It.

TIt.

Iv.

CORONARY CARE

TABLE OF CONTENTS

GENERAL INTRODUCTORY REMARKS
CORONARY CARE UNITS
MOBILE CORONARY CARE UNITS

CORONARY CARE TRAINING

 
 

1. GENERAL INTRODUCTORY REMARKS

 
 

CORGHARY CARE

General Introductory Remarks

 

Care for the acute coronary patient received a great impetus just

prior to the enactment of the Regional Medical Programs Law (PL 89-239).
Inasmuch as the coronary care unit embodied an entirely new concept

for managing patients with acute myocardial infarction and the arrma-
mentaria for coronary care units required special accommodations in
design and engineering, a host of hospitals were intrigued and sought

financial support for local undertakings.

This new source of funding gave opportunity to many community hospitals
to initiate this new concept. Further, it was a way by which the local
RMP could establish a community service and immediate community ex-
posure in which life-threatening events could be managed. As a result
the RMPS became involved with a number of projects dealing with coronary
care units. It became immedicately apparent that highly specialized and
trained personnel were necessary for the efficient operation of these
specialized units. Nurse training programs were established to meet
local and national needs. Early, the RMPS responded to the local demands
and became intimately involved with training of nurses to staff the

coronary care units. Physician training to deal with these newer tech-

”

niques were also included,

Concurrently, computerization of electrocardiographic interpretation.
was gaining momentum. Efforts at regionalization from smaller hospitals

to medical centers for consultation and interpretation via electronic
Devices bezan to develop. Based on the hope that electronic trans-
mission could provide service, attempts were made to proliferate

ECG computer systems. Here again RMPS became an involved partner.

A review of project funding in the RMPS since the inception of
operational programs indicates that approximately 19 million dollars
has been awarded for coronary care training and demonstrations, in-

cluding equipment and facilities, and computerized ECG systems.

The following is a breakdown of the 100 individual projects which have
been supported in these areas. The funding represents an estimate of
fiscal investment through fiscal year 1970.

Training and Demonstration; Turses, MDs and $15,284,000
Allied Health (many included equipment)

87 Projects

 

Mobile Coronary Gare Facilities 789,000
7 Projects

Computerized ECG Systems | , 3,050,000
7 Projects

Total - 100 Projects . $19,123,000

 
 

ven - 7 11. CORONARY CARE UNITS

 
 

It.

Coronery Care Units

Regional Medical Programs Service endorses the comcept of a strati-

fied system of coronary care described in the attached report which

is based upon a draft of a proposed report by the Coronary Heart

Disease Study Group of the Inter-Society Commission for Heart Disease

' Resources. RMP regions are partiailarly encouraged to explore the

following areas:

A.

The organizational structure to implement the system - com-
munity multidisciplinary committees concerned with acute

coronary care - is non-existent in most regions.

The mechanisms for entry into the system and the emergency
transport systems are the phases of the system in which

technology and resources are inadequately developed.

The various levels of education and training within the system -
public education, training of ambulance personnel, physician

and nurse training required continuous up-dating and streamlin-

ing.

fhe financing of established technology for a.coronary care

unit, especially when such a unit is proposed independent of a
regional plan, does not appear warranted. Exceptions might be

made if grave community needs exist, and alternative funding is

unavailable.
IT.

ITr.

INTER-SOCIETY COMMISSION FOR HEART DISEASE RESOURCES

( Draft )

ACUTE CARE FOR CORONARY PATIENTS

Introduction

Community Coronary Care Planning 7

Components of a Stratified System of Coronary Care
A. Public Education in Early Care

B. WNechanisms for Rapid Entry into the System
of Coronary Care

C. Emergency Transport and Life-Support System
D. Coronary Care Unit

E. Regional Reference Centers
 

ACUTE CARE FOR CORONARY PATIENTS

I, INTRODUCTION

It has been estimated that about one million Americans experience
acute myocardial infarction or sudden coronary heart disease death cach
year, and that about 25% of these patients dictbefore reaching medical
care. (Reference: Official RMPS ~ U.S. Public Health Service estimate,
See TCHD Atherosclerosis report for supporting documents.) The mortality
in acute myocardial infarction is highest during the first few hours fol-
lowing the onset of symptoms. (Reference: Kuller, et al, Epidemiologic
study of sudden and unexpected death due to arteriosclerotic heart dis~
ease, Circ 34:1056, Dec. 1966.) It seems probable that mortality is
due most often to ventricular fibrillation, and less frequently to the
consequences of brady-arrhythmias or profound pump failure manifested
by shock or acute pulmonary edema. (Footnote: The definitive study of
the cause of sudden death in patients with coronary artery disease has
not. and probably can not be done. Because of the nature of these deaths,

the best judgment is that they occur secondary to arrhythmias.)

