Cardiac Intensive Care UnitFellow Orientation

Version: July 2019

CICU Faculty:Christopher B. Granger, M.D (Co-Director)L. Kristin Newby, MD (Co-Director)John Alexander, M.D.Terry Fortin, M.D.Robert Harrison, M.D.James Jollis, MDDan Mark, M.D.Eric Peterson, M.D.Matt Roe, M.D. Tracy Wang, M.D.

Overview:The Duke CICU provides critical care for adult patients with acute cardiovascular disease and critical illness. While the history of cardiac intensive care is rooted in care of acute cardiovascular conditions like acute MI and cardiogenic shock, the diseases managed have shifted to a much larger portion of respiratory failure (the most common reason for admission) and multisystem organ failure, requiring interface with the medical ICU team for many patients.

The CICU moved into its new, state-of-the-art, 17-bed unit in January 2017. Training in the CICU is concentrated on providing experience in caring for patients with acute coronary syndromes and their complications, cardiac arrest, serious cardiac arrhythmias, decompensated heart failure and cardiogenic shock, pulmonary embolism, pulmonary hypertension, pericardial tamponade, endocarditis, valvular emergencies, and complications of cardiac interventions. Participation in clinical research protocols, interface with emergency medicine and EMS, interpretation and application of quantitative clinical information, and a focus on quality of care is integrated into patient care and teaching. The Duke CICU serves a network of emergency departments, hospitals, and emergency medical services in the region to triage and manage patients with critical illness and cardiovascular emergencies.

Fellow Responsibilities Evaluation and management of all patients admitted to the CICU Performing procedures including bedside right heart catheterizations,

temporary pacemaker insertions, and bedside echocardiography. Coordinate acute myocardial infarction care with referring hospitals, local

EMS services and the Duke Emergency Department via the Acute Myocardial Infarction Hotline and ICC Express protocols in collaboration with Life Flight and the interventional cardiac catheterization laboratory

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Consultation and coordination with Duke Emergency Department on admissions to the CICU

Coordination of outside hospital transfers to the CICU (all hours) and stepdown services (after hours).

Through rounds, conferences, and emergency consultations, the fellows have a major role in teaching house staff and students.

Team Structure: Attending: The CICU attendings are some of the most experienced experts

in critical care cardiology in the world, with representation on national clinical practice guideline writing committees (including current or recently on NSTEMI, STEMI, and the Ventricular Arrhythmia/Prevention of Cardiac Arrest guidelines). They have led many of the programs that have established best practices and standards of acute cardiovascular care around the world, including the largest randomized trials of reperfusion for acute MI, RACE, HeartRescue, and the ACTION registry. They are responsible for sharing their expertise with the fellows. The CICU attendings cover the CICU one week at a time, from Friday evening to Friday evening. The attendings are ultimately responsible for patient care and operations of the unit for the week they are on service. The CICU attending is present during morning rounds with the CICU team to determine care plans for the patients and remains on the unit at least 2 pm. The CICU attending will perform informal evening rounds daily. The CICU attending will be available 24/7 by telephone to discuss any change in patients’ conditions, adverse events, new admissions, interface with other services like CT surgery, or address clinical dilemmas, and he or she will be available to assist or supervise bedside procedures, and/or assure that appropriate assistance is available (e.g., insertion of temporary transvenous pacemaker or pulmonary artery catheter). The CICU attending also must be engaged for DNAR orders and decisions about end of life decision-making, including withdrawal of life support.

Cardiology fellows: There are 3 fellows on the rotation for one calendar month at a time.

House staff: There are usually 8 house staff rotating in the CICU at any time: 4 PGY1 interns (caring for rooms 7701-7708), 3 PGY2 residents (caring for rooms 7709-7717) and 1 PGY3 teaching resident. PGY2 residents rotate every 3rd night overnight call with a fellow and may be in the unit for 2 or 4 weeks per rotation. The 4 PGY1 interns cover 12-hour day or night shifts with 2 PGY1 interns present per shift with the exception of one weekend night where 1 PGY1 intern covers all 8 beds, and one 24-hour weekend shift covered by the teaching PGY3 resident.

Pharmacist (Jeff Washam, PharmD): Jeff has decades of experience in the Duke CICU and is a nationally recognized expert in cardiac critical care. He is available for consultation even when not physically present on the CICU.

Nurses: CICU nurses are central to quality care of the patient. Nursing leadership is committed to coordinating care with the fellows and residents.

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The charge nurse is the immediate nurse contact for nursing questions or challenges that arise that are not effectively addressed by the care nurse, and the charge nurse has a critical role in bed management. The nurse manager is responsible for working with the attending staff to foster an environment of effective teamwork of nurses and physicians. It is mandatory that a patient’s care nurse is present on rounds.

RRT Nurse: The RRT nurse (charge nurse level training) responds to codes with the house-staff and floor rapid response calls with the fellow.

Respiratory therapists: Respiratory therapists are present or can be called to assist in airway management and report on patient progress. They are also excellent teachers and are willing during quiet times to provide education to the CICU team on ventilator management.

Fellow Schedule: Fellows determine their sequence in the call schedule which is every 3rd day

over the calendar month The on-call fellow arrives on the unit ~ 7:15 in the morning to receive a

handoff from the post-call fellow. The on-call fellow leads rounds from 7:30- approximately 11:30 am.

The post-call fellow remains in the CICU during rounds and will handle CICU patient issues and is encouraged to participate in post call rounds to facilitate care transition and to participate in case discussion

The pre-call fellow will be present in the CICU from 7:30 until rounds are complete and is responsible for ED and off-service issues and calls during rounds.

Fellows have one day off per week when their pre-call day falls on a Friday, Saturday, or Sunday

Short-call fellows will attend continuity clinic approximately twice per month

Supervision and SupportThe CICU attending is the primary resource available for support to the CICU fellow and is available 24/7 to assist with questions regarding patient care, triage, STEMI activation. Additional resources include:

Interventional cardiology attending and fellow: Available 24/7 within 30 minutes for STEMI activation, emergent IABP placement, and emergent pericardial drainage. Also available to assist with IABP complications, Impella placement, and EKOS catheter treatment for PE.

