Multispecialty SICU - how long did you wait before orienting to CABG?

[CNL2B]

My SICU is pretty small - 8 beds - and we take all specialties but we are pretty high volume CV surgery (I would say about 50%.) We do 1-2 CABGs and/or valves a day. Our current practice is to start putting the new orientees with open hearts right off orientation. They get two weeks or 6/12 hour shifts with a preceptor with only open heart patients in their last phase of orientation -- this is after they have oriented to everything else. We then expect them to go ahead and take a CABG independently, regardless of what their prior clinical experience was.

Is this reasonable or safe? We do try to look out for the new staff, but with 8 beds and only 5 nurses, you can imagine that often, there just aren't a lot of bodies around to resource a new nurse that is supposed to be functioning independently if something comes up suddenly -- and it often does following OHS. The last place I worked was a multispecialty ICU (medical and surgical) and had a much lower volume of CV surgery patients, and we were not allowed to orient to open hearts until we had been on the unit a solid year. I know that CVICUs obviously have all their nurses take fresh CABGs right away but I think their orientation is a lot more extensive.

Any thoughts on what is appropriate or standard for this?

[meandragonbrett]

All of our nurses are expected to be able to take care of all of our patients after the end of their orientation regardless of your background and experience. Mixed-specialty SICU that includes trauma, general surgery, ENT/Plastics, vascular, multi-visceral transplant and thoracic transplant and CV. High acuity high volume ICU. We are sink or swim when you get out of orientation.

[suanna]

My unit isn't a open SICU, we do post-CABG and post-vascular. Orientation for a new Critical Care experienced nurse is 8-12weeks (3 12hr shifts/wk) 80% of the orientation is with fresh post-op CABG patients. Even after comming off orientation newer nurses do not take IABP (unless they have extensive prior experience) for 6mos. Without critical care background a nuerse can spend as much as 16weeks on orientation. I think your orientation is a bit light for a post open heart unit, but it depends on the level of autonomy your docs expect of you. Is the RN making the weaning and extubation decisions? Are you titrating multiple hemodynamic agents based on your critical thinking skills?, Do you have resident coverage to the unit? The RN is ultimately responsible for the smooth recovery of the patient in the unit, but if your support staff (resp. therapy, resident physicians...) are taking a lot of the responsibilities, I can see the orientation you described as being OKish- not good, but doable with lower acuity patients.

[fiveofpeep]

my SICU has the nurses work for at least 6months to a year before training for OHS.

I think it is definitely safer this way because the initial orientation is only 3 months and includes didactic and you need to develop some cajones to deal with all that spaghetti and cardiac surgeons

[CNL2B]

My unit isn't a open SICU, we do post-CABG and post-vascular. Orientation for a new Critical Care experienced nurse is 8-12weeks (3 12hr shifts/wk) 80% of the orientation is with fresh post-op CABG patients. Even after comming off orientation newer nurses do not take IABP (unless they have extensive prior experience) for 6mos. Without critical care background a nuerse can spend as much as 16weeks on orientation. I think your orientation is a bit light for a post open heart unit, but it depends on the level of autonomy your docs expect of you. Is the RN making the weaning and extubation decisions? Are you titrating multiple hemodynamic agents based on your critical thinking skills?, Do you have resident coverage to the unit? The RN is ultimately responsible for the smooth recovery of the patient in the unit, but if your support staff (resp. therapy, resident physicians...) are taking a lot of the responsibilities, I can see the orientation you described as being OKish- not good, but doable with lower acuity patients.

Our nurses get about 2-3 months on the unit as well but they only do about two weeks of OHS at the end. This isn't nearly enough for someone without a lot of other ICU experience including lots of Swans/gtts etc. to feel comfortable. I think our orientation is a little light on OHS too and I think at some point I might take on trying to change that. I think the 6 months to 1 year guideline that fiveofpeep mentioned is more reasonable considering what everyone has said and that we still have lots of patients that aren't fresh open hearts.

We have plenty of autonomy. We do all the weaning/extubation in conjunction with the RTs (but we pretty much tell them what to do. We also have a protocol we refer to for this), we do all our own titrations (is there any other way?) We do have resident coverage but they do not sit there holding your hand telling you what to do. You call them if there is a problem or you need orders for something (and you better know what you want, because they sure as hell don't, unless you call the fellow -- but he's probably already at home so we usually don't bother them unless the patient needs to be re-opped.)

Would like other responses too if anyone else out there cares to share.

[tri-rn]

I'm also in a multi-specialty ICU (combined MICU/SICU) that gets roughly 1 OHS pt each weekday, sometimes 2. The batch of new nurses that finished orientation about 6 months ahead of me did fresh CABGs during orientation and there was no waiting period. Our orientation program changed dramatically just as I was coming off orientation. Now there's an OHS class followed by taking several fresh OHS pts with a preceptor (not sure how many). As far as I know there is no formally defined "waiting period" but I came off orientation about a year and a half ago and I won't get the class until this fall. However, there are other reasons for the long wait. I can take them post-op day one, although if they are still vented and on multiple pressors I prefer to wait for the class.