1Poria Medical Center, M.P. Lower Galilee, Tiberias, Israel
2Hopital Europeen Georges Pompidou, Paris, France
3Evangelismos General Hospital, Athens, Greece
4Cardiovascular Institute, University of Barcelona, Spain
5Universitat Klinikum, Aachen, Germany
6Sheba Medical Center, Ramat Gan, Israel
7Ukrainian Institute of Cardiology, Kiev, Ukraine
8Aarhus University Hospital, Aarhus, Denmark
9San Fillippo Neri Hospital, Rome, Italy
10Uppsala Cardiothoracic Center, Uppsala, Sweden
11P. Stradins Clinical University Hospital, Riga, Latvia
Received 15 September 2004; revised 1 February 2005; accepted 10 February 2005; online publish-ahead-of-print 21 March 2005.
* Corresponding author. Tel: +972 4 6652648; fax: +972 4 6652678. E-mail address: yhasin{at}poria.health.gov.il
Abstract
Two major changes in patient characteristics and management occurred recently that demand distinctive alterations in the function of the intensive cardiac care unit (ICCU). These changes include the introduction of an early invasive strategy for the treatment of acute coronary syndromes, enabling early recuperation and shorter need for intensive care on the one hand, while the number of older and sicker patients requiring prolonged and more complex intensive care is steadily increasing. A task force of the European Society of Cardiology Working Group on Acute Cardiac Care was set to give a modern updated comprehensive recommendations concerning the structure, organization, and function of the modern ICCUs and intermediate cardiac units. These include the statement that specially trained cardiologists and cardiac nurses who can manage patients with acute cardiac conditions should staff the ICCUs. The optimum number of physicians, nurses, and other personal working in the unit is included. The document indicates the desired architecture and structure of the units and the intermediate cardiac unit and their relations to the other facilities in the hospital. Specific recommendations are also included for the minimal number of beds, monitoring system, respirators, pacemaker/defibrillators, and necessary additional equipment. The desired function is discussed, namely, the patients to be admitted, the length of stay, and the relocation policy. A uniformed electronic chart for ICCUs is advised, anticipating a common European database.
Key Words: Intensive care unit Acute cardiac care Functional recommendations Medical equipment
The following represents an expert consensus document written by the nucleus members of the European Society of Cardiology (ESC) Working Group for Acute Cardiac Care (ACC).
The first description of the intensive cardiac care units (ICCUs) was presented by Julian1 to the British Thoracic Society in 1961 and was based on monitoring patients with acute myocardial infarction (AMI) for the early diagnosis and treatment of ventricular fibrillation. Nevertheless, significant benefit of the units was not obtained until some decisive policy changes were made, including treatment protocols and structural organizations.2 The current objectives of the ICCUs are the monitoring and support of failing vital functions in acute and/or critically ill cardiac patients, in order to perform adequate diagnostic measures followed by medical and invasive therapies to improve outcome.
The current published literature regarding the structure, operation, and function of ICCUs is insufficient because of the following reasons: it focuses on non-cardiac care,3 it is limited to part of the needs,4 it describes only local standards,5 it is published in non-English literature,6 or it is very old.7
In a continental survey among hospitals from different parts of Europe, a great deal of divergence was found concerning the whole spectrum of organization and function of ICCUs (ESC WG on Acute Cardiac Care; unpublished results).
The ESC Working Group on ACC was established in 2001. One of its declared tasks is to improve and unify the function of ICCUs across Europe.
A task force composed of the nucleus members of the Working Group set out to write the following document in order to provide an updated guide indicating the minimal optimal requirements for the modern functioning ICCU. The manuscript is based on the current available literature; it reflects the existing working states in different European countries and the personal opinion of the task force members.
The manuscript has undergone extensive revision by the Guideline Committee of the ESC and by the editorial board of the European Heart Journal.
Local modifications should be implemented according to the local special needs derived from specific patient case-mix, available resources, and different laws and regulations.
Two changes occurred over the past two decades that demand distinctive alterations in the function of the ICCUs in the next decade. Changes will take place both in the patient population admitted to the ICCU and in the medical care supplied.
Patient population
Acute coronary syndrome (ACS) will probably remain the most frequently primary admission diagnosis in ICCU in the next decade. Today these patients are treated effectively and quickly in different ways, thus the length of stay both in the unit and in the hospital is expected to decrease. On the other hand, the aging population in Europe, with increasing co-morbidities will probably change the ICCU population. Dramatic improvement in therapeutic measures will lead to a better outcome, with a prolonged survival for patients with coronary artery disease, with either a normal or a depressed left ventricular function. Therefore, the case-mix of our patients in the ICCU will change dramatically in the next decades.