Advanced heart failure attending/fellow: Available in house or via phone to assist with management of cardiogenic shock, particularly when there is a question about escalation of mechanical circulatory support.

CT surgery attending, fellow, and resident: Available in house or via phone to assist with ECMO deployment when indicated, management of axillary IABP, postoperative complications, and to assist with questions about escalation of mechanical circulatory support.

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Moonlighting fellow/attending: From 7pm-7am there is an in-house fellow or attending supervising house-staff on the stepdown services. They are available to help with questions about patient management and triage, and to assist with procedures when needed.

MICU fellow: There is a 24/7 in-house MICU fellow who can assist with difficult to ventilate patients. As a general rule, the MICU team should be consulted on patients with ARDS, severe persistent hypoxia (PaO2/FiO2 < 100), refractory hypoventilation, and/or patients who are difficult to wean from the ventilator.

ECHO fellow/attending: There is 24/7 ECHO coverage at Duke hospital for STAT TTE and TEE when needed. All fellows will receive training on use of the Vivid IQ bedside echo on CICU patients.

STAT airway team: Anesthesia staff available for emergency airway management and intubations

ECMO team: Team of perfusionists, attending surgeons, and nurses available 24/7 for rapid ECMO deployment

Electrophysiology attending/fellow. Available 24/7 in-house or from home to assist with VT storm, post-procedural complications, and can assist cases requiring emergent pericardial drainage.

Conferences and Education Conferences

o Thursday 12-1 pm: Didactic education conference led by CICU attending and fellow for fellows and house staff on CICU specific topics. Food is served. Location: CICU conference room

o CICU Morbidity and Mortality conference: Fourth Thursday each month at 7 am. Location: DN Rm 1308. Team of fellows should prepare a case to be discussed and invite other services or cardiology subspecialties as needed.

o STEMI meeting: Third Thursday each month at 7 am. Location DN Rm 1308. CICU faculty, STEMI coordinators, EMS, ED, and ICC teams review STEMI data and discuss systematic regional STEMI processes.

o Critical Care Grand Rounds: Duke-wide critical care conference held monthly on Thursday from 12-1 pm in DN Rm 2002. Depending on the topic this may replace the Thursday CICU didactic conference

o CICU fellows should make all attempts to attend core fellowship conferences, but the fellow on-call should expect to be available on the unit when needed.

Teachingo CICU fellows are responsible for teaching the residents, interns, and

students rotating through the CICU. Teaching can occur informally through discussion of patient management, via procedural supervision, reviewing patient studies (cath, ECHO), or more formally using prepared materials (chalk talks) and leading the Thursday

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didactic sessions. Fellows are responsible for providing input on evaluations of all interns and residents.

Resourceso Duke Heart videos:

https://www.youtube.com/playlist? list=PLBPPJmonlKtALPaCpX5IZN6XPokKjicBr

o Publications: Guidelines/Consensus statements

2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Part 8- Post-Cardiac Arrest Care https://www.ahajournals.org/doi/10.1161/CIR.0000000000000262

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. http://www.onlinejacc.org/content/61/4/e78

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. http://www.onlinejacc.org/content/64/24/e139

Positive Pressure Ventilation in the Cardiac Intensive Care Unit. http://www.onlinejacc.org/content/72/13/1532

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. https://www.ahajournals.org/doi/full/10.1161/cir.0000000000000525

Fourth Universal Definition of Myocardial Infarction (2018). https://www.sciencedirect.com/science/article/pii/S2211816018301388?via%3Dihub

2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000549

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Objectives and Competency Expectations

ACC 2015 Core Cardiovascular Training Statement (COCATS 4) (Revision of COCATS 3)https://www.acc.org/~/media/non-clinical/files-pdfs-excel-ms-word-etc/guidelines/2015/031315_cocats4_unified_document.pdf

Competency Components Milestones (Months)

MEDICAL KNOWLEDGE 12 24 36 AddPATIENT CARE AND PROCEDURAL SKILLS 12 24 36 AddSYSTEMS-BASED PRACTICE 12 24 36 AddPRACTICE-BASED LEARNING AND IMPROVEMENT 12 24 36 AddPROFESSIONALISM 12 24 36 AddINTERPERSONAL AND COMMUNICATION SKILLS 12 24 36 Add1 Know the pathophysiology, differential diagnosis, and characteristic

clinical, hemodynamic, radiographic, and laboratory findings of cardiogenic, hypovolemic, septic, and mixed circulatory shock, and of the systemic inflammatory response syndrome.

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2 Know the indications for, and characteristic findings with, bedside invasive and noninvasive hemodynamic monitoring.

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3 Know the indications, contraindications, and clinical pharmacology for vasoactive and inotropic medications used in the treatment of patients with advanced heart failure, hypotension, or shock.

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4 Know the indications, contraindications, and clinical pharmacology for anticoagulant, antiplatelet, and fibrinolytic agents.

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5 Know the indications for, contraindications to, and clinical pharmacology of agents used to treat hypertensive urgencies and emergencies.

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6 Know the indications, contraindications, and clinical pharmacology for agents used to treat pulmonary hypertension, including intravenous, inhalational, and oral agents.

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7 Know the indications, contraindications, and clinical pharmacology for agents used to treat supraventricular and ventricular arrhythmias.

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8 Know the indications for, contraindications to, and risks of catheter-based techniques to treat supraventricular and ventricular arrhythmias.

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9 Know the characteristic clinical, electrocardiographic, echocardiographic, and radiographic findings with pulmonary embolism, aortic dissection, pericardial tamponade, acute decompensated severe heart failure, severe valvular heart disease, and myocardial infarction.

