SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY

PS1070 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: ADMISSION/DISCHARGE CRITERIA: CARDIOVASCULAR INTENSIVE Job Title of Reviewer: Director, CVICU EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: (SPECIAL CARE) 04/00 3/09, 8/09 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 8 PURPOSE: POLICY STATEMENT: EXCEPTIONS: To determine criteria and priorities for admission to and discharge from the Cardiovascular Intensive Care (CVICU). The following criteria will be used by the medical and nursing staff in making decisions regarding the admission and/or discharge of patients from CVICU. Laterally transferred patients do not need to meet discharge criteria before leaving CVICU. Pediatric patients less than 15 years of age (unless too critical to transfer to another facility). ADMISSION CRITERIA: 1. Seriously or critically ill patients will be admitted to the CVICU unit according to the established criteria. In All CVICU patients will receive a consult by a cardiologist, cardiovascular surgeon, critical care physician or appropriate subspecialty as outlined in policy 01.MD.40 Requirements for Consultation in Special Care Units. the event a very critical patient needs to be admitted to CVICU and all beds are occupied, an attempt will be made to identify patients meeting CVICU discharge criteria and transfer the most stable patient in that unit. Decisions will be made by consensus of the Clinical Manager/Relief Communicator and admitting physician(s). The Medical Director will be contacted if resolution of patient placement requires his intervention. Critically ill patients may be admitted to other appropriate special care units with an available bed. 2. Patients will continue to be cared for in the CVICU until the physical assessment, acuity level, and physiological monitoring no longer indicate a need for intensive care intervention. Patients will also be transferred from the CVICU when the patient/family, in collaboration with the primary physician, choose a less intensive level of care (e.g., Care and Comfort Measures only.) Patients who are a DNR (DO NOT RESUSCITATE) status and who do

2 of 8 NOT meet admission criteria are not appropriate candidates for CVICU. 3. All patients with an Intra-Aortic Balloon Pump or a Ventricular Assist Device will be cared for in the CVICU. 4. The criteria for patient admission and discharge may include the following: ADMISSION CRITERIA: (cont d) DIAGNOSIS ADMISSION CRITERIA DISCHARGE CRITERIA Acute MI Hemodynamically unstable Patient has EKG changes consistent with an acute MI and or positive cardiac enzymes with any of the following. 1. Ventricular dysrhythmias AV blocks, sustained supraventricular tachyarrhythmias. 2. PA catheter present. 3. Unstable BP: SBP <90 or DBP >120. 4. Frequent adjustments of inotropic/vasodilator IV's. 5. Persistent Ischemic chest pain. 6. IABP present. 1. No ST changes for 12 hours. 2. No increase in cardiac enzymes for 12 hours. 3. Rhythm stabilized with or without intravenous antiarrhythmic agents. 4. PA catheter absent. 5. BP stable. SBP >90, DBP <120. 6. Inotropic/vasodilator IV's have been weaned off or to a non-titrated dose. 7. Free of ischemic pain. 8. IABP absent. Hemodynamically unstable dysrhythmia 1. Symptomatic dysrhythmia (hypotension, chest pain, diaphoresis). 2. Lethal dysrhythmias: VF, VT, asystole. 3. Unstable BP or labile BP, SBP <90, DBP >120. 4. Transvenous/transcutaneous; epicardial pacing. 5. Complications with Implantable cardioverter defibrillator. 1. Dysrhythmia stable. 2. No lethal dysrhythmias present X 24 hours. 3. SBP >90, DBP <120 or parameters set by physician. 4. Transvenous pacer discontinued (unless patient transferring to 7TA)

3 of 8 Post OP Surgical Patients requiring epidural catheters 1. Epidural Catheter present 1. Catheter removed OR patient stabilized enough for transfer to unit.

4 of 8 DIAGNOSIS ADMISSION CRITERIA DISCHARGE CRITERIA Hemodynamically unstable 1. Frequent adjustments of inotropic/vasodilator infusions 2. PA catheter present. 3. Unstable BP; labile BP, SBP <90, DBP >120. 4. Volume resuscitation 1. Inotropic/vasodilator agents have been weaned off or to a non-titrated dose. 2. PA catheter absent. 3. SBP >90, DBP <120 or parameters set by physician. Heart Failure/ Pulmonary Edema 1. PA catheter present. 2. Acute respiratory distress with hypoxia: respiratory rate >30 or <6/min. 3. Require mechanical ventilation or aggressive non-invasive ventilation. 4. Abnormal Sp0 2 /ABG: Sp0 2 <92%, P0 2 60 torr, PC0 2 50, ph <7.30 or >7.50. 5. Ventricular dysrhythmias: AV blocks, sustained supraventricular tachycardias. 6. Unstable BP: SBP <90, DBP >120. 7. Frequent adjustment of inotropic/vasodilator IV's. 8. Aquapheresis Therapy 1. PA catheter absent. 2. Absence of signs and symptoms of hypoxia. 3. Mechanical ventilation absent or discharged to subacute setting. 4. Sp0 2 >92%, or ABG within physician ordered parameters. 5. Stabilization of rhythm. 6. Stable BP: SBP >90, DBP <120. 7. Inotropic/vasodilator IV's have been weaned off or to a non-titrated dose. Pulmonary Hypertension 1. PA catheter present. 2. Initiation of Flolan 3. Transition of IV Flolan to IV Remodulin 4. Initiation of IV Remodulin 1. PA catheter absent 2. Discontinuation of Flolan if ineffective. Transfer patient stable on Flolan 3. Transfer patient when on maintenance dose of Remodulin.

