CCU

Hello and welcome to the Moses CCU rotation! We are very excited to have you with us in the CCU 

We hope you will find this rotation rewarding and educational.

The CCU rotation has undergone significant changes over the last several years and continues to evolve and improve, month to month. Even if you are a returning resident or fellow, please (re)familiarize yourself with the comprehensive  and updated “Housestaff CCU Manual” and “CCU Presentation Script” which highlight policies and procedures as well as how standardized patient presentations are done in the Moses CCU. When you encounter a patient with a particular disease or problem, you are encouraged to refer to the attached CCU reading list for articles that our faculty think are particularly worth your time.

Some highlights to draw your attention to:

***CCU conference room*** The CCU conference room is used by the house officers and nurses. It is used also for family meetings. We have received comments that it was unprofessional in appearance from grieving family members (jackets and personal belongings all about the room, leftover food on the table causing flies, papers all about, etc). Please keep it clean. There is a call room in the CCU. Please store your jackets and personal belongings there. Thank you in advance for your help with this.

Brief Guide

1) CLABSIs and CAUTIs. We have had too many CLABSIs and a CAUTI recently. There was an epidemic of them in May and June. Please make sure each day on rounds you present the day # of the line (as per the presentation script) and look to remove lines when not needed. If you are sending a urine culture, please always send a UA with micro as well! If you are sending blood cultures, make sure it is 2 sets of blood Cx, not just 1 set. For any transfer from an outside hospital, please send 2 sets of blood cultures as part of routine admission work-up (we have identified transfers from an  OSH as a risk factor for CLABSI). Hospital Infection Prevention is monitoring closely.

2) New admissions and clinical deterioration in old patients. All new admissions and old patients who have acute worsening must be discussed with the CCU attending in real time. Examples include acute bleeding requiring blood transfusion, tachyarrythmias requiring defibrillation, recurrent chest pain necessitating going back to the cath lab or intensification of medical therapy, hypotension requiring starting vasoactive medications or worsening hypotension requiring escalating dosages or addition of new drips, respiratory failure requiring intubation, etc. If a patient is on levophed 5 and you need to go to levophed 6, that’s okay, but if you need to go to levophed 15, you need to communicate with the CCU attending. When in doubt, call the CCU attending. It is better to err on the side of caution. At a meeting of the Program Evaluation Committee (PEC), it was mentioned that residents are afraid to call the attending to let the attending know because the housestaff don’t want to seem like they don’t know or that they couldn’t handle the situation. It actually does show that you do know there is a problem and that you can successfully run the unit with proper communication of these important events to the attending! So please, follow CCU protocol and call the attending in real time about clinical deteriorations.

3) Brief Notes for Patients Decompensating. Any significant change in clinical status requires a brief note in the electronic chart for documentation. A previous review by risk management for a patient who was ill found ZERO documentation over 5 hours while the patient was getting sicker. This is not acceptable. You may be providing exceptional care, but the lawyers say that if it’s not documented, it never happened. These brief updates should be written by the resident and/or fellow as appropriate and mention that was discussed with the attending.

4) STAT Orders: For any STAT order during daytime and overnight, please put the order in and *tell* the patient’s nurse. Just writing the order is not enough; a STAT order needs to be communicated verbally to the nurse.

5) Restraints/Sedation. Restraint documentation is a big issue and one for which Montefiore was found to be deficient. By the Joint Commission. When restraints are used, there needs to be an active order. The order can only be for a max of 24 hours. It cannot lapse. Please make sure these orders are kept up-to-date. If a nurse asks for a restraint order, please enter the order right away because if you delay and it lapses, then Monte gets dinged. Similarly, sedation and analgesia needs to be titrated to an ordered RAAS. The orders for an individual patient must be titrated to the same RAAS. For example, the fentanyl can’t be to a RAAS for -2 and the versed to a RAAS of 0. We were cited by the Joint Commission for this as well. The sedation and analgesia orders must match.

6) Discharge Medication Prescriptions. Please ensure when you give prescriptions for patients being discharged that you give adequate refills (at least 3 month supply). Sometimes the patients miss their 1 week follow-up appt and sometimes the appt is canceled by the doctor’s office. We do not want the patients to run out of their meds, particularly their antiplatelet agents.