As the population is aging, the unit will have to treat elderly patients who tend to suffer from multisystem diseases; the number of patients treated by multiple percutaneous or surgical revascularization procedures will increase; moreover, the ICCU is becoming the treatment centre for patients suffering from severe cardiac arrhythmias and decompensate heart failure or different combinations of diseased heart and other organs. As a result, it may likely be that the ICCU will be utilized for more complex patients who require a relatively longer length of stay in the Unit and will provide the treating staff with a special challenge. For these reasons, the requirements of the ICCU will increase, not decrease.
A special group of patients are those suffering from complications following invasive treatments in the catheterization lab. The still growing number of severe cases with multivessel disease, complex lesions, reduced left ventricular function, and a multitude of co-morbidities treated in the catheterization lab may increase the number of complications during and after coronary intervention procedures. These patients represent a special group of patients admitted to the Unit and need specific cardiological nursing and medical expertise.
Treatment policies
Reperfusion in acute ST-elevation myocardial infarction patients is undoubtedly an emergency.9 Direct mechanical revascularization is becoming more and more popular, even though its availability is still restricted owing to lack of trained staff and budget constraints. In the near future, the catheterization laboratory and the ICCU will become more and more inseparable.
In the coming decade, the cardiologists will continue to observe constant efforts of the pharmaceutical industry to improve reperfusion at the patient's bedside, with new, more efficient thrombolytics, anticoagulants, and antiplatelets agents, and more effective interventional therapy, which, in combination with newly developed drugs aimed at the salvage of the microvasculature and of the myocardium from ischaemia/reperfusion injury, will hopefully improve outcome in these patients.
This pre-vision has clear implications for the necessity of constantly updating the Units about novel resources for diagnosis and treatment, as well as preparing them to participate in multicentre research in order to determine the efficacy of the new therapeutic developments.
Professionalization of medicine is becoming more intense, with the need for cardiac patients be treated preferentially by properly trained cardiologists. In those hospitals in which the patients are transferred directly to the internal medicine ward, the physician in the Unit is compelled to determine a long-term treatment policy, in addition to being obliged to provide acute treatment. Thus, the different Units will develop methods for prognostic stratification (index-risk stratification), which will most probably include a combination of clinical data (age, sex, heart rate, blood pressure); ECG (ST-segment depression or elevation, T-wave inversion); cardiac markers of elevation, especially troponin; evaluation of the left ventricular function; residual ischaemia; and electrical instability.
Staff
The change in patient population and treating policies necessitate appropriate staff training. An increase in the number of complex and/or elderly patients (who may need respiratory treatment, intra-aortic balloon counter pulsation, haemodynamic complex monitoring, or dialysis) and participation in multicentre research projects require suitable training of the physicians and the nursing staff. It is reasonable that for specific specialization, there will be suitable training and accreditation both for physicians and for nurses, especially for the research nurses who will be an integral part of the ICCUs nursing staff.
Equipment
The standard monitoring equipment, including invasive and non-invasive electrocardiographic, haemodynamic, and respiratory assessment, will continue to be the basis of the ICCU.10 Monitoring for the evaluation of autonomous function and electrical instability (heart rate variability, baroreceptor sensitivity, signal average electrocardiogram, and built-in continuous ECG Holter monitoring11) is likely to be added to standard equipment. Non-invasive assessment of cardiac function such as cardiac output12,13 as well as continuous CO2 and O2 saturation monitoring, is becoming available and is routinely used in the modern ICCU.
Computers are a part of the everyday monitoring of the patients; it is used for collecting and analysing patient's data. A uniform electronic database management system of all the European ICCUs is an important task for the Working Group on ACC, including at least basic demographic and clinical data, modes of interventions, and in-hospital outcome. This will make communication among the different ICCUs simpler and could serve as database with an enormous source of information both for research and for quality control purposes.
ICCU patients
The decision to admit a patient will be made by the ICCU physician on duty; in case of physician disagreement, the decision will be made at the senior physician level. It is advisable for the following patients to be routinely admitted to the ICCU.14,15
This list is conclusive and should be adapted according to each individual case.
Intermediate cardiac care unit patients
Decision to admit a patient to the intermediate ward is at the discretion of the treating physician, and according to the local policy at the particular institution.16 It is recommended to consider the following conditions:
Number of beds in the ICCU
The number of beds in the ICCU must suit the size of the reference population and the relative specific workload of the hospital. The hospital's specific workload can be evaluated in a number of ways: the simplest measure of the relative workload is the number of visits to the hospital's internal emergency room.
Recommended formula for calculation:
The number of beds will be determined according to the highest of the two.
Number of beds in the intermediate cardiac care unit
The desired ratio of beds between ICCU and the intermediate CCU is 1:3.
Patients beds for the ICCU
Beds in the ICCU have to allow vertical movement, with the possibility of up and down head and leg positioning. Every bed must be equipped with oxygen, vacuum, and compressed-air intakes. It is desirable that one of the beds be suitable for patients with active contagious infectious diseases (e.g. methicillin resistant Staphylococcus aureus, HIV, tuberculosis, etc.) and filtered accordingly.
