Cardiac Surgery Intensive Care Unit — Unit 77

The Cardiac Surgery Intensive Care Unit (CICU) is a 24-bed in-patient unit that provides complex invasive hemodynamic monitoring and treatment of adult patients during the critical phase of recovery from cardiac and thoracic surgery. The unit is comprised of 24 private rooms. Monitoring capability is available at each bedside and is remotely monitored at the central nurses’ station with unit wide alarm system. There are a total of 2 negative air-flow isolation rooms.

The average bed occupancy is 91%.

Monitoring capabilities include Phillips Intellivue MX 800 bedside cardiac monitor at each bedspace capable of EKG, pulse oximetry, continuous temperature, end tidal CO2, NIBP, 5 invasive hemodynamic pressure signals, and advanced arrhythmia detection. The bedside may be equipped with a CCO/SvO2, SVV, SV, ScvO2, SVR via both invasive and non-invasive platforms. In addition, we have capability for bispectral index, train of four, cerebral oximetry.

Patients with special requirements are placed strategically to provide optimal nursing care to meet individual needs.

The unit remains operational 24 hours per 7 days per week.

Description of Patient Populations

Patients are admitted to 77 CICU following cardiothoracic surgery for:

  • Aortic Dissections
  • Aneurysm repair
  • Coronary Artery Revascularization
  • Heart Valve(s) Repair or Replacement
  • Surgical Repair of Congenital Cardiac Anomalies
  • Ventricular Assist Support: Heartmate II, Heartmate III, Heartware, Tandem Heart, Centrimag and Impella for both bridge and destination therapy.
  • Trans-aortic valve replacement (TAVR)
  • Transcatheter mitral valve repair (TMVR)
  • Adult Extracorporeal Membrane Oxygenation (ECMO)
  • MAZE

Ages of patients admitted to 77 CICU range from adult to elderly. The average LOS is 5.07 days.

Common medical procedures and therapies performed in the unit include: arterial, central venous, and pulmonary artery line placement, chest tube placement and removal, intubation and extubation, temporary cardiac pacing, mechanical ventilation, intra-aortic balloon counterpulsation, continuous veno-venous hemofiltration, hemodialysis, percutaneous tracheostomy and support with a ventricular assist device (VAD).

Nursing Care

Nursing care is focused on the assessment, diagnosis, planning, treatment and evaluation of preoperative and post- operative surgical patients with emphasis on cardiovascular and thoracic surgery care including rhythm interpretation, hemodynamics, airway management, pain management, medication management, safety precautions, patient/family education and support, and initiation of the rehabilitation process. Registered nurses in 77 CICU meet the basic requirements for Registered Nurse staff, and function in accordance with the nursing department job description, as described in the Hospital Plan for Nursing Care. Additional unit requirements for registered nurses include temporary epicardial pacing, open cardiac arrest management, PA catheter removal, Chest tube removal (selected nurses) external cardiac defibrillation, CRRT (selected nurses), IABP (selected nurses) and VAD (selected nurses).

Health Care Team

The Medical Director for CICU is a Critical Care Medicine Attending physician. The Cardiovascular Surgery (CVS) faculty, CVS Fellows and CVS Advanced Practice Providers (APP) (physician assistants & nurse practitioners) provide surgical management of care. The Critical Care Medicine (CCM) faculty, CCM fellows and CCM APP provide continuity of intensive care to all patients in 77 CICU. CCM rounds several times daily and provides ICU related care needs such as ventilator management and emergent interventions. CCM are on the unit 24-hours/7 days per week. Interdisciplinary, comprehensive care is provided by the medical and nursing staffs, social services, case management, rehabilitative services, food and nutrition services, cardiopulmonary services, pharmacy, pastoral care, perfusion and other health care providers as indicated by the patient’s health status and identified needs.

The nursing management structure consists of a Nurse Manager and Clinical Leader with support from a Unit Assistant and Clinical Nurse Educator. The management team provides training experiences to attain and maintain competence as defined by the unit/role specific job descriptions and the departmental education plan.

Unit staff includes registered nurses and support techs. Support techs meet the basic requirements for their positions and function in accordance with their unit-based job description, as described in the Hospital Plan for Nursing Care. Their job responsibilities are performed under the immediate supervision of the registered nurse.

