Hello all! I am a critical care RN with 10 years experience on a 32 bed adult MICU. I've taken all patients including Neuro/Trauma/Surgical but Cardiac has been unfamiliar. I recently moved to a new facility with a high cardiac focus and have become trained to take fresh CABG pts. Our fresh hearts come off of 1:1 status as soon as they are extubated per (I'm assuming) hospital policy. A recent request to our surgeon to keep his pt 1:1 prompted questions of our policy as he was unaware of this staffing policy. Frequently, the second patient we pick up after our CABG is extubated is a new admit. I personally am uncomfortable with a second patient immediately after extubation. I believe the pt to be potentially more unstable once an airway is removed.
What are the guidelines/policies within your facility? I'm asking in hopes to work with our surgeon and administration to develop new standards for the care of our CABG pts. Also, do you have any articles or references for CABG ratios?
In our unit a pt does not have to be extubated to be 2:1. Do to the high acuity of the unit and the number of VAD's,ECMO, transplants and CVVH post ops doing well are usually paired a few hours after surgery depending on what is going on in the unit. In the ideal world it would be great to keep those patients on 1:1 but unfortunately it just doesn't happen. You learn to get comfortable with tight situations very quickly and people either go with the flow, or leave and go to another unit (I don't blame them at all btw).
It seems to be dependent on your facility, level of nursing training, availability of staff physicians and policies.
I am at a large hospital and the only ones are 1-1 are patients on devices (ECMO, VAD, IABP) and high acuity d/t instability. Sometimes they may do 1-1 if they have extra staffing for road trips and end of life patients (to accommodate family and processes). They also try no to give back to back fresh cases (within 2 hours of each other) despite mechanical ventilation status. Its rare but it can happen. It is possible in one day that I can get 2 patients out and get 2 fresh cases before I leave, again this is rare and we compensate by having a great team.
The surgeries we get: valve repairs, aortic aneurysm repairs (ascending, descending w/spinal drains), CABG, congenital defect repairs, myectomies, and combinations of these. 98% of our patients are intubated upon admission and we attempt to extubate ASAP.
I worked in a few HCA facilities and we were always short and it was not uncommon to be doubled up. The goal was to be 1:1 for the first 6 hours as there were serial labs and lots to monitor. We had shifts where you land a heart and maybe get 2 hours before your second CABG comes rolling in. It was not everyday but too often. Usually you have one stable patient then take the next heart. What made it more bearable is the open heart portion of the unit was an open 12 bed unit and it was easy to keep an eye on everyone at once - so if a nurse had a crashing patient you had many hands helping without the need to call anyone.
At my hospital, hearts are 1:1 for the first 6 hours. Hearts are never doubled before this point, and if they have an IABP, they're kept 1:1. Even if the heart technically goes off 1:1 during day shift, they won't typically give you an admit. This is because the hearts usually come back at 11:00 at the earliest and instead of giving you an admit, they just double the night nurse with a patient that's already on the floor.
What is the standard for CABG post op day 1 nursing staff? I feel like open heart trained staff should be required for the first 72 hours.
Like any patient, any nurse assigned to the patient should be competent in caring for that type of patient.
In my experience though there are different types of "open heart trained staff", nurses who are appropriate to care for a POD 2 or 3 patient may not necessarily be appropriate for landing an open heart straight out of the OR.
cticunurse33
9 Posts
In our unit a pt does not have to be extubated to be 2:1. Do to the high acuity of the unit and the number of VAD's,ECMO, transplants and CVVH post ops doing well are usually paired a few hours after surgery depending on what is going on in the unit. In the ideal world it would be great to keep those patients on 1:1 but unfortunately it just doesn't happen. You learn to get comfortable with tight situations very quickly and people either go with the flow, or leave and go to another unit (I don't blame them at all btw).