It is important to make sure that the patient can be X-rayed on the bed.
Additional equipment17
ICCU and intermediate CCU staff
The ICCU should be staffed by at least one physician for every three to four patients, including the Unit director. The director of the Unit should be a board certified cardiologist, specially trained and accreditated as an acute cardiac care specialist, as cardiologists are the physicians better trained to assist patients with ACS and life-threatening cardiac diseases.
The cardiologist in charge of the ICCU should be skilled in treating urgent cardiac situations, including rhythm and haemodynamic disturbances and acute ischaemia. The cardiologist must be skilled at inserting an endotracheal tube, a temporary pacemaker, a catheter in the pulmonary artery, and a balloon in aorta for counter-pulsation. The cardiologist should be able to perform a transthoracic echo study on a basic level (i.e. evaluate the left ventricle systolic function, identify severe valvular disease, and find pericardial fluid) and should have further training in the general intensive care unit.
On-duty and on-call physicians
A skilled physician on duty should be present in the Unit at all times. This physician should be able to handle acute cardiac emergencies after short local training and approval for night duties by the director of the unit. An attending cardiologist on call should always be available for consultation and assistance.
Nurses
Nurses are as important as physicians. Proper nursing staff is the strength of the ICCU. A head nurse for the ICCU is appointed with authority and responsibility for the appropriateness of nursing care; they must have extensive experience in intensive care nursing and proper medical managerial skills, must be able to conduct routine nursing activity of the unit, must be involved in the on-going training of the unit staff, and must take an active part in research activities. The ICCU will employ only registered nurses. At least 75% of them should have completed formal intensive care training (which includes formal cardiology training).18
A unified recommendation for the size of the nursing staff is an intricate issue hampered by the divergence of nursing working habits and skills, case-mix of patients, and different Therapeutic Interventions Scoring System levels.19
The following recommendation is based on the estimated workload of an average ICCU, the calculated Whole Time Equivalents,20 and the personal experience of the authors. Furthermore, allocating nursing manpower should take into account the need for the number of shifts per day, the number of beds in the units, the desired occupancy rate, extra manpower for holidays, and the ability to transfer the nurses from one facility to the other (intensive to intermediate to cardiology and vice versa).
The nursing staff should be constructed of at least 2.8 nurses per bed, to cover three shifts per day, so that the minimal number of nurses in a given time will be at least one nurse per two beds during day time and one per three beds during night shift.21,22
The intensive care nurse should have further training once in at least 5 years in the general intensive care unit. It is also advisable that further training courses be reciprocal so that the nurses working in the general intensive care unit could work in the cardiac intensive care unit as well.
Intermediate cardiac care unit staff
ICCU and intermediate CCU: construction2325
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The computer system is regarded as a positive means of collecting information, at local, national, and international levels. It facilitates everyday activities in patient management and data archiving. It can be used as database and enables analysis of information and quality control. Nevertheless, there are objective difficulties and obstacles on the way to adopt a uniform programme to be used as a continental database.
It is recommended that the ICCU will use an electronic chart routinely. This could facilitate patient admission, discharge, and follow-up as well as research and quality control. As several hardware and software facilities are available, and obviously many Units in Europe have already implemented their own electronic chart, a common European electronic chart would be an impractical dream. Yet, some key items common to all electronic charts could be chosen, transmitted through the internet, and will be used as a common European database for patient admitted to the different ICCUs.
Recently, the European Society of Cardiology launched the Cardiology Audit and Registration Data Sets (CARDS) initiative, under the auspices of the European Union.27 One of the three main issues in CARDS is ACS, and the related Expert Committee on ACS published a report on the data standards for a ICCUs DB on ACS. This data set can constitute the common basis for all the different databases in European ICCUs, allowing interoperability and data sharing.
Quality assurance should be an integral part of the organization and standards of a ICCU: processes currently considered effective for patients outcome, such as adequately timed reperfusion and evidence-based care at discharge, should be monitored and quality control performed reviewed at least on an annual basis, together with personnel and administrators.
The current recommendations have been written as a guide and a rule for the function of a modern ICCU. The exponential speed of changes in technology, procedures, and treatment policies will undoubtedly provide a repeated need for updating these guidelines. For instance, what will be the effect of chest pain units (which are emerging throughout Europe) on the ICCU?
In the near future, reference centres for primary or facilitated PCI for ST-elevation myocardial infarction, as well as for early intervention in patients with non-ST-elevation myocardial infarction, will play a key role in the treatment of patients with ACS. The concept of networking for the coordination among tertiary centres, community hospitals, emergency rooms, and transportation, might also result in a need for updating.
The lack of evidence-based recommendation on the structure and function of ICCUs call upon properly designed studies looking at unresolved issues such as numbers of ICCU beds required for a given populations size, specific equipment, required personnel, and alike.
References
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