Staffing Plan

Nursing care for CICU is based on the Total Patient Care Delivery model with co-worker assistance, as described in the Hospital Plan for Nursing Care. Each shift has a designated Charge Nurse. On most shifts, the CN is free from bedside assignment and available to all staff for consultation and assistance in providing patient care. Patient bed assignments are made by the CN and are based upon patient safety/isolation concerns and acuity levels. The bedside registered nurse has authority and accountability for decision making for the patient(s) assigned on his/her shift.

The skill mix for the unit is 100% RN. The usual staffing ratio is 1:1.5. The staffing plan is based on a budgeted 19.97 HPPD, 7.29 HPWI, and acuity of 2.74 and adjusted for the skill mix as identified above. Adjustments to staffing are based on Targeted Staffing projections in Quadramed and are reflect the census and acuity of classified patients (WinPFS Classification System). Patient care assignments are made each shift by the Charge Nurse, as described in the Hospital Plan for Nursing Care. Additional unit-based considerations for staffing needs include:

  • Complexity of patient condition
  • Number and type of isolated patients
  • Experience level of the staff
  • Previous days’ assignment to facilitate continuity of care
  • Frequency of monitoring and technological support
  • Unit geography and location of assigned patients
  • Competency level of supplemental and float staff
  • Staff mix
  • Unit activity

Requests for Scheduled Paid Time Off (STO) will be reviewed on a case-by-case basis and will take into account the staffing needs of the unit. The unit schedule committee will be in charge of preparing the unit schedules for the staff. Preparation of the unit schedules will take into consideration the need to balance unit-staffing needs and requested time off. Employees will submit their request for time off 2 weeks prior to schedule completion. Requests are limited to 2-3 RNs and 1 support tech per shift. If more than two individuals have made the same request, these individuals should first try to resolve this issue amongst themselves. If this is unsuccessful, the following criteria will be utilized: date of STO request, amount of STO taken in the past year, and seniority. Staff are encouraged to trade shifts for day to day STO needs after the deadline for requests has occurred. Trades should not incur overtime.

In the event of an emergency, such as extreme weather conditions or other disaster, the minimum amount of staff required to safely operate this unit with a 75% capacity is 14 RNs and 1-2 support techs per shift.

Additional Staff

The Nurse Manager/designee makes decisions concerning overall adjustments of staff, including need for extra shifts/overtime, according to unit census and acuity in accordance with the Hospital Plan for Nursing Care. When additional staff are required, the Central Staffing Office is notified and additional staff may be sent, floated or scheduled. If census and/or acuity is decreased, the Central Staffing Office will be notified of float availability, or the staff may be utilized for unit activities such as quality initiative monitoring, educational programs, inservices, etc. If floating is not required, the staff, may be granted time off per request or on a rotating basis. Staff are granted time for educational programs by requesting Administrative Leave for off unit activities. Mandatory programs sponsored by the unit are given during shift hours or staff is paid to attend. Staff are paid for attending staff meetings. Staff attendance at meetings, education offerings, and other activities are coordinated so that patient care coverage is continuous.

Addendum: Plan for Unit Coverage

When no CSO or Float help is available:

  • Can assignments be adjusted to pair patients as acuity allows?
  • Are 1:1’s due to unit geography? Can patients be moved to facilitate pairing?
  • Are schedule manipulations possible; evaluate numbers for the week.
  • Know which staff wants extra worktime. Ask what shifts they are willing to cover, work extra, or switch to.
  • Ask current staff if they are willing to stay and work extra/overtime.
  • Evaluate orientees. If they are experienced and have been here greater than 6 weeks or inexperienced and have been here greater than 12 weeks, pair up more difficult patients. Ask the orientee how comfortable he or she is with expanded role.
  • Evaluate whether CN can come into the numbers.
  • Ask Nursing Coordinator whether boarded patients can go to another unit until staffing is better. Cardiac surgery patients must come to CICU on post-operative day O.
  • Ask Nursing Coordinator for help outside the usual float pool, i.e. temporary help from ED.
  • If all possible resources have been evaluated and implemented to the best of your ability, notify on call unit management team member.

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Jennifer Zimmerman, RN, explaining to a parent and her daughter how to use a bedside asthma action plan.