7) Procedure Cart: There is a procedure cart stocked with all the goodies one needs to do procedures. You no longer need to go to the supply closet and hunt for things. Please roll the cart to the patient’s room when a procedure needs to be done. If you need something intra-procedurally, no one needs to run to the supply closet anymore – everything is on the cart. So the cart can be restocked by the assigned nursing assistant after every procedure, please let the CCU clerk know a procedure has been done and the cart needs to be restocked.

8) CIIT Program for Diabetes: There is an IV insulin infusion order set for patients with hyperglycemia who are admitted to the CICU and in need of an insulin gtt. For new diabetics, definitely involve the DM Nurse Educator as well as endocrinology as appropriate.

9) Ticagrelor (Brilinta) and Dual Antiplatelet Therapy: Ticagrelor is a newer antiplatelet agent being used more frequently on our STEMI patients. Unfortunately, it is relatively expensive. For any patient started on ticagrelor, a social work consultation must be placed to determine if the patient’s insurance will cover it at reasonable cost for the patient. We need to prevent the patient being discharged on this drug and being unable to fill the script. There is already one patient @ Weiler who was discharged on ticagrelor, could not fill the script, and then re-presented with a large STEMI due to stent thrombosis.

The “Antiplatelet Therapy Program” was designed to help with education and compliance for our STEMI patients being discharged on antiplatelet therapy. In a nutshell, all STEMI patients will receive a pharmacist visit and will be educated regarding all their cardiac medications and their antiplatelet medications in particular. The patient will also receive the 1st 30 days of their second antiplatelet therapy (clopidogrel or ticagrelor) free from the Montefiore pharmacy. The program has been very well received. Much of the Antiplatelet Therapy Program is happening virtually now due to the pandemic…See The Housestaff manual for further details…

IMPORTANT: If for whatever reason you want to change the antiplatelet therapy on a patient, please discuss it with the interventionalist who did the procedure. Sometimes it is perfectly okay to change the antiplatelet agent, and sometimes it is very important that they are on one agent as opposed to another. So, please discuss it with the interventionalist first.

10) CCU Housestaff Lectures. On Tuesdays and Wednesdays at 2 PM, the CCU fellow will be giving the housestaff a curricula lecture in the CCU conference room. All housestaff who are not post-call, have the day-off, or are in clinic are expected to attend.

11) Pharmacist Coverage in CCU. Daryl Nnani, the Transplant and LVAD pharmacist, is an excellent resource.

12) Transfers to the floor: Any patient being transferred out of the CCU to another service must be verbally discussed with the attending physician or designee of the receiving service (eg. HF fellow, EP PA/fellow). There have been multiple examples where an attending was not informed of a transfer and the patient sat on the floor for 48 hours without an attending seeing the patient. Clearly, this is bad medicine. The attending physician for the floor service should be called up to 6 PM by the fellow. If a patient needs to be transferred overnight to make a bed for a sicker patient, the fellow must call the receiving attending either before or after morning conference at 7:30 or 8:30 AM. Residents - Please *DELETE* from the transfer summary that “both Sending and Receiving attending agree to the transfer” – this probably is not the case if the patient is transferred out in the middle of the night. Please confirm with the fellow in the morning that the receiving attending has been called about the transfer.

13) Short Call - ORDERING PHYSICIAN. To improve the timely placement of important orders during rounds, the chief resident has designated a "Short Call - Order Physician". On the schedules it should appear as "CCU-Work Day OP". During rounds from approximately 8:30 AM-end of rounds, the nurses will come to the "Short Call - Order Physician" to place important orders for patients. The hope is that this will improve patient safety and assist in the timely care of our patients, but also be less disruptive to rounds overall. Ultimately, we want rounds to be an effective learning environment with residents focusing on presentations and teaching. Having a point resident for urgent orders, will hopefully help everyone else focus.  This responsibility is only for rounds. During other times, nursing can speak to the resident in charge of the patient for that day.

