What is your hospital's policy regarding Rule-Out MI's?

[Ted]

I work in a very small rural hospital. . . and we're getting smaller!!! We're in the process of combining the med/surg unit and the ICU/CCU unit so that it's all basically one unit on the same floor. Modifications are being made so that there will be four dedicated ICU/CCU type rooms with all of the monitoring devices, etc. The hospital is also having (finally!!!) real telemetry devices so that telemetry-type patients can walk untethered and still be monitored. (Currently, the ICU/CCU lacks the tele-packs so that a telemetry patient has to be hooked up to a monitor at all times.) I believe that an additional five or so tele beds will be made available on this combined med/surg/ICU/CCU floor. Total beds will be 15!!! (This is being done in order to qualify to receive special funding which, apparently, will mean more money than what the hospital is already receiving in reimbursements. . . .I don't know. . . . I'm just a staff nurse. . . .)

In actuality, most patients admitted to our happy little unit are telemetry-type patients. They're usually older patients with a new onset of a-fib or had a syncopal or near-syncopal episode etc. Another large population of patients are the "rule-out MI's". They are currently admitted as CCU patients until they either rule-out or remain a CCU patient if they do indeed rule-in.

The question has been raised as to whether "rule-out" patients should be - could be - admitted as telemetry patients until they either rule-in, in which case they would become CCU patients, or rule-out and either remain as telemetry patients for further cardiac-stress testing or go home with something to help their GERD. Actually, my nurse-manager has asked me to seek input from other ICU/CCU nurses who work in similar small-hospital situations and ask, "How do you classify your 'Rule-Out MI' patients when admitted to your hospital?".

O. K. . . . all you small-rural-community hospital type nurses (who may or may not work in the CCU/ICU). . . . I'm asking! :) What is your policy regarding admitting patients with the diagnosis of "Rule Out MI"? Are they considered CCU patients or are they considered telemetry patients?

My personal opinion. . . . I think they should remain catagorized as CCU patients. What if they are admitted as telemetry patients, then rule-in as positive for an MI which would currently make them CCU patients (and are not shipped out to a bigger hospital which does cardiac caths, etc!) and all of the four ICU/CCU beds are full with real ICU/CCU patients?????

Thank you ahead of time for your thoughtful input and suggestions. :)

Regards,

Ted Fiebke

[prn nurse]

Did I change my mind?? I don't see it.

[MollyMo]

Originally posted by willie2001

I also work in a small rural hospital.

We admit R/O MI patients to our Med/Surg floor on telemetry if they are pain free and their first set of cardiac enzymes are normal as well as their EKG. If their status changes, they start to have pain or their enzymes go up or their EKG changes, they will go to ICU or transferred to a larger facility for an angiogram. We will not do Nitro drips on med/surg. We will however do IV amiodorone and IV Cardizem on Med/Surg for atrial fibrillation.

How do you not do NTG on med/surg and take amiodarone or cardizem? Why are you doing any of them on med/surg?

The hospital I work at admits all ROMI as 23 hour observation to either the interventional cardiology unit or to the ER overflow if interventional is full. In the ER they use serial cardiac markers--the idea is if all 3 sets of markers are negative there will be no need for serial enzymes q 8 x 3. But we are finding that the enzymes will be positive even if the markers are negative, so we still do serial enzymes on the unit.

[Ted]

You've given me a lot a information which I will share with my nurse manager . . . . after my two week vacation!

As it stands. . . most rule-out MI's are admitted as CCU patients, although many of them could very well have been telemetry patients. I guess my nurse manager is thinking about the times when some of the "Rule-Out's" could have been admitted as a tele patient. . . especially when the hospital is going to cut down the total med/surg/CCU-ICU beds to 15 in about a year's time. If a stable "Rule-Out" is admitted as a telemetry patient and they take a turn for the worse, they will, of course, need to be appropriately re-designated a CCU patient. But with only 4 beds being set aside for this new hospital redesign, 4 ICU/CCU beds can easily be filled. So . . . . what happens when they're filled and we need a CCU because our "rule-out" tele patient "ruled-in" and for whatever reason is now not stable.

Please excuse me. . . I'm just thinking/writing out loud.

Of course, I'm not sure that this new redesign is a good thing all around. However, it seems like it could potentially be potentially dangerous if the hospital decided that, depending on criteria of course, stable "rule-outs" would automatically be admitted as tele patients. For a hospital that wants to be a total of 15 beds, there doesn't seem to be much room for drastic changes in acuity.

Again, I appreciate your collective wisdom. I will convey this information to our restructuring committee.

Cheers! :)

Ted

[prn nurse]

Here's what usually happens Ted. If you have the 4 CCU beds filled and the tele R/O goes bad, you can generally switch out the stablest CCU pt.

Re-evaluate and re - prioritize....name of the game in ICU.

Or, Someone calls in a nurse to do 1:1 with the patient who is deteriorating.

Or If they are in the same area, a CCU nurse would take over his care in tele.

Most places go with switching them out..... usually you get at least one out of 4 CCU's that's stable.

Sounds like a good plan you all have going.

Are you going to try for the monitor tech position?

[prn nurse]

P.S. CCU is generally pretty quiet once you get the anti-arrhythmics going.... and a little O2 and heparin, etc....

not much action really.

And lucky you...vacationing in this perfect weather.... I am too...in 2 hours !!

Have a wonderful well deserved vacation !!

[New CCU RN]

ok

[CATHYW]

Ted, I was hospitalized in Dept. last year with c/o CP. The CP was relieved by NTG w/no H/A. I was a 23/hr admit to Med-Surg. Dx: CP, R/O MI. I had a tele pack, serial bloods and serial EKGs. The next mroning I had a Stress Echo that revealed I had a less than 10% chance of cardiac probs. If I HAD been cardiac, the ICU was about 6 doors down, rather like your little hospital.

I can't see tying up critical beds for r/o MI's, unless you have several cardinal s/s. The ER folks generally have a good feel for what is real and what isn't.

[deespoohbear]

Ted,

The county hospital I work in also has a 4 bed ICU and a general med/surg/tele/peds/ (dump everything floor, but that is a whole other thread ). Anyway our R/O MI's admissions are based on the pt's condition, past hx, labs, ekgs. NTG gtt goes to ICU, regardless. So does Cardizem gtt. If the patient is stable, pain free, and everything else is looking okay they will usually be admitted to M/S. If the enzymes are elevating, chest pain not relieved with Ntg SL, unstable, they will go to ICU. The main problem we run into is one ER physician can be a real jerk and put pts in ICU who could be on M/S and vice versa. (I work on M/S, but help out in ICU as the 2nd nurse occ). I really think this ER doc does it for kicks and giggles. Sometimes if M/S is really busy and ICU doesn't have any pts, some ER docs will tuck them in there for a few hours until all the testing is done or cardiology clears them for tele.

I believe the other factor here is how comfortable is the med/surg staff with R/O MI's? I am comfortable with them, and will not hesitate to have them transferred to ICU if their condition changes. A couple of the M/S nurses I work with aren't as comfortable with these pts and would rather have them in the unit. Is the med/surg staff ACLS certified? Can they recognize changes in the monitor? I am not the best at reading tele's, but I do know the "biggies." Some of this will probably depend on how comfortable the M/S staff is R/O MI's. Let us know what happens.