Welcome to

Duke Hospital

Teaching

Technology

Teamwork
Rebecca Johnson, RN, Lupino Washington, BSN
Duke University Health System, Durham, NC

CCU Description
16 bed cardiac intensive care unit
Major Diagnoses include
Cardiogenic shock
Acute myocardial infarctions
Cardiomyopathy
Unstable angina
Life threatening arrhythmias

Overflow of patients other than cardiac

CCU Staffing
Charge Nurses - act as resources to
nurses and physicians
Charge Nurses do not take patients
The staff is 90% Registered Nurses
There are 60 RNs in the CCU
Nurse patient ratio is 1:1 to 1:2

CCU Staffing
Nurse Clinician
Liaison between the patient,
family and healthcare team
Assists in end-of-life issues
Patient Resource Manager
Manages discharge planning
and insurance issues

CCU Staffing
Attending physicians
Round morning and evening
Available 24 hours a day

Cardiology fellow, resident, and intern

On the unit 24 hours a day

Pharmacists
Available on the unit for rounds and
consultation from 7:00AM to 11:00PM

Patient Room
Cardiac Care Unit

Progressive Care Unit

Description
Two 31 bed medical cardiology progressive care
units
All beds have telemetry
Patient populations consist of
Unstable angina and post acute MI
Cardiomyopathy
Pre-heart transplants
Dysrhythmias
These units offer opportunities to use innovative
technologies, participate in research based
practice, and facilitate patient education

Progressive Care Unit

Patient Room
Progressive Care Unit

Typical Day on the CCU

Nurse-to-nurse report using

computerized charting

Daily Rounds

using computerized physician order entry

The entire team rounds daily on each patient
Every team member has input in creating the plan of
care:
Attending
Fellows
House staff
Care nurse
Clinical pharmacist
Patient Resource Manager

Nursing Contribution
to Rounds
Update

team on vital signs and hemodynamics

Relate patient response to medication

(vasopressors and oral agents that have been
titrated by nurse)
General changes in patient status
Input into the decision whether or not the patient is
able to transfer to another unit or rehab facility
Identify patient and family concerns and questions

Education, Leadership and

Responsibility
Nurses are responsible for monitoring patients
and interpretation of information as well as
operating a wide variety of equipment such as:

Intra aortic balloon pumps

Pulmonary artery catheters
Continuous venous-venous hemodialysis
Temporary transvenous pacemakers
Ventilators
Defibrillators/cardioversion
Pericardial drains

Routine Care

Responsibilities and
Nurse Driven Protocols
Titration of vasopressors to patient
hemodynamics
Phase I Cardiac Rehab
Nurse Driven protocols
Heparin titrate according to nomogram
Potassium supplement according patient lab value
Magnesium - supplement according patient lab value
Tube feedings

Staff Nurse using critical thinking

skills to titrate vasopressor to
patient hemodynamics

HEPARIN ADJUSTMENT CHART

CARDIAC CARE UNIT --- 7200

Goal of Therapy --- therapeutic aPTT of 50 - 75 seconds.

aPTT
(seconds)

Bolus
Dose
(units)

Stop
Infusion
(minutes)

Rate
Repeat
Change
aPTT
(ml/hour)

< 40

3,000 units 0

+ 1 ml/hr

6 hours

40 - 49

+ 1 ml/hr

6 hours

50 - 75

no change

next AM

76 - 85

- 1 ml/hr

next AM

86 - 100

30 minutes

- 1 ml/hr

6 hours

101 - 150

60 minutes

- 2 ml/hr

6 hours

> 150

60 minutes

- 3 ml/hr

6 hours

*** Rate change is based on Heparin infusion of 100 units/ml. ***

Instructions for Heparin Nomogram

For patients who received thrombolytic therapy: (ie, tPA, TNK, rPA)
From 6 - 12 hours after start of thrombolytic agent ---1. Do NOT discontinue or decrease the infusion unless significant
bleeding occurs or the aPTT is > 120.
2. Adjust the infusion upward if aPTT is < 50.
12 or more hours after start of thrombolytic agent ---Adjust Heparin using the entire chart. Deliver the bolus, stop the
infusion and/or change the rate of infusion based on aPTT result.
For all patients who did NOT have thrombolytic therapy:
Adjust Heparin using the entire chart. Deliver the bolus, stop the infusion,
and/or change the rate of infusion based on aPTT result.
HO should weight, age and gender adjust the initial infusion rate to the
patient.
If patient has not reached therapeutic range after 2 adjustments are made
using the chart, ask HO to write order for additional bolus or additional
increase in drip rate, if appropriate.