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10 Know the indications for oxygen supplementation, endotracheal intubation, and mechanical ventilator support for patients with hypoxia and/or respiratory failure.

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11 Know the differential diagnosis and characteristic laboratory findings of oliguria and acute kidney injury.

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12 Know the characteristic physical examination, echocardiographic, angiographic, and hemodynamic findings of mechanical complications of myocardial infarction (e.g., ventricular septal defect, mitral regurgitation, and right ventricular infarction).

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13 Know the types of, and indications for, mechanical circulatory support, including intra-aortic balloon counterpulsation, ventricular assist (both percutaneous and surgical) devices, and extracorporeal membrane oxygenation.

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14 Know the principles of treatment of hypotension in special populations, including patients with cardiogenic shock, hypertrophic obstructive cardiomyopathy, right ventricular infarction, massive pulmonary embolism, pericardial tamponade, and distributive shock.

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15 Know the indications for emergency surgery in patients with aortic dissection.

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16 Know the indications for emergent/urgent surgery and transcatheter valve replacement/repair in patients with severe valvular heart disease.

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17 Know the differential diagnosis of heart failure or shock in cardiac transplant patients.

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18 Know the elements of risk scoring systems for the assessment of prognosis in acute coronary syndrome, advanced heart failure, and pulmonary hypertension, including demographics and findings from the clinical examination, electrocardiogram, biomarker testing, angiography, echocardiography, and invasive hemodynamic assessment.

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19 Know the indications for use of hypothermia protocols and the principles of postresuscitation bundled care.

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20 Know the elements of scoring systems for assessment of the risk of major bleeding in patients treated with antithrombotic medications.

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EVALUATION TOOLS: conference presentation, direct observation, in-training examination, and simulation.

1 Skill to manage patients with acute myocardial infarction and any associated rhythm, conduction, or mechanical complications.

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2 Skill to evaluate and manage acutely unstable cardiac patients by integrating the findings from clinical, electrocardiographic, telemetry, imaging, and hemodynamic assessment—and to develop a plan for bedside intervention.

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3 Skill to place arterial, central venous, and pulmonary artery catheters and temporary transvenous pacemakers in sequence with cardiac catheterization laboratory rotations.

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4 Skill to recognize when renal replacement therapy is indicated, and to manage in conjunction with nephrology consultants.

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5 Skill to appropriately utilize therapeutic hypothermia protocols in survivors of cardiac arrest in conjunction with neurological consultants.

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6 Skill to evaluate and manage patients with hemodynamic instability following cardiac surgery.

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7 Skill to evaluate and manage patients with hemodynamic instability following transcatheter valve therapy.

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8 Skill to evaluate and manage supraventricular and ventricular arrhythmias and conduction disturbances in unstable patients in collaboration with electrophysiology specialists.

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9 Skill to use vasopressor and inotropic therapy appropriately in various types of shock.

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10 Skill to incorporate mechanical circulatory support in the management of critically ill patients.

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11 Skill to place intra-aortic balloon pump emergently. III∗12 Skill to identify and manage pericardial tamponade, including

emergency pericardiocentesis.I

13 Skill to participate in the perioperative care of heart transplant and ventricular assist device patients, in collaboration with heart failure experts, interventional cardiologists, and surgical consultants.

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14 Skill to monitor blood pressure and hemodynamic state in patients with continuous flow left ventricular assist devices, in collaboration with heart failure specialists, interventional cardiologists, and/or surgeons.

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15 Skill to manage hypertensive urgencies and emergencies. I16 Skill to manage special populations of critically ill cardiovascular patients

including those with aortic dissection, massive or submassive pulmonary embolism, acute severe valvular regurgitation, and advanced pulmonary hypertension with right ventricular dysfunction.

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17 Skill to manage patients with acute bleeding, including bleeding from vascular access or spontaneous bleeding.

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18 Skill to perform noninvasive ventilation and CO2 monitoring. I19 Skill to incorporate oxygen supplementation and mechanical ventilation

in patient management.I

20 Skill to perform endotracheal intubation. III21 Skill to utilize risk assessment scoring systems when appropriate in

patient management and counseling.I

22 Skill to identify when further medical care is futile and to counsel families on end-of-life care.

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23 Skill to coordinate safe and effective transitions of care in collaboration with other members of the care team.

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EVALUATION TOOLS: conference presentation, direct observation, logbook, and simulation.

1 Work effectively with all members of the critical care unit team including heart failure/transplant specialists, electrophysiologists, interventionalists, surgeons, pulmonary critical care physicians, nephrologists, neurologists, nurses, physician’s assistants, pharmacists, social workers, and other team members as required.

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2 Function effectively as team leader for the critical care unit team. III3 Participate in hospital quality and safety initiatives in the critical care

units.I

4 Design quality and safety initiatives. III5 Utilize interdisciplinary input and expertise in comanagement of critically

ill patients, including transitions of care.I

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

1 Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement.

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2 Utilize point-of-service resources to enhance adherence to guidelines and protocols and obtain new information from trials and professional

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societies.3 Incorporate appropriate use criteria, risk/benefit analysis, and cost

considerations in the use of testing and treatment.I

EVALUATION TOOLS: conference presentation and direct observation.1 Work effectively in an interdisciplinary critical coronary care unit

environment.I

2 Demonstrate sensitivity to patient preferences and values and end-of-life issues.

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3 Practice within the scope of expertise and technical skills. I4 Interact respectfully with patients, families, and all members of the

healthcare team, including ancillary and support staff.I

EVALUATION TOOLS: conference presentation, direct observation, and multisource evaluation.

1 Communicate with and educate patients and families across a broad range of cultural, ethnic, and socioeconomic backgrounds.

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2 Communicate and work effectively with physicians and other professionals on the healthcare team in the management of critically ill patients and their transition to other care environments.

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3 Communicate with families with regard to end-of-life decisions with respect to programming of pacemakers and implantable cardioverter-defibrillators.

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EVALUATION TOOLS: direct observation and multisource evaluation.

