Opening a new heart program

joeyzstj, LPN · Aug 19, 2008

No, and there is a VERY good chance it IS going to be a disaster. The people recovering hearts need to know how to deal with post-op hearts and valves. This is a huge chance of error that requires advanced skill and quick decision making. Often, hearts require multiple drips and different ventilator strategies. Part of national STS data which compares your hospital to other hospitals will review your ventilator weaning times, pneumonia rates, extended ventilator rates of intubation and such data. This can effect reimbursement for you hospital, so it is very important that not only the RN but the Respiratory Therapist be familiar with Fast Track weaning of a post op heart. In the last two days we have had a post MVR/ACB who had a massive PE code and die, and a simple off pump ACB who crash and was a near code, so it happens more often then you would assume.

jbp0529 · Aug 20, 2008

I agree with the prev poster: this sounds like the potential for a hot mess...not because you and your staff aren't "capable"...but bc of lack of training. An 8 hour class? And a reference person to stick around for the first few cases? Thats it? In my opinion, its going to be hard, if not impossible, to adequately cover terminology, hemodynamics, cardiac medications, vent modes/weaning, IABP, and so on in only 8 hours of training. I can understand why you had staff leave.

Alot of heart recovery is somewhat routine, and you find yourself doing the same stuff over and over...get them from the OR, stabilize hemodynamics, monitor bleeding, give fluid/blood as needed, extubate, control pain, treat electrolytes, pulmonary toilet, promote activity/OOB, transfer to tele. Its the smaller percentage of pts that crash and kick your butt and challenge you.

I dont know, I hope things go smoothly for you. Hopefully they will staff you guys 1:1 for the cases that come right out of OR, especially since its a new endeavor for your ICU (typically my unit makes them 1:1 for the first 8-12 hrs, assuming things go well).

Best of luck, keep us posted!

joeyzstj, LPN · Aug 20, 2008

If you read a lot of the posts on here, many hospitals require several month of orientation before they allow staff members to even touch a fresh heart. AS JBP0529 mentioned, for someone experience it can be very routine, however in is a lot less routine to someone with no experience. Its often routine to us becasue we do it everyday and know what to look for and how to fix it. Another issue................what type of protocols is your unit going to set up for you? This is another area where CVICU differs. You dont have time when you need A pressor, Epi for poor index or Nipride for a systolic pressure of 230 to stop and page a surgeon and wait for them to call you back in 20 minutes when you have a bleeding hemodynamically unstable patient. Most places I have been to give CVICU's a little more freedom in terms of drugs to use and protocols.

SWEnfermera · Aug 21, 2008

I worked in a semi-rural hospital that started a CV Surgery program while I was there. It took over a year of planning. Several meetings took place with representatives from lab, radiology, blood bank, OR, EKG, anesthesia, nursing, pharmacy, PT, cardiac Rehab, Case mgt/dc planning, respiratory, Purchasing for added equipment, and the CV surgeon. We had to ensure that labs would be run STAT on post-op patients and that the results were posted quickly. We needed cooperation from radiology and EKG on post-ops. Blood bank had to insure that blood products would be readily available. (This hospital's practice was to not keep platelets, but retrieve them from a larger hospital's blood bank that was over an hour away when needed; this had to change). Pharmacy had to change some of their practices, and make drugs more readily available to nurses. We also had to develop a calcium, potassium and Magnesium replacement protocol specifically for the post heart pt. Responsibility of the cardiac rehab and PT departments had to be discussed and agreed upon. Then there is the formulation of Pre-op orders, immediate post-op orders, and step-down unit orders. All of these need to comply with your hospital's existing protocols, or new ones need to be developed.

Then there is the training:

We had little cooperation from neighboring hospitals who had existing heart programs. (There were only 3 others in the state; again this is a mostly rural area). We brought in a CV CNS from 2 states over. She presented a 40 hour didactic/theory course on the care of the post op heart patient. (All CCU nurses and a core of RTs attended, the course had to be repeated 3 times so all could attend).

Then all the nurses went to a neighboring state for 1 week to observe and learn how to recover patients (we were lucky to find a magnet hospital to help us with this).

Then we did a lot of Mock practices. (Roles of the primary nurse and secondary nurse). We also did Mock open-chest scenarios. (Your staff needs to know what to do if a chest needs to be opened in the unit).

When we finally started doing cases, we brought in 4 nurses on contract (2 for days, 2 for nights) that had extensive open-heart experience. They were at the hospital for 3 months, and helped train our nurses. (so the 1st cases actually had 2:1 staffing). We started with a group of core nurses. Ince they had recovered at least 6 patients with little help form the preceptor, we began adding additional nurses to the core.

Meetings continued well after the program started to discuss problems and ways to improve.

As you can see, it took a lot of work. There is no way you can adequately prepare nurses with only an 8-hour class.

joeyzstj, LPN · Aug 22, 2008

Thats the type of training your hospital needs listed above. I would love to be a part of something like that, but it would be insane getting it together. Let us know how it goes.

juraviel · Aug 25, 2008

I find myself wondering, what kind of MD would be willing to preform CABG's under these conditions?

lotlie · Aug 26, 2008

Thank you so much, SWEnferema, for such a specific explanation of all that went into beginning your program! :bowingpurWe do have much of what your described before you got to the training. The orders, the protocols for BP and electrolyte replacements, lab is supposed to be completely on board, etc.

But, the training we will get is not going to compare to yours I'm afraid. One additional experienced nurse is to be brought in, I've heard. Additional to the trainer, who will be on staff with us for a month or so to precept us.

We are not that far out. In fact, we are within 20 miles of an amazing medical center. Our nurses would love to spend some time in one of those hospitals. I wish we could get an agreement with one to have a few nurses work with us to train. I think they are holding back because of the cost of that training, but I am sure you agree, to not do so will very likely be so much more costly.

I am not completely in the loop, since I am part time. But, I think I can have a conversation with our director at least, to discuss adding the mock senerios and some additional class time at the very bare minimum. I believe they are going to be more receptive to listening, with so many staff members running. Surely they MUST know that more will follow as the program nears the start date.

Thanks again! I will keep you posted on how this shapes up.

SanFranSRNA · Sep 9, 2008

I'm currently involving in a Cardiac Surgery training program at my hospital. The qualifications are as follows: at least one year of ICU experience, 6 hours class in iABP, 6 hours hemodynamic class, 4 hours 12 leads class, 4 hours cardiovascular pharmacology class, watch 1 CABG case, watch 1 valve case, shadow 1-2 fresh heart cases, recover 8 cases with a preceptor, recover 4 on your own then you will be officially off orientation.