Before the establishment of coronary care units, average mortality

rates of hospitalized patients with acute myocardial infarction were

approximately 30%. In the past decade, there have been significant

 

 
 

+

advances in the management of this disease, most importantly the concept
of surveillance and therapy in the specialized environment of coronary
care units, In an effective unit a reduction of 50% of. the carly hos-
pital mortality rate has already been achieved. This reduced mortality

is directly related to the prompt detection, effective prevention, and

treatment of potentially life-threatening cardiac arrhythmias by means

“of specific drug therapy, defibrillation, and pacemaker insertions.
Pp 5 PY> >

However, the prognosis of patients with other serious complications,
particularly pump failure, has not changed significantly. The results

of intensive research on the pathophysiology of pump failure, and the

‘development of more successful therapy should reduce mortality in the

future,

Because the fatality rate from acute myocardial infarction is so
high during the first hours after the onset of symptoms, the objectives
are to bring the patient rapidly and safely into an optimal system of
coronary care, and to monitor him thereafter for an appropriate period
of time to detect life-threatening complications, particularly arrhythmias.
In order to accomplish these goals, a stratified and intesrated system

of coronary care is proposed to include the following components:

a. Improved education of public and of health professionals so

that the individual with symptoms of acute myocardial infarction will

make an earlier decision to seek medical care.

b. Investigation of new mechanisms to facilitate rapid entry of

patients into the medical system.

 
 

, -3-

c. Development of effective emergency transport systems for de-

livering patients to an optimal system of coronary care.

d. Establishment of emergency life-support stations where ap-

propriate, and improvement of hospital emergency areas in rendering

immediate coronary care,

e. Increase in the number and improvement of coronary care units

to provide continuous monitoring and capacity for definitive therapy.

£. Designation of regional reference centers with capabilitics

for providing .comprehensive cardiovascular care.

g- Establishment of continuous training programs for medical,
nursing, and other allicd health personnel in the care of coronary

patients.

The implementation of such a system can diminish the waste of
manpower, resources, facilities, and time which now characterize the
delivery of acute care, The alternative is for each hospital to pro-
vide identical, competitive services in an isolated and autonomous .
fashion. The components and mechanisms of the stratified system will
vary with community resources, but with innovative planning the pro-
posed system can be developed inte a coordinated network in which .
medical facilities perform different functions according to a system-

atic analysis of the needs and capabilities of each community.

 
whe
If, COMMUNITY CORONARY CARE PLANNING ee , . -

To implement the stratified care system, it is recommended that
a standing multi-disciplinary committee be established in each com-
munity for the planning, organization, integration, evaluation, and
(when necessary) the revision of the comnunity coronary care system,

The method of function of this committee will vary depending vpon '

:

local circumstances. The committee should include physicians, nurses,
hospital administrators, representatives of emergency services, and
consumers of medical care, The functions of the committee should

include:

a. Evaluation of existing facilities and determination of the

need and priorities for the various components of the stratified system

of coronary care,

b. Recommendation of policies concerning the criteria for patient
admission to various levels within the system of coronary care, and sug-

gestion of criteria for the length of stay and the time of discharge,

c. Planning, development, and coordination of an effective public

and professional educational program.

d. Development of mechanisms for facilitating the prompt entry of

patients into the system, e.8-, centralized screening telephone centers.

e. Definition of policies regarding the responsibility and authority

for patient management within various components of the system.

 

 
£. Evaluation of the impact, efficiency, and cost effectiveness
of the syston.