Sample Daily Schedule for CICU Rotation

Time On-Call Post-Call Short Call0730-1130

Rounding with team

Rounding with team Triage and manage new admissions, consults

(Leave hospital by 1130)

Assist with management of CICU pts to allow post call fellow to leave at 1130

1200-1300

Conference Home Conference

1300- New admissionsTriageTransfersProcedures

Outpt clinic (approx 2 sessions per CICU month)

1 day off per week (Fri, Sat or Sunday)

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CICU Fellow General Guidance: Communicate with the charge nurse, specifically when:

o Leaving the unit – please report where you are headed and how long you are expected to be off the unit

o You are performing a procedure and will not be available to immediately answer the STEMI hotline

o You are considering accepting a patient for transfer to the ICU or stepdown floor

Procedures:o Fellows should perform PA catheter and transvenous pacer

procedures. Experienced residents may assist at the discretion of the fellow but should not perform these procedures without direct (scrubbed-in) supervision

o Residents/interns can perform most central line and arterial line procedures. The fellow should be expected to supervise these procedures when needed. Ideally the teaching resident and post-call or pre-call fellows can provide the supervision to avoid prolonged periods of on-call fellow unavailability for the STEMI phone.

o Respiratory therapists can perform and supervise radial arterial lines.o Respiratory therapists will perform most intubations and extubations

but are happy to allow the fellows or residents to attempt the elective procedures when appropriate clinically.

o Femoral IABP removal is done by the cath lab staff. Femoral IABP retraction can be performed at the bedside without fluoroscopy. Femoral IABP advancement must be done under fluoroscopy. All axillary IABP adjustments are performed by CT surgery residents or attendings.

o PA catheter removal should be done with fluoroscopy when an intracardiac RA and/or RV device (pacer, ICD) is present.

o The CICU attending and/or moonlighting fellow/attending is available to assist with procedures when needed

It is important for all concerns or disagreements about patient management to be communicated at the appropriate level. Fellows should involve the CICU attending whenever consulting services disagree with CICU patient management.

Transfers to the CICU: All transfers to the CICU, either from another hospital or another ward within

Duke Hospital, should be coordinated with the charge nurse who is aware of bed status/availability.

Review diversion status (ICU diversion, adult diversion) with the charge nurse at the beginning of each shift and periodically thereafter. This will guide our ability to accept patients to the CICU.

ER consultations/admissions:o The ED may call for a consultation for admission. The CICU fellow

should evaluate the patient to determine whether CICU admission is 11

necessary. If CICU is not deemed necessary the CICU fellow can advise the ED team on treatments and recommend alternate services to contact for admission (e.g., cardiology step-down, MICU, Gen Med). In the event that ICU level care is needed and there are no beds in the most clinically appropriate ICU, the OA will direct bed assignment by an established triage plan.

o If specific treatments may stabilize a patient to avoid need for CICU admission (short term BiPAP to facilitate diuresis), these can be discussed with the ED but the CICU fellow should always follow-up to reassess patient stability.

o Conflicts regarding admission should be avoided – the CICU attending should be contacted for dilemmas or disagreement regarding CICU admission from the ED.

Internal transfers:o Services may call the CICU for transfer of patients. The CICU fellow

should evaluate the patient and determine ability to assume care of the patient with the charge nurse.

o All services who transfer patients to the CICU should clearly communicate their recommendations to the CICU at the time of transfer.

o Transfers from other ICUs should be discussed at the attending-attending level.

Outside Hospital transferso From 7 am-7 pm The CICU fellow will handle CICU specific transfer

requests. From 7 pm-7 am the CICU will handle both CICU and cardiology stepdown transfer requests.

o Duke provides an important service to our referring hospitals and we always strive to bring patients to Duke Heart. When receiving a transfer request:

Know bed status to ensure whether we can accept a patient immediately or accept pending bed availability if we are on diversion.

Review the case with referring providers to determine if patient is appropriate for CICU vs. stepdown.

Occasionally patients may be better served on another service (MICU, gen med). If this conclusion is reached, ask the transfer center to route the call accordingly. Try to avoid making the referring physicians make additional calls to Duke.

o If Duke hospital is on divert status, yet the CICU has/could have available beds, then the Duke CICU fellow can ask the CMO (Lisa Pickett or designee) to override divert status. The CICU fellow should discuss with the CICU attending whether the divert status should be overridden to get the transfer to Duke rather than losing/diverting the patient to another hospital. The charge nurse can help facilitate the diversion override process. We accept ALL STEMIs, even when Duke Hospital is on full divert.

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o For all NSTEMI transfers, have the referring physician fax an EKG to ensure the case is not a missed STEMI, and review the guidance for CICU vs. stepdown for NSTEMI admission.

o If a referring hospital calls the fellow phone for a case of STEMI, the fellow should initiate a conference call from the fellows phone with Life Flight to facilitate transportation and cath lab activation: 919-684-LIFE

o If a step-down transfer is accepted after hours, alert the moonlighting fellow/attending.

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NSTEMI guidance

The following criteria should be used in deciding if a patient presenting with NSTEMI or UA is appropriate for admission to a Stepdown bed rather than admission to the CICU.For purposes of this document, NSTEMI is defined by a presenting clinical syndrome consistent with ischemia, absence of ST-segment elevation on the presenting 12-lead ECG and elevated troponin (specific assay depends on facility. Review the Duke hsTnT guidance for our high sensitivity assay). UA is defined as for NSTEMI, but without elevated troponin.

