proper orientation for CTICU

[rn6889]

I have been a nurse for almost a year now and currently work on a Progressive Care Unit. We receive transfers from the ICU, admits from the ER, and MET/Rapid Responses from the floors. We get chronic vent dependent patients, patients on cardiac gtts such as cardizem and amio, insulin gtts, heparin gtts, sandostatin gtts and we can also take patients on low doses of inotropes (we do not titrate anything except insulin and heparin per pharmacy protocol) we do take ICU overflow when the unit is full so all the nurses on my unit are trained to take the patients if need be. I got 4 months of orientation and have no seen many ICU patient, actually only 2 which one was on levo and the other on a propafol gtt. I recently got hired at a large inner city hospital in the CTICU and was told the orientation would be 8 weeks and i would do 1 week on days and the next 7 on nights which i was hired for. I would also be expected to take hearts out of the OR if they happened to roll out on night shift. Is only having 8 weeks of orientaion in a CTICU with my experience normal? I am ACLS certified and have taken the ECCO (essentials of critical care orientation) critical care course. Thanks for the input!

[MLB55]

I work at a very large teaching institutio, in neuroICU. When I started almost 2 yrs ago with 1 yr of neuro floor experience I received 8 weeks with Ecco class during that time. Now a days, nurses get 3 weeks. And then continue on this "mentorship" with their preceptor. But after 3 weeks, you are taking two pts on your own w your preceptor close by. So yes, it is normal. And with your experience w GTTs and vents, you will do just fine.

[CVmursenary]

I got 8 weeks in cticu as a new grad. You will likely not be taking fresh hearts after 8 weeks; more training will follow.

[Biffbradford]

I would say that 8 weeks orientation is on the short side, but to be frank, you never stop learning in CTICU/CVICU and it takes several years to get really comfortable. Fresh post-ops are heavy on fluid replacement as they third shift everything, as well as bleeding management (giving lots of PRBCs, FFP, Platelets, managing clotting chest tubes), while at the same time, dealing with confused/restless/intubated patients, multiple inotropes/pressors/insulin drip, rhythm changes/pacemakers, family ... and hopefully you're one-to-one and not managing another patient at the same time!

Good comaradere with solid team members is key to survival.

It's very challenging so say the least.

[jelly221,RN, MSN]

I would say that 8 weeks orientation is on the short side, but to be frank, you never stop learning in CTICU/CVICU and it takes several years to get really comfortable. Fresh post-ops are heavy on fluid replacement as they third shift everything, as well as bleeding management (giving lots of PRBCs, FFP, Platelets, managing clotting chest tubes), while at the same time, dealing with confused/restless/intubated patients, multiple inotropes/pressors/insulin drip, rhythm changes/pacemakers, family ... and hopefully you're one-to-one and not managing another patient at the same time!

Good comaradere with solid team members is key to survival.

It's very challenging so say the least.

Sorry to go off-topic, but I'm moving to CVICU this summer and this post made me SO excited!!! Can't wait to join y'all...

[jezlynh]

You will never feel ready. It's normal.

[Sugarcoma, RN]

In my opinion the length of orientation is less important than the quality. Your previous experience with gtts and vents will give you a bit of an advantage over a nurse without this experience. However, it really is a different world dealing with hearts regardless of your previous experience. Things that I feel are essential and wish that I had as a new nurse to the CTICU would be the following:

Critical care classes where hemodynamics are covered in depth including PA catheters. (You should not be caring for these patients until you have a good baseline knowledge of this subject! No matter what other nurses may tell you!). Make sure you know how to set up/troubleshoot/ these devices BEFORE you are standing at the bedside!

A good solid review on cardiac physiology/pathophysiology and a good review of the physiology of the ANS/CNS.

Current evidenced based practice on administration and titration of vasoactives/chronotropic/inotropic medications. Know what meds your docs use. They may be different from doc to doc. Know your unit/facility policies regarding administration/titration of these meds.

An EKG review.

IABP instruction.

Hypothermia instruction/protocols.

Be familiar with the use and operation of the pacemakers on your unit! How to program them/place pads/connect them to the wires on the patient etc.

Know your unit/facility Insulin protocol.

In a perfect world orientation would include observation at cath lab and an actual CABG.

The books I have found most helpful are the following. Your mileage may vary.

Drugs for the heart: Opie/Gersh

The only EKG book you will ever need: Thayer (I seem to be weird in this respect most people prefer the book by dale dubin sp?)

Manual of perioperative care in adult cardiac surgery: Bojar

Manual of critical care nursing: Baird/Bethel

Fast Facts by Kathy White.

The ICU book: Morino

My pharm and pathophys books from nursing school.

What you need to do: Take as many hearts as possible while on orientation. Identify nurses you can learn from/count on when you are on your own. Lots of self study! Ask questions, ask questions, ask questions!!!! 8 weeks may be enough for you, if not DO NOT HESITATE to speak up. Even if you are denied, at least you will have voiced your objections!

Good luck and I hope you love it!

[CABGx4, ASN, BSN, MSN, CRNA]

I worked in medical ICU for 2 years prior to transfer to CT so 8 weeks was enough for me. Your step down has given you plenty of experience to handle it. Good luck!!

[volunteerpioneer]

I completely agree with the comment that it is the quality of the training, not the quantity. Also, with sugarmama's comment to take as many open hearts as possible.

I am a new grad who was hired straight into CTICU, and have so far been training one month in CT ICU. (after 3 mos Med Surg?!?!? didn't help..) After a short "introduction" to the unit, most of my training has been focused around taking "fresh hearts" straight from the OR. If they don't give them to me, I now ASK for them. Even though it's VERY hard, take as many as you can while you have a preceptor-- you will learn the most those first few hrs post-op. I will be on my own on nights in 3 weeks-- but will mostly be getting 2 - 3 day post-ops. Also I always study, study, study on my time off.

[NewGoalRN]

May be a dumb question but what do you learn when you take a 'fresh heart'? Are you transferring it somehwere? I'm lost here but find this thread fascinating.

[PedsDrNurseTheo, ADN, BSN, MSN, DNP, RN, EMT-P, NP]

"fresh heart" - first 24 hours post-op open thoracotomy case, generally valvular surgery and/or CABG

"pump case" - any surgical case placed on cardiopulmonary bypass

"Thorc" or "thoraco" - unilateral thoracotomy approach, usually for lung biopsy, mass resection, pneumonectomy, or wedge resection

"TEVAR", "EVAR" - Thoracic endovascular Aneurysm Repair - a minimally invasive approach to deploy internal Dacron stents to an aortic aneurysm. Usually bilateral groin cath sites, a subclavian cath site, and often a spinal drain to prevent spinal cord ischemia.

"TAVI" Transcatheter Aortic Valve Implantation - an endovascular approach to aortic valve repair or replacement. Similar to TEVAR but without a spinal drain.

Just some of the terms we toss around regularly. HTH.

[volunteerpioneer]

May be a dumb question but what do you learn when you take a 'fresh heart'? Are you transferring it somehwere? I'm lost here but find this thread fascinating.

Sorry for the confusion, 'fresh heart' is what we call a patient just received from the OR right after cardiac surgery.