umcRN 20,037 Views
Joined: Nov 28, '10;
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We teach our new grads to not get too hung up on the cardiac defects during the first weeks of orientation. Better to get your "normal" cardiac anatomy down and focus on getting solid assessment, knowing the normal pediatric vitals and charting skills. So many kids may have the "same" defect but have very different hearts, with time the defects come to be easily remembered but there will always be a kid that comes along and trips up even the most experienced nurses (and doctors!).
Our unit was recently built and opened a little over 3 years ago.
We have booms and 99% of the time I love them. The only part I do not like is that only one boom has the necessary oxygen/medical air ports for vents and usually the other boom is reserved for the built in IV poles and monitors so if a parent wants to hold an intubated patient you have to transfer IV pumps onto the transport pole so everything can reach (not always if it's a newborn in a warmer but if its an older baby in a bed/crib it can be tricky). Otherwise all the ports/suction/O2 is always pretty easily accessible.
IV poles are included on the boom and we use transport poles for roadtrips, personally I prefer this and we are the only unit in the hospital (including picu/nicu) to have the IV poles set up this way. I think it looks neater...
We have large patient rooms and the booms are set up probably 2/3rd's into the room, the back 1/3rd is reserved for family (couch/rocker/tv/storage/bathroom). The rest of the room is patient, the beds face out with the boom on either side. This does mean for toddlers and older children who are more awake they cannot see their parents unless there is room for the parents to move the rocker next to the bed. On the other hand for more stable/long term kiddos (vads/kids awaiting transplant) we can actually swing the booms towards one wall so the pt has their parents and window on one side and the door to the unit on the other.. It creates more of a "bedroom" feel for some of our kids who can't go to the floor for whatever reason but are stable enough and don't need to be facing out of the unit all the time (also makes for easier movement around the room for family).
Another thing about booms is that they and all the things they hold can be moved pretty easily to accomodate for more stuff, need room for a vent? no problem, need to add an ecmo machine? just shift everything a foot or so to the left, dialysis? go right ahead, it can get crowded with all that stuff but the booms I think are more accomodating to relocating things than a headboard would be, they also move far enough back into the room that we could take over the parent space if necessary as well as far enough forward that if you wanted to face the bed the other way (towards the back of the room) you can and everything still works. OH and portable head CT's (we do a lot of those on our post arrest ecmo kids). The CT scanner can get as far into the room as possible then as we move the patient onto the scanner we can slowly inch the booms/monitors/iv's/suction etc up as we move the patient, then slowly move everything back when we're done and we almost never have to disconnect anything.
It's hard to explain but our booms move in three directions on three different "joints" if you will. You can move one part or all three so they are really customizable to the patient and their needs
they look something like this:
That probably makes no sense but at each area where the lines touch they can be moved almost 360
One thing I definitely wish we had more of is contained patient storage. Right now each patient has a larger countertop with a computer access (rarely used unless emergent situation/pt on ecmo and ecmo tech needs own space) and a small (like 1.5ft x 1ft) counter with a computer which is the one the nurse usually uses. We have cabinets for linen but otherwise supplies typically line the larger counter out in the open things like diapers, bath supplies, trach/wound care, formula etc all stacked into bath basins). For longer term kids it can look cluttered and messy, we would prefer closed cabinets for this (sometimes we use the parent ones if they don't have stuff in them).
Anyways I prefer the booms, I used to work in the NICU and we have headboards there which I didn't like as much and definitely don't think I'd like that if I had a big kid in a bed, the PICU sort of uses a combined headboard/boom system, their booms don't have IV poles so they need transport poles for all their kids and if you're intubating, someone has to jump over lines/monitors to get between the headboard and head of the bed to intubate opposed to in our unit the head of the bed is usually easily accessible.
We don't have a vent unit so all our long term kids (who usually are trached/vented) stay with us. We just celebrated two first birthday's back to back actually.
Now assessments and monitoring are pt and acuity dependent. If the kid is stable and working on transitioning home then no, usually a doc will write an order for q4 blood pressures, assessments etc. but if that same kiddo comes down with RSV carried in on a family member and gets really sick then standard ICU monitoring will apply. All depends on the acuity of a pt.
Typically though all our kiddos only get hourly vitals unless very unstable, so a kid going to the floor within the next day or two will still get q1 vitals but most people wouldn't wake a stable sleeping toddler in the middle of the night to look at pupils, common sense!