Patients with NSTEMI or UA who are within 12 hours of initial hospital presentation and who meet the following criteria may be triaged to a Stepdown bed:

No ongoing ischemic symptoms and not requiring nitroglycerin infusion Resolution of ischemic ECG changes and/or absence of dynamic ST-

segment shifts on ECG No pulmonary edema or other signs of heart failure and O2 sat >92% on RA Hemodynamically stable (SBP >90 and <180 and HR <100 and >50) No unstable rhythms (e.g., sustained or non-sustained VT/VF, Mobitz II or

higher degree heart block; AF/flutter with RVR) NSTE ACS GRACE risk score for in-hospital death <3% (i.e., low to

intermediate risk)

Patients with NSTE ACS who are pain free and hemodynamically stable at 12 or more hours from initial presentation (including transfer patients) do not generally require admission to the CICU

If an NSTEMI patient does not meet the above criteria but there are no CICU beds available or there are other considerations that may render stepdown more appropriate, then the case should be discussed with the CICU attending and PAC attending to determine an appropriate disposition.

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Acute MI Hotline/ICC Express Guidelines

General Guidance: EMS

o If an EKG can be transmitted this is helpful but not necessaryo Clarify with EMS personnel if they are calling for a definite vs a

possible STEMI. o If EMS reports a definite STEMI with appropriate symptoms and ECG

interpretation, the ICC express should be activated without delay or confirmation of the ECG

o If the call is due to a possible STEMI based on the symptoms/story or ECG interpretation, the fellow should have a LOW threshold to active ICC express.

If the ECG can be transmitted and does not show STEMI, or the ECG cannot be transmitted but the EMS description of symptoms and ECG are not consistent with STEMI, the fellow can elect to see the patient in the ER before committing to activation

However, consider the delay that may be caused by waiting for ER arrival before ICC activation before considering this option

Outside hospitalso You should rely on the emergency department providers for their

interpretation of presence/absence of STEMI. Demographics and an ECG should be transmitted but should not lead to delay in activation.

o If the transmitted ECG is not consistent with STEMI and the CICU attending concurs, the activation can be cancelled.

o Diversion does not apply to STEMI activations Duke ER patients

o The Duke ED staff can activate ICC express without alerting the CICU fellow. Once the page alert goes off, proceed to the ED to evaluate the patient

Stepdown patients: o Rarely an inpatient STEMI occurs. The ICC activation can be done

manually by calling 115 and reporting an ICC activation for STEMI to the emergency operator who will ask for additional details on location.

Background & PurposeBeginning in 2003, Duke Heart Center established an “Acute MI Hotline” that has resulted in major reductions in the time required to transfer patients in order to undergo primary percutaneous coronary intervention (PCI) for acute ST elevation myocardial infarction (STEMI). The current process, which follows the ACC Guidelines, is outlined below.

The purpose of the AMI Hotline is to provide support for appropriate treatment and facilitate rapid transfer/admission for catheter based reperfusion therapy or post-thrombolytic therapy for acute STEMI. The decision of which reperfusion therapy is best is ultimately made by the referring physician and the primary purpose of the call is to provide help with decision making and, if needed, facilitate transfer. Once the call is made and the

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patient is determined to be a STEMI, the patient will be accepted immediately, even if the Emergency Department is on EMS diversion.

Goals: 1) To provide immediate consultation with a Duke University Medical Center cardiologist

who can assist with decision-making regarding choice of reperfusion therapy (fibrinolysis or primary PCI).

2) To assist in rapid transfer and to assure the prompt treatment of patients requiring primary PCI.

A patient must have one (1) of the following inclusion criteria (determined by the referring physician or EMS agency) to be an appropriate candidate for use of the AMI Hotline:

a) Suspected acute STEMIb) ST segment elevation and/or LBBB (new or not known to be old)

Symptom onset within 12 hours

AMI Process for Outside Hospitals using Hotline proceeding directly to Cath Lab

1.1The referring physician from an outside emergency department (ED) will identify a patient who presents with one (1) of the AMI inclusion criteria and appears to be a candidate for acute reperfusion therapy.

1.2 The referring physician will then call the AMI Hotline: 1-866-MI2-DUKE (1-866-642-3853). A single call is all that is needed.

1.3 The Duke Life Flight (LF) Communications Center will receive the AMI Hotline call as follows: “You have reached the Acute MI Hotline, please hold while I connect you to the CICU.”

1.4 LF Communications will then relay the call to the CICU Fellow on the designated phone line at 681-1077 OR will immediately page the CICU Fellow on functional pager number 970-7603 to 668-2663 (the CICU Charge Nurse will take the call if CICU Fellow is not available). This call is recorded.

1.5 The referring physician, the CICU Fellow, and the LF Communications Center personnel will briefly discuss the patient situation (i.e.: physician name and hospital location, patient name, age, gender, symptoms and time of symptom onset, amount and location of ST segment elevation, blood pressure, heart rate, and the patient’s height and weight). The referring physician and the CICU Fellow will determine the most appropriate reperfusion therapy based on the patient’s characteristics and expected time to balloon inflation (if the patient is to be transferred for primary PCI).1.5.1Thrombolysis is generally considered if the patient is unable to undergo balloon

inflation within 120 minutes from first door arrival, especially if the patient is presenting early (<3 hrs.) after symptom onset

1.5.2 Primary PCI is preferred if the patient has any of the following:1.5.2.1 Contraindication for thrombolysis1.5.2.2 Cardiogenic shock1.5.2.3 High risk of bleeding1.5.2.4 Intervention can be done within 90 to 120 minutes

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1.6 An estimate of the time to balloon inflation is provided if primary PCI is to be pursued, which is dependent upon the status and availability of transport (for hospitals

within 45 miles, the generally preferred fastest transport mode will be local EMS, ifavailable). A decision is then made about whether to pursue fibrinolytic (lytic) therapy orPrimary PCI. If primary PCI is selected, transport will be initiated. If fibrinolytic therapy is given, the patient will still be transported to DUH immediately for subsequent management (in anticipation for rescue PCI, should the patient have continued pain and/or ST segment elevation).

1.7 Upon decision to transport, the LF Communications Center will dial 115 to page the “ICC Express Team.” Life Flight Communications will remain on the line to arrange transport if necessary. They will assist with:

1.7.1 Locating vehicles1.7.2 Check weather if flight needed1.7.3 Check for local EMS availability1.7.4 Local EMS transport may be used if ACLS level care is available and the patient does not have an Intra-Aortic Balloon Pump (IABP) or is not deemed to be unstable.1.7.5 Estimated time of arrival (ETA) to DUH cath lab will be established.