Nurse Physician Collaboration

Responding to Emergencies

Nurses use critical thinking to pull together the patient

assessment data, effects of medications and
hemodynamic numbers to respond to emergency
situations

How are our

nurses
prepared to
practice ?

Nursing Education
AD Associate degree 2 years
Diploma in Nursing 3 years
BSN Bachelor of Science in Nursing 4 years
MSN Master or Science in nursing 2 -3 years
NP Nurse Practitioner
CRNA Certified Nurse Anesthetist
CNS - Clinical Nurse Specialist
MHA Masters in Hospital Administration

Men in Nursing

Nursing Education
Ph.D. Doctorate in Nursing
Researchers
Administrators of practice
Educators
Dr. Bradi Granger
Heart Center Nurse Researcher

Nursing Structure
Medical Cardiology
Clinical Operations
Director

Nurse
Manager
Operations
7100*

Nurse
Manager
Education
71 / 73

Nurse
Manager
Operations
7300*

Nurse
Manager
Operations
7200**

Nurse
Manager
Education
7200

Staff Nurses

Staff Nurses

Staff Nurses

Nursing
Assistants

Nursing
Assistants

Nursing
Assistants

* 7100 and 7300 are Progressive Care medical cardiology units

** 7200 is the Cardiac Care Unit

Orientation
Unit Orientation
Coordinator
RN
Facilitates
Orientation

Classes:
IABP
Hemodynamics
Shock
Pacers, etc.

Preceptor,
Experienced RN
Coaches new nurse
In developing critical
thinking skills

Mentoring
Experienced RN
Continues to coach
and support after
formal orientation

New staff members begin their work experience

on the CCU with a thorough orientation

Beginning the Clinical Ladder

Orienting New Staff Nurses

( Clinical Nurse I )

Clinical Ladder Program

Advancement for the Staff Nurse

Education, Leadership and

Responsibility
Nurses are responsible for many
areas of their own practice:
Scheduling
Interviewing potential staff members
Create policies and procedures
Conduct yearly skills validation
Ongoing inservices and education
Evaluate new product for hospital use

Teamwork
Nurses have the additional responsibility
to participate in hospital wide
multidisciplinary committees
Mortality and Morbidity
Cardiovascular Medicine Performance
Improvement
Cardiovascular Serviceline Council
Medical Directors meeting
Heart Center Discharge meeting

How do nurses maintain their

proficiency as well as learn new
competencies?
Yearly skills revalidation on the unit
Unit inservices of new equipment and
techniques
Hospital wide programs
Local Conferences present as well as participate
National Conferences present as well as
participate

Nurses Presenting at National

Critical Care Conference

Teamwork
Education, experience,
autonomy and responsibility
prepare nurses to be
competent and respected
members of the healthcare
team.

Nursing Is an Integral Component of

the Healthcare Team
al
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Attending
Physicians

Pharmacists

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R
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The
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Team Collaboration at Duke

Its More than just the doctors and nurses . . . . .

In addition to the healthcare

team, we value families

Family presence is important for the

well-being of our patients

% of Time Needs Met

Needs of Family Members (2003)

J Clinical Nursing, 12(4) 490-500

Physicians speak with families daily

Family Conference with Physician, Care Nurse and
Charge Nurse

Family Visitation
Visiting hours are daily from morning until
bedtime and are open, but not unlimited
Visitors are requested to use an intercom
system to call back before entering the unit
Staff members have the right to ask family to
wait before coming
Yes, He is in
room 7214.

r.
M
e
Can g h av
in
s
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u
Cla isitors
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If life support has been withdrawn, we

encourage families to be present as much
as they wish - 24 hours per day

There are times when

children are allowed to visit

Teaching, Technology,
Teamwork
Teaching, technology and team work
have allowed Duke to successfully
achieve extraordinary care for our
patients and their families.
and
Through education, responsibility and
autonomy, nurses have a strong impact
on patient care and outcomes.

Duke Hospital
achieved Magnet
Status for
excellence in
Nursing Services
in 2006

First Critical Care Unit in

North Carolina to receive
the Beacon Award for
Excellence in Nursing
practice

Teamwork!