14) Myocardial Infarction core measures: There are 6 discharge core measures for MI patients. We need to document the 6 measures: 1) ASA at discharge, 2) statin at discharge, 3) b-blocker at discharge, 4) ACEi or ARB at discharge if LV systolic dysfxn, 5) smoking cessation advice, and 6) cardiac rehab referral.

Overall defect free care at Monte was very poor, but thanks to yours and your co-residents help, we have improved the performance measures substantially. On every MI patient, you must document these core measures in the DISCHARGE SUMMARY. If the patient is currently smoking, or the patient quit within the last year, you must document that you have spoken to them about smoking cessation here (in addition to your H and P). A referral to cardiac rehab should be documented here as well. Even if a patient is to be discharged over the weekend, as soon as they are admitted on a weekday, you can call up and get them an appt at cardiac rehab. The EPIC discharge summary was supposed to include a section for this, but the builders unfortunately left it out. They are aware of this problem and  are working on correcting it. Unfortunately this has gone slower than I would like. In the meantime, you can cut and past the below core measures, or, make a .dot phrase incorporating them which can be shared. To make it easier for you, the below Core measures blurb has been placed on the desktop of ALL the CCU computers. Please CUT and PASTE and update this CORE MEASURE blurb into the end of your discharge summary in EPIC.

Core Measures

This patient was treated for a Myocardial Infarction (MI) during this admission.

1) The patient is being discharged on an aspirin.

2) The patient is being discharged on a statin.

3) The patient is/IS NOT being discharged on an ACE inhibitor or an ARB due to normal LV function OR renal failure OR hyperkalemia OR hypotension OR allergy (please choose one and delete the others).

4) The patient is/ IS NOT being discharged on a Beta Blocker due to symptomatic bradycardia OR significant asthma OR hypotension OR allergy (please choose one and delete the others).

5) If patient was a smoker within the last one year, Smoking cessation counseling was given.6) A cardiac rehab referral was made for the patient. The date, time and location is listed below OR Patient was referred for cardiac rehab. The phone number for them to schedule a session is (718) 405-8471 OR The patient was given a referral for cardiac rehab. They are going to go to their own local cardiac rehab center OR The patient is not a candidate for cardiac rehab because they have dementia OR they have only 1 leg OR the patient has said don’t have the financial resources or transportation resources to go to cardiac rehab 3x/week. (Please choose one and delete the others)

Please be aware that the CCU nurses and the 6B nurses have been empowered NOT to take out IVs, NOT to take off tele, and NOT to discharge the patient until the STEMI patients’ core measures have been documented on the discharge summary.

15) PHYSICAL THERAPY Huddle. Briefly, a physical therapist will interrupt rounds sometime in the morning to go over which patients have PT/OT needs and need to be seen that day. This helps them focus on the patients with the most pressing PT needs. Feedback is this is going well. PLEASE let me know if PT is not huddling with you in the morning.

16) Vasopressin use. The manufacturer has significantly increased the price of vasopressin so Montefiore’s pharmacy is looking to decrease use. We will be “capping” dose of vaso for patients with cardiogenic shock and hypotension @ 0.06 U/min. 1st line pressor for patients on DBA or milrinone or mechanical circulatory support will still be vaso up to this dose. If they require further pressor, then add norepi up to a dose of 15 mcg/min. If the patient requires further pressor, at CCU attending’s direction, can add a 3rd agent or increase vaso to 0.1 U/min.

Please do not hesitate to contact Daanish Chawala (firm 1 chief) or Dr. Sims if any problems arise or with any suggestions for improvement.

Again, welcome to the Moses CCU!

For Issues...

Please contact Firm 1 chief, Daanish Chawala and Dr. Sims. Letting us know of issues in real time allow us to better address them and find solutions

Our CCU Nurse Manager, Ms. Geraldine Dilorenzo, is a tremendous asset and we are lucky to have our partnering with us here in the CCU.  Please communicate with her and/or the unit clerk with any problems you encounter (ie: computers not working, printer not working, ultrasound not working, weights not getting done, call room not getting cleaned, etc.). We can only fix the problem and make your lives easier if we know about it.