5 of 8 DIAGNOSIS ADMISSION CRITERIA DISCHARGE CRITERIA Status Post Percutaneous Coronary Intervention 1. Positive cardiac enzymes. 2. EKG changes. 3. Ventricular dysrhythmias or unstable dysrhythmias AV blocks, sustained supraventricular tachycardias. 1. No increase in cardiac enzymes x 24 hours. 2. No ST changes x 24 hours. 3. Rhythm stabilized with or without minimal IV antiarrhythmic agents. Post Cardiac Arrest Pulmonary embolus 1. PA catheter present. 2. Ventricular dysrhythmias or unstable dysrhythmias (heart blocks, sustained atrial tachycardias.) 3. Frequent adjustments of inotropic/vasodilator IV's. 4. Unstable BP: SBP <90, DBP >120. 5. May have IABP or Hypothermia protocol in effect. 1. Acute respiratory distress or failure: RR >30 or, <6/min. 2. Require mechanical ventilation or imminent intubation. 3. Abnormal Sp0 2 /ABG: Sp0 2 <92%, P0 2 60 torr, PC0 2 50, ph <7.30 or, >7.50. 4. Hemodynamic instability. 1. PA catheter absent. 2. Rhythm stabilized with minimal antiarrhythmic agents or with temporary or permanent pacemaker inserted and functioning appropriately 3. Inotropic/vasodilator IV's have been weaned off or to a non-titrated dose. 4. Stable BP: SBP >90, DBP <120. 5. IABP absent or Hypothermia protocol completed. 1. Absence of signs and symptoms of hypoxia. 2. Mechanical ventilation absent or discharged to subacute setting. 3. Normal ABG/Sp0 2 for this patient. Sp0 2 >92%/ or ABG within physician ordered parameters. 4. Hemodynamically stable.

6 of 8 DIAGNOSIS ADMISSION CRITERIA DISCHARGE CRITERIA Acute Renal Failure 1. Electrolyte abnormalities requiring emergency hemodialysis or CVVHD. 2. Rhythm changes secondary to electrolyte abnormalities. 3. Fluid overload requiring hemodialysis. 1. Electrolyte imbalances corrected CVVHD discontinued. 2. Rhythm stabilized. 3. Fluid balance status stabilized. Cardiogenic Shock 4. Acute unstable hemodynamics. 5. PA catheter present. 6. IABP present. 7. Ventricular dysrhythmias or unstable dysrhythmias. 8. Frequent adjustments of inotropic/vasodilator IV's. 9. Unstable BP: SBP <90, DBP >120. 4. Stable hemodynamics. 5. PA catheter absent. 6. IABP absent. 7. Rhythm stabilized with or without minimal intravenous antiarrhythmics. 8. Inotropic/vasodilator IV's have been weaned off or to a non-titrated dose. 9. Stable BP: SBP >90, DBP <120. Status Post Cardiac Surgery Respiratory failure/arrest 1. CHF 2. Dysrhythmia 3. Ischemic chest pain 1. Acute respiratory distress or failure: RR >30 or <6/min. 2. Require mechanical ventilation. 3. Abnormal SpO2/ABG: SpO2 <92%, PO2 60 torr, PCO2 50, ph <7.30 or >7.50. 1. Absence of signs and symptoms of hypoxia off mechanical ventilation. 2. Dysrhythmia stable 3. Painfree, vss stable 1. Absence of signs and symptoms of hypoxia or hypoventilation. 2. Mechanical ventilation absent or discharged to sub-acute setting. 3. SpO2 >92% or ABG within physician ordered parameters. 4. Patients requiring continued airway management via endotracheal tube, requiring suctioning no more than q4 hours and have a DNR order.

7 of 8 Cardiac, Vascular or Thoracic Surgery patients, including patient who have undergone: Coronary Artery Bypass Surgery, Valve repair or replacement, Ventricular or Atrial Septal Defect Repair, Myxoma removal, Transmyocardial Revascularization, Thoracic aortic aneurysm repair, Abdominal Aortic aneurysm repair, Vascular surgeries, and Thoracotomies. Other non-specified Serious Condition 1. Acute unstable hemodynamics 2. Frequent adjustments of inotropic/vasodilator agents 3. PA Catheter and Arterial Line present 4. Requiring mechanical ventilation 1. Requiring invasive monitoring. 2. Requiring close monitoring of cardiac, respiratory, metabolic or neurological status. 3. Requiring specialized skills of the critical care nurse. 1. Stable hemodynamics 2. Inotropic/vasodilator have been weaned off or to a minimally titrated dose (see Nursing Policy 3. PA Catheter and Arterial Line absent 4. Mechanical ventilation DC d 1. When patient is not in need of critical care services. 2. Patients requiring continued airway management via endotracheal tube, requiring suctioning no more than every 4 hours and have a DNR order. RESPONSIBILITY: REFERENCE(S): AUTHORS: It will be the responsibility of the CVICU Director to inform the staff of this Department policy and assure compliance. The Joint Commission Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Author. Leeann Putney, RN, MSN, CCRN-CSC, Clinical Educator, CVICU Sue Olsen, RN, BS, CCRN, Clinical Manager, CVICU Lisa Baumgardner, RN, MSN, Cardiac Educator Connie Andersen, RN, Director, Cardiac

8 of 8 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Date Title: Connie Andersen, Director, CVICU Title: Title: Title: Title: Committees/Sections: (if applicable) Nursing Standards and Practice 8/6/09 Vice President/Administrative Director (if applicable) Name and Title: Jan Mauck, V.P., Chief Nursing Officer