1.8 The referring physician will fax the 12-lead ECG and patient demographics to the DUH CICU (919) 681-6557 immediately if there are questions about the diagnosis or once the AMI hotline call has ended. A faxed ECG is not needed for Duke Heart Center to accept and transfer the patient for potential primary PCI.

1.9The referring physician will continue to manage the patient, assess for changes in status, and will prepare the patient for transfer.

1.10 The referring physician will consider administration of the following medications prior to transport:

1.10.1 ASA 325 mg po 1.10.2 Nitrates (topical)1.10.3 Morphine sulfate IV1.10.4 Heparin bolus of 70 Units/kg IV, not greater than 4000 Units total; no

continuous infusion 1.10.5 Clopidogrel (Plavix) 600 mg po OR1.10.6 Ticagrelor (Brilinta) 180 mg po

1.11 DUH notification of appropriate physicians and staff will occur as follows:1.11.1 CICU Fellow will notify ICC Fellow with plan of care and patient ETA.1.11.2 CICU Fellow will notify CICU Charge Nurse so that an inpatient bed can

be located for post-procedure care1.11.3 CICU Fellow will notify CICU Attending as appropriate (complicated or

questionable cases)1.11.4 ICC Fellow will notify ICC Attending of plan of care and ETA, and will

ensure that the ICC team received notification1.12 The DUH Cath Team will report to ICC lab within 30 minutes of notification to set up

procedure room and receive the patient.1.13 The CICU Charge Nurse will register the patient in Maestro Care; the CICU Fellow

or CICU Charge Nurse will order the Heart Cath and also ensure a CICU bed is available.

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1.13.1 If CICU is full, the patient will still be transported immediately and the CICU team will work to make a bed available as soon as possible.

1.14 Upon arrival to DUH, facilitation of the patient to the ICC lab will occur as follows: 1.14.1 EMS will enter the DUH ED through the Resuscitation Area doors from the

ambulance garage.1.14.2 The EDUC will complete the quick registration process, and an armband

will be generated and applied to the patient’s arm.1.14.3 If the ICC lab is ready the patient is then taken directly to ICC procedure

room. The ED Primary Nurse will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs.

1.14.4 If the patient’s condition deteriorates during transport requiring immediate stabilization the registration will be cancelled. The patient will be re-registered and cared for in the ED until disposition decision made. Based on available time, consider additional IV access, obtain baseline labs, initiate interventions per physician order (medications, procedures), prep patient for transfer to ICC Lab (getting patient completely undressed, gathering transport equipment—monitor, defib/ pacer, transport backpack, pacing pads on patient, obtaining oxygen tank, gathering needed paperwork).

1.14.5 When the ICC lab is ready, the ED Primary Nurse will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs.

1.15 Immediately following completion of the cath, the ICC Attending will call the referring physician with the results of the intervention.

AMI Process for Emergency Medical Service (EMS) using AMI Hotline:

2.1EMS responds to 911 request.2.2Based on chief complaint, the paramedic will perform a 12 lead ECG (goal< 5 min)

while on scene and will interpret tracing (and also use the computer interpretation as additional information.)

2.3 If ST elevation is identified; the paramedic will call the AMI Hotline (1-866-MI2-DUKE).2.4 The Duke Life Flight (LF) Communications Center will receive the AMI Hotline call as follows: “You have reached the Acute MI Hotline, please hold while I connect you to the CICU.”2.5 The LF Communications Center will then relay the call to the CICU Fellow on the designated phone line at 681-1077 OR will immediately page the CICU Fellow on functional pager number 970-7603 to 668-2663 (the CICU Charge Nurse will take the call if CICU Fellow is not available). This call is recorded. The LF personnel will stay as a party to the phone call.2.6 The paramedic will provide a verbal 12-lead interpretation and email, text or fax EKG to the CICU Fellow phone (919-812-5840) brief patient information (patient name, age, gender, symptoms and time of symptom onset, vital signs, approximate height and weight) and ETA to the CICU Fellow.

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2.7The CICU Fellow will advise the LF personnel to activate the 115 page as appropriate. If there is uncertainty as to the diagnosis, the CICU Fellow may elect to meet the patient upon arrival in the ED and make the decision to activate then.

2.7.1 CICU Fellow will notify ICC Fellow, CICU Charge Nurse and CICU Attending.2.8The LF Communication Center will page 115 and will call the ED charge nurse at 919-

681-4410 to alert that EMS patient with potential STEMI will be arriving and ETA.2.9 The CICU Fellow will then respond to the ED.2.10 The CICU Charge Nurse will ensure a bed will be available in the CICU for this

patient.2.11 While en-route to hospital, EMS will provide a radio report to the ED, including the

information that this is an ‘ICC Express’ patient. The ED will register the patient in Maestro Care and order the cath.

2.12 Upon arrival to DUH, facilitation of the patient to the ICC lab will occur as follows: 2.12.1 EMS will enter the DUH ED through the Resuscitation Area doors from the

ambulance garage.2.12.2 The Emergency Department Unit Clerk (EDUC) will complete the

quick registration process, and an armband will be generated and applied to the patient’s arm.

2.12.3 The Emergency Medicine (EM) Attending, CICU Fellow and ICC Fellow (if present) will the assess patient and EMS ECG and plan of care will be established.

2.12.4 If patient is determined to NOT have a STEMI, the EDCU will page 115 to cancel the ICC team.

2.12.5 If the patient is determined to have a STEMI, facilitation of the patient to the ICC lab will occur as follows:

2.12.5.1 If the ICC lab is ready the patient is then taken directly to ICC procedure room. The ED Primary Nurse will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs. The process from ED arrival to departure to the lab, when the lab is ready, should take < 10 minutes.