I made the switch from NICU to CICU for several reasons. One; my original "5 year plan" was (like many new grads) to get my two years experience and move on. I am not from the state where I work and I always wanted to travel then move home. NICU was not my first choice but it was my first and only offer and I wanted to work in a large children's hospital so i took it. I loved it but the long stretches of time not having a "sick" kid really dragged me down, there's only so many times I can encourage a pokey preemie to eat and the PPHN/CDH/ECMO and other more interesting surgical kids were just fewer and far between. I also had some personal issues with some of the docs (work related and mostly all boiling down to one patient whom the docs refused to listen to many nursing concerns, not just mine, until it was too late). I got ready to go traveling but figured while I was in such a great children's hospital I should get a little more experience and try another unit to make myself more marketable. PICU was out for me, I'm just not interested in it and the varying cardiac anatomy was always interesting to me, especially since every so often we would get a cardiac baby in the nicu and have to transfer it out once we figured it out.
Shortly after starting in the CICU I got sick and was out of work for a few months. Once I went back it was really more of a necessity to stay in order to keep my great health insurance and benefits (luckily I did since I got sick again a year and a half later and doing that on travelers health insurance would have been hard). I'm now going on almost 4 years in the CICU (total of almost 6 at my hospital) and I am happy. I love the intensity of the CICU and am soon taking the class to sit on the ecmo pump side (take over the care of the pump not the patient), I am happy in my unit, I have great coworkers and the patients keep my on my toes. I have found love in this state (for now though I do hope it lasts) and while I never got around to travelling I am ok with it right now. In two weeks I will be going on a cardiac surgery mission trip and couldn't be more excited, I love these heart kids.
I'm sorry that was the really long winded answer to "why did you leave the nicu" but it's just sort of how my life happened.
Also as far as new grads in the ICU all of the ICUs at my hospital have new grad programs (I was one in the nicu) and I think with appropriate training, support, classes and flexibility with orientation length that new grads can do very well in any ICU setting. We have had new grads that didn't do well for whatever reason and in those instances (in both units I worked in) the educators worked hard to find them a more suitable unit within our hospital if possible.
Whichever unit you choose will give you a solid ground for icu experience and make the transition to pretty much any unit more feasible than having no icu experience at all. Let us know which you choose and good luck!
I have done both and prefer CICU which is where I work now. While there is a MAJOR focus on the heart you also have to remember that the heart effects every organ system, and many kids with congenital heart defects may have a syndrome of defects which affects multiple organ systems. We have kids with kidney, respiratory, liver, bowel, neuro, endocrine, oncology issues and hosts of others. Just an example I had two patients today, one is a premature neonate with a prenatally diagnosed congenital heart disease, now that the baby is out we actually don't think there is a heart defect at all but a brain MRI showed severe abnormalities. The parents are now facing decisions related to quality of life and palliative care - completely unrelated to a heart issue. The other kiddo is a few months old with a corrected complex heart defect, unfortunately this patient has a host of complications and a syndrome. Active issues aren't even related to the heart but to inability to wean from the vent (trach dependent), inability to advance feeds, dialysis dependence and new seizures - none of those things are cardiac but are all issues she has and that we deal with in the cardiac ICU.
Some kids are born with their problems and others acquire them later in life, we'll get older kids who end up with post chemotherapy induced cardiomyopathy and other diagnosis that can turn up later. Yes most of the patients are babies but we get all ages, in one day you can be taking care of a two day old and a 56 year old (yes I had that day) at the same time.
Generally speaking I think the patients in the CICU are sicker but it's because they have such little reserve to begin with. I worked in the NICU (Level IV) for two years and I will tell anyone that the babies up there can be sick as snot, especially the term PPHN/CDH kids and the preemies who get NEC and spiral down fast however looking at the units as a whole the cardiac kids are much less trustworthy. My first cardiac code was a three year old who spent the morning bouncing on his bed watching mickey mouse and waiting for a bed on the floor to open up. One moment he was fine next we were coding him, cracking his chest and putting him on ecmo. Sadly he didn't survive. Their hearts are so tenuious, one point drop in a base deficit or a half point rise in a potassium level can completely knock them off the edge and into a deadly spiral. Many, MANY of the babies have their chests left open after surgery so consider that too, is that something you feel like you'll be able to handle? Literally watching your patients heart beating with the possibility of needing to use three fingers to do chest compressions on it?
I don't think you can say the units are similar at all personally. I think the transition was easy enough though there were a few things I struggled with initially but I think any ICU to ICU transition shouldn't be all that hard, so long as you know how to code a patient technically you should be safe in any of them but to say they are similar I don't think that's true.
