to the morbidity, mortality, and cost of critical illness, and we need to be vigilant in
our efforts to prevent such infections among our patient population. For this reason, central
venous catheters inserted outside this hospital and those placed without a completed checklist
must be removed. Femoral lines and any line placed in a code situation also need to be
removed once the patient has been stabilized or within 24hrs.
The procedure documentation will be this check sheet. This includes unsuccessful procedures,
such as failed attempts at line placement, paracentesis, or lumbar puncture. Please use the
standard hospital procedure forms for central lines, and follow the same format for all other
procedures (i.e. arterial lines and PA catheters). Please document the specific procedure,
anatomic site, operator, indications, timeout, sterile technique, and any complications. The CCU
fellow or attending (or the overnight intensivist) must be present for all non-emergent
procedures done on the unit.
An order needs to be placed in POE prior to insertion of a central venous line. Any central line
placed between 6:00 AM and 6:00 PM Monday through Friday need to be observed by the PEVA
team (page 31116).
EDUCATION – We place a major emphasis on education in the CCU.
There is a wealth of experience and knowledge from the nursing staff that you can feel
comfortable asking for help. During this rotation Donna Williams, CNS has a wealth of
experience regarding all critical care issues including evidence based practice. Colleen Donahue
RN, who is one of the Clinical Educators, will give you an inservice on IABP’s. Maria Wilkens RN is
an expert in ECG interpretation.
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You are expected to attend the following conferences during your CCU rotation:
Cardiology Clinical Conference
Tuesday 8-9a, Baker 4 Library
Zoll Firm Conference
Wednesday 11a-12p, Baker 4 Library
Cardiology Grand Rounds
Friday 8-9a, Deaconess 315
Every other Friday at 1:00 PM there is a critical care conference in CC250; the entire CCU team
should make every effort to attend. There are also monthly orientation sessions conducted by
the New England Organ Bank to review indications for referral and protocol regarding potential
solid organ donors
Ethics rounds are held the first Monday of every month at 12-1pm for nurses and MD’s. These are
conducted by Lachlan Farrow or someone on the Ethics Service. Please bring a case that
generated ethical concerns or conflict among the team, support staff and / or patients and their
families.
The educational goals of this rotation are more than content-based Please consider the following
learning objectives during your time in the CCU:
Skills:
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Learn how to communicate data clearly and concisely.
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Learn how to organize your presentations and notes.
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Learn to assess and manage very sick patients.
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Master the basics of central line and arterial line insertions.
Attitudes:
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Understand and apply the concept of team care.
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Appreciate the need for constant vigilance and early interventions in critical
care.
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Develop a values-neutral approach to family meetings and end-of-life
discussions.
EVALUATIONS – The attending and fellow are expected to sit down with each intern twice during
the rotation to discuss strengths and weaknesses, and make suggestions. We are all busy, and
this is one responsibility that is easy to neglect. We strongly encourage you to request an
evaluation session with each attending you work with during the rotation. We observe you in a
different way than other attending will over the course of your residency, and we may have
some useful insights. You are expected to evaluate both the CCU fellow and the CCU attending
using the MyResidency website. If there is a problem, and you do not want to speak directly to
the attending, please let Dr. Eli Gelfand know of any fellow issue, and let the unit director Dr.
Peter Zimetbaum know of any attending physician issue. You should feel free to utilize your
Chief Residents, as well.
FINAL POINT – The CCU is an intense experience, not just for you, but also for patients and
families. We make a major effort to provide support for families experiencing this stress. We
pride ourselves on doing a good job, but we are always trying to improve our practice. Caring for
these patients is often stressful, sometimes frustrating, and occasionally terrifying, but it also
should be rewarding. Remember, there is always someone available to help. Never feel that you
are alone in any situation. If you need help, ask the resident, the fellow, the nurse, the
respiratory therapist, or the attending. We do not expect you to know all the answers; we only
ask that you try to do your best.
Enclosed in your packet:
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Please find copies of studies that Critical Care and CCU are a part of. The clinical
investigators would be ever so grateful!
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Articles that pertain to CCU.
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Please go to the website below where there is an article compendium.
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On the home page go to Cardiology Resources Cardiology Fellowship Website Article
Compendium.
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There is a host of articles on various topics. On the Cardiology Fellowship Website there
are other links to clinical cases, ECG tutorials, Cardiac atlases, ACC/AHA website etc. It is
really extensive and well worth checking out!
General CCU Schedule:
7:00-8:00 AM
8:00-9:00AM
8:00-10:30 AM
Noon
1:00 PM
4:00 PM
Pre-round
Cardiac Conferences Tues and Fri
Work rounds
Post-call team leaves
Critical care or pulmonary conference (Fri)
Sign-out rounds (swing resident and on-call teams, with attending or fellow)
General Template for CCU Presentations:
1. One sentence description of the chief complaint
2. History of present illness
a. Events prior to medical care
b. EMS response
c. ED (or floor) course and events leading up to ICU admission
3. Past medical history / ROS
4. Medications
5. Allergies
6. Social history
7. Family history
8. Initial patient assessment on arrival to CCU
9. Overnight events, including diagnostic and therapeutic interventions
10. Current vital signs
11. Results of your physical exam during pre-rounds
12. Labs, microbiology, and other new diagnostic studies
13. Review of “blue book” medications
14. Physical examination by the team in the patient’s room
15. Problem-based plan of care