2.12.5.2 If the ICC lab is not ready: The patient will be cared for in the ED and evaluated by the ICC and CICU Fellows until the ICC lab is ready. Based on available time, consider additional IV access, obtain baseline labs, initiate interventions per physician order (medications, procedures), prep patient for transfer to ICC Lab (getting patient completely undressed, gathering transport equipment—monitor, defib/ pacer, transport backpack, pacing pads on patient, obtaining oxygen tank, gathering needed paperwork).

2.12.5.3 The EM/CICU Fellow will consider administration of the following medications:

2.12.5.3.1ASA 325 mg po 2.12.5.3.2Nitrates (topical)2.12.5.3.3Morphine sulfate IV

2.12.5.3.4 Heparin bolus of 70 Units/kg IV, not greater than 4000 Units total; no continuous infusion

2.12.5.3.5Clopidogrel (Plavix) 600 mg po OR2.12.5.3.6Ticagrelor (Brilinta) 180 mg po

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2.12.6 When the ICC lab is ready, the ED Primary Nurse will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs.

AMI Process for Walk-Ins and Local EMS AMI Hotline not Activated Pre-Arrival:

Patients who present to the ED via private vehicle or by EMS who do not call the AMI Hotline with signs/symptoms consistent with myocardial ischemia described as any patient

> 18 years of age with non-traumatic chest pain and/or anginal equivalent: Left arm, shoulder, jaw, upper back or neck pain; Palpitations; Dyspnea; Diaphoresis; Nausea/Vomiting; Syncope; Elderly with vague symptoms; Medical history of diabetes with vague symptoms; Any pt > 35 years of age with upper abdominal pain; or if suspected acute coronary syndrome or acute MI:

3.1The ED Nurse First or Triage Nurse will register the patient and identify who meets the above criteria as needing an immediate ECG and will notify the ECG technician to complete a stat ECG (goal < 10 min) through the electronic order paging system.

3.2Patient is either placed in a Triage room or treatment room.3.3The ECG is obtained and handed to the EM Physician for immediate interpretation.3.4 If ST-elevation MI is identified, the EM Physician will request that the “115 - ICC

Express” page be activated. The Chest Pain Standing Orders or AMI Order set will be entered into Maestro Care.

3.5The CICU Fellow will respond to the ED to assess the patient and collaborate in plan of care development with the EM Physician.

3.6 If patient is determined to NOT be a STEMI, the CICU Fellow or ICC Fellow will clearly state to cancel the team and the EDCU will page 115 to cancel the ICC team.

3.7If the patient is determined to have a STEMI, an order will be placed in Maestro Care by the ED and the facilitation of the patient to the ICC lab will occur as follows:

3.7.1 If the ICC lab is ready the patient is then taken directly to ICC procedure room. The ED Primary Nurse will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs.

3.7.2 If the ICC lab is not ready: The patient will be cared for in the ED and evaluated by the ICC and CICU Fellows until the ICC lab is ready. Based on available time, consider additional IV access, obtain baseline labs, initiate interventions per physician order (medications, procedures), prep patient for transfer to ICC Lab (getting patient completely undressed, gathering transport equipment—monitor, defib/ pacer, transport backpack, pacing pads on patient, obtaining oxygen tank, gathering needed paperwork).

3.7.3 The EM/CICU Fellow physician will consider administration of the following medications:

3.7.3.1 ASA 325 mg po 3.7.3.2 Nitrates (topical)3.7.3.3 Morphine sulfate IV3.7.3.4 Heparin bolus of 70 Units/kg IV, not greater than 4000 Units

total; no continuous infusion 20

3.7.3.5 Clopidogrel (Plavix) 600 mg po OR3.7.3.6 Ticagrelor (Brilinta) 180 mg po

3.7.4 When the ICC lab is ready, the ED Primary Nurse will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs.

AMI Process for Simultaneous STEMI Presenters:

4.1In the event that two (2) or more patients are identified and/or present at approximately the same time with a potential STEMI, and/or the ICC does not have immediate capacity to perform primary PCI (for example, nights or weekends), the following process, requiring clear communication and coordination between EMS, ED(s), ICC and CICU teams, will be followed:4.1.1 If the second patient is coming via EMS or via transport from an OSH and

can possibly be re-routed prior to their arrival at Duke, the CICU Fellow may ask Life Flight Communications to patch the call to the Duke Regional (DRH) Hotline (919 470-7223). The Hotline is answered by the DRH ED Charge Nurse who is aware if their lab is available and is able to activate their staff. The CICU Fellow can then instruct EMS, while on the AMI Hotline with all participants, to re-route and go to Duke Regional Hospital. If for some reason DRH is unable to accept the patient, the referring agency/EMS should come to the DUH ED for evaluation, possible lytics, or possible ICC intervention if the ICC lab becomes available within the 90 minute window.

4.1.2 CLEAR COMMUNICATION of the plan should be established between referring/transporting agency, LF Communications, the CICU Fellow, the Cath Lab Fellow (if possible) and Duke Regional Hospital. When communicating the plan to re-route the patient, please use the term “re-route” to avoid confusion with ED/Hospital Divert Status terminology.

4.1.3 If the second patient is already in the DUH ED, and primary PCI is not anticipated to be possible within 90 minutes, fibrinolytic (lytic) therapy should be considered UNLESS contraindicated or if the intervention of the first patient is almost complete in the ICC lab.

4.1.4 If the second patient is unable to be re-routed and arrives in the Duke ED, they should be treated at our facility. Extenuating circumstances require ICC/CICU Attending Physician consult/approval.

4.1.5 Patients coming by aircraft cannot be re-routed. They should come to the Duke ED and be held until the lab becomes available, or given fibrinolytics.

STEMI Launch AMI/ICC Express Process:

V.1 EMS responds to 911 request.5.2 Based on chief complaint, the paramedic will perform a 12 lead ECG (goal< 5 min)

while on scene and will interpret tracing (and also use the computer interpretation as additional information.)