I work in a peds CICU but also float to the picu and nicu (and used to work there). No where in my hospital are parents required to stay, even on the floors where nurses have much less visibility of their patients. At my hospital kids can stay in the ICU for weeks to months and there's no way parents can afford to stay 24/7, they have to work and take care of other children, we even encourage the parents of our post ops to go home and get some real sleep the nights after the kiddos have their surgeries. There are VERY few children who could try to get out of bed and if they are they're either headed out to the floor or in a caged/covered crib. If they're really a risk to themselves (pulling lines/tubes etc) then they buy themselves restraints and/or in severe cases a one to one sitter.
same code cart used throughout the hospital (children's hospital). Top drawer has meds, each subsequent drawer is organized by weight with each weight being a different color drawer, I'm not sure the exacts but I believe first drawer is 0.5kg-2kg, then 3kg-5kg, 5-10, 10-25...etc. We keep intubation trays between every room that has all the various ett sizes and as far as access goes every patient has a bedside cart with just about every supply you could need (private rooms). There is a defibrillator and pads on top of the cart
We don't transfer out often, I've seen a few instances:
1. chronic ex preemie with pulmonary hypertension being followed by the PH docs in house, they will often transfer to the cardiac icu somewhere around their first birthday, especially if they get a cath to measure pressures or do any intervention (asd closure)
2. older stable gut babies (usually bad gastroschesis) they might go to the intestinal rehab floor to work on feeds and transitioning home on tpn
That's all i've seen. 56 bed level 3c, *not* a delivery hospital which also might make a difference
There isn't much I would consider "safe" right around WHC, as others have said most people commute
If only the amount of frustration caused to nurse got her higher on the transplant list...
We're going on four months...O negative...
Our VAD kids stay with us in the CICU, we won't send them to the stepdown so they are at most a 2:1 assignment. As far as dressing changes our current kids don't require sedation although if the risk is there that the child will infect the insertion sites that would have to be taken into consideration. Our policy is to do any VAD, central, or art dressing with 2 RNs so one does the dressing change while the other assists keeping the child calm or holding them still.
Well our hospital will definitely not be sending them to the floor anytime soon...years maybe, our "stepdown" is a bit of a joke. (" oh we have to wean your milrinone by 0.2? Back to icu for you, home bipap at night? Nope sorry icu for you too). And parents are definitely not doing dressing changes. I think people are a little scarred because our very first Berlin had a massive wound that never fully healed until after transplant so dressing changes are a huge to do niow. At least this kid has no breakdown or wound issues anymore but she freaks out so Much that we give her a little versed which helps a lot...we tried with out and it was a disaster so our vad coordinator nixed that. We also require two vad nurses just to walk around the unit. Parents are not taught anything abourt the machine except what to do if its alarming because the cannula is kinked (all the freakin time w this kid who somehow ended up with two different catheter sizes and lengths, the aortic one kinks all the time if she is sitting and leans forward too much).
Interesting to learn what I hope our future can be like. For now though we are stuck with them (and our states tax payers are left footing the multi billion dollar bill for the extended icu stay in the patients who lack insurance). We do have our first heart ware right now whose getting ready to go home (didn't go to the step down either) but still required two vad RNs for all travel, hall walks etc. Total overkill especially if you're walking around IN the unit...one would hope that if the kid went down for so!e reason SOMEONE in our 26 bed unit would come help
Hello all! My units been doing Berlins only for about a year now and our previous patients have all been babies. Our current patient is two. Our unit does not send vads to step down and this pt is a total floor status kid. No iv meds, ng feeds,stable and was previously healthy and just wants to run and be a toddler. Thing is she's paired now because she's stable and while her mom never leaves and is pretty god about entertaining her there are just some days when she's in her room screaming because she's bored and we can't let her out of the stroller because she will just run off. Our child life is a joke, we can't get volunteers, pt/ot doesn't come for long or on weekends and if we're lucky we can get her out for a walk or two I the hall. Usednto take her outside but with her being paired and the recent spike in our acuity we can't scrounge up two vad trained RNs (per our policy) to get her out. What do you with these kids all day? Mom needs breaks too sometimes, she doesn't leave the hospital but showers and leaves to eat and kiddo just sits in her room screeching for attention if mom is gone. She's pretty good with her toys but it gets to a point I just feel bad that we have to confine her to the stroller and her room all day.
Also as a side question of interest, what do you do for dressing changes in this ave group? Sedation/no sedation? Just curious.
Thanks for the insight, we're still learning with these kids but so far our success rate has been good.
We use regular crrt (as in the same machine the picu uses) in our cardiac icu neonates all the time with or without ecmo. Smallest i've seen was 3kg. I'll have to read that article at some point
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