5.3 If ST elevation is identified, the paramedic will call the AMI Hotline (1-866-MI2-DUKE) and request STEMI Launch.

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5.4 The Duke Life Flight (LF) Communications Center will receive the AMI Hotline call as follows: “You have reached the Acute MI Hotline, please hold while I connect you to the CICU.”

5.5 The LF Communications Center will then relay the call to the CICU Fellow on the designated phone line at 681-1077 OR will immediately page the CICU Fellow on functional pager number 970-7603 to 668-2663 (the CICU Charge Nurse will take the call if CICU Fellow is not available). This call is recorded. The LF personnel will stay as a party to the phone call.

5.6 The paramedic will provide a verbal 12-lead interpretation, brief patient information (patient name, age, gender, symptoms and time of symptom onset, vital signs, approximate height and weight) and ETA to the CICU Fellow.

5.7 The CICU Fellow will advise the LF personnel to launch the Life Flight helicopter and activate the 115 page. The LF Communication Center will page 115 and will call the ED charge nurse at 919-681-4410 to alert that EMS patient with potential STEMI will be arriving and ETA.

5.8 Life Flight will meet EMS at an arranged landing zone (LZ); obtain a brief report, load & go.

5.9 Following liftoff, Life Flight will ensure by radio contact that the lab has been activated.

5.10 Life Flight may administer the following medications:5.10.1 Aspirin, if not given by EMS5.10.2 Heparin 70 Unit/kg IV bolus, not greater than 4000 Units total if fibrinolytic therapy was delivered; no continuous infusion5.10.3 Nitrates as needed5.10.4 Morphine Sulfate IV as needed, but this will impair absorption and effect of

oral P2Y12 inhibitors.5.11 The CICU Charge nurse will ensure a bed will be available in the CICU for this

patient.5.12 Cath lab staff will notify LF Communications when lab ready to receive patient. LF

Communications will call cath lab to ensure availability prior to patient landing at Duke if call from cath lab has not been received. LF Communications will notify CICU Charge Nurse of patient ETA if cath lab not available immediately.

5.13 The CICU Fellow and/or ICC Fellow will meet the patient upon arrival to DUH on the helipad, confirm the STEMI and transport the patient to the ED for registration, then to the ICC lab.

5.14 If the lab is not immediately available (nights and weekends) the patient will be transported to the ED. The CICU HUC will complete the quick registration process, and an armband will be generated and applied to the patient’s arm and the patient will be held until the ICC lab is ready.5.14.1 The CICU Fellow and ICC Fellow (if present) will the assess patient and EMS

ECG; a plan of care will be established.5.14.2 If patient is determined on the helipad to NOT have a STEMI, the Fellow will

page 115 to cancel the ICC team. The patient will be taken to the ED from the helipad.

5.14.3 If the patient is determined to have a STEMI, facilitation of the patient to the ICC lab will occur as follows:5.14.3.1 When the ICC lab is ready the patient is then taken directly to ICC

procedure room. The CICU Fellow, ICC Fellow and an ED Nurse 22

will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs.

5.14.3.2 If the ICC lab is not ready the patient will be cared for in the ED and evaluated by the ICC and CICU Fellows until the ICC lab is ready. Based on available time, consider additional IV access, obtain baseline labs, initiate interventions per physician order (medications, procedures), prep patient for transfer to ICC Lab (getting patient completely undressed, gathering transport equipment—monitor, defib/ pacer, transport medications, pacing pads on patient, obtaining oxygen tank, gathering needed paperwork).

5.14.3.3 The CICU Fellow will consider administration of the following medications (if not already given): 5.15.4.3.1 ASA 325 mg po 5.15.4.3.2 Nitrates (topical)5.15.4.3.3 Morphine sulfate IV5.15.4.3.4 Heparin bolus of 70 Units/kg IV, not greater than 4000 Units total; no continuous infusion 5.15.4.3.5 Clopidogrel (Plavix) 600 mg po OR5.15.4.3.6 Ticagrelor (Brilinta) 180 mg po

5.14.4 When the ICC lab is ready, the CICU Fellow, ICC Fellow and ED Nurse will transport the patient to the ICC lab with transport bag, monitor and defibrillator. Report is given and transfer of care occurs.

Monitoring of the process and continuous quality improvement (CQI):

6.1There will be a monthly team meeting including: Life Flight Communication Center, Life Flight Operations, Director of the ICC Lab, ICC Clinical Lead, Director of the CICU, CICU Nurse Manager and/or Charge Nurse, Director of the Duke Heart Network, and the Director of the Heart Center of Excellence, RACE Coordinator, ED Leadership, QI Leadership.

6.2The Duke Life Flight Communication Center will maintain a log of all calls coming into the AMI Hotline.

6.3All STEMI patients will have various data points tracked, and the admitting intern or resident should include the metric of first medical contact to device (goal of < 90 minutes for EMS to Duke, < 120 minutes for transfer from another ED to Duke), and including a minimum of: 6.3.1 Basic patient information, including symptom onset6.3.2 Referring hospital/EMS agency6.3.3 Date & Time call made to 1-800-MI2-DUKE6.3.4 Date & Time of First Patient Contact6.3.5 Date & Time of First EKG6.3.6 Time patient leaves local referring ED6.3.7 Time patient arrives at Duke University Hospital6.3.8 Time of patient arrival at ICC lab6.3.9 Time of arterial access

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6.3.10 Time to needle (lytics only)6.3.11 Time to First Reperfusion Device (PTCA, Thrombectomy, Stent)6.3.12 Other extenuating events/circumstances

6.4Data and any outstanding issues will be reported at monthly meetings.6.5Feedback will be provided to Physicians involved in the case, including Duke

Physicians, each referring hospital and EMS agency within 24 to 72 hours for continued quality improvement.

6.6Referring hospitals and EMS agencies will also receive cumulative feedback at least every 12 months.

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