&» Coordination of. other community facilities for coronary care,
€.g8., services for the identification and treatment of individuals at
high risk of developing coronary heart disease, early detection units

for heart disease, rehabilitation centers, work evaluation units, etc. -

Each community should recognize its responsibility to provide
optimal care for patients with acute myocardial infarction. It should
be recognized that not all medical facilities can or even should be
expected to have the same capability, and that local circumstances will
determine the nature of the components of a coordinated system whose
goal is to place the patient with the symptoms of acute myocardial

infarction into an optimal system of care,
TIT. COMPONENTS OF A STRATIFIED SYSTEM OF CORONARY CARE ;
A. PUBLIC EDUCATION IN EARLY CARE

The first few hours after the onset of symptoms suggestive of acute
myocardial infarction are-critical, since the high mortality associated
with this time period is presumably due in most cases to the preventable
and treatable occurrence of ventritular fibrillation. Ideally, indi
viduals with these symptoms should be placed under competent medical

surveillance within one hour after the onset of symptoms.

 

 
The most important and frequent cause for delay is the patient's
indecision when he develops cppressive chest pain. (Reference: Olin
and Hackett: Denial of chest pain in 32 patients with acute myocardial

infarction, JAMA 190:977, 1964.) This indecision may be related to:
1. Lack of information regarding the significance of the symptoms.

2. Denial of the importance of. chest discomfort because of the

fear of myocardial infarction and its consequences.

3. Misinterpretation of symptoms as reflecting disorders of

other organ systems.

4, Failure to establish a relationship with a personal physician,
or to disturb a physician at an inconvenient time, such as night hours

or weekends.

5. Failure of relatives or co-workers to encourage the patient

to seek medical help.

6. Psychologic, socio-economic, and physical barriers barring

rapid entry into the system.

Many of these problems can be mitigated by a major educational
program directed at the public to.teach the frequency of coronary
artery disease, the common early symptoms of acute myocardial infarction,
and the effectiveness of prompt medical care in altering the immediate

prognosis of this disease. Individuals, particularly those who are

 

 
 

, ~7-

middle-aged and without _a history of angina, should seck imnediate
entry into the system of coronary care if they develop severe pain or
oppressive discomfort in the retrosternal region, especially if it
radiates to the arms or neck and does not promptly disappear, Although
acute myocardial infarction can present with other symptoms, the charac-
teristics noted above are sufficiently sensitive and specific to serve
“as a warning message directed to the general public, Individuals at
high risk for coronary artery disease, such as those with hypertension,
a history of cigarette smoking, hyperlipidemia, or diabetes should

constitute a particular target population for this educational message,

Patients with a history of angina pectoris should not enter the
system of coronary care after every episode of angina. They should be
instructed that more frequent or more severe angina, or a change in

pattern, may herald acute myocardial infarction.

More education of the public will probably produce a large number
of false alarms, However, the number of lives saved should justify the
‘inconvenience and cost in terms of time and dollars. Analysis of such

false alarms should result in improvement of the educational programs.

B. MECHANISMS FOR RAPID ENTRY INTO THE SYSTEM OF CORONARY CARE

- -

When an individual makes the decision to seek medical attention

for symptoms of acute myocardial infarction, access into the system

should be rapid and efficient. One mechanism, if the patient has a

 

 
: -S-

personal physician, is to contact hin immediately. Unnecessary phy-
sician delay often results fron difficulty in reaching the personal
physician, the physician's hesitation in making the presumptive diag-
nosis of acute myocardial infarction over the telephone, or his lack
of information about community facilities and resources for. coronary
care. It should be emphasized that almost two-thirds of the patients
with acute myocardial infarction have prodromal symptoms including pro-
gressive or crescendo chest pain within one week before the onsct of

the acute attack and frequently consult a physician during this time.

fo improve the response to the individual seeking help, physicians
and other health personnel likely to make primary contact with the
patient experiencing symptoms of acute myocardial infarction should be

educated in the following areas:

1. Recognition of the signs and symptoms of impending acute

myocardial infarction.

2._ Familiarity with community resources and facilities so that
the patient can be advised how to reach a monitored bed as rapidly as

possible,

3. The ability to perform cardiopulmonary resuscitation,
(Reference: Definitive Therapy in Cardiopulmonary Resuscitation,

AHA, 1965.)

 
 

, _9-

4. Understanding by the physician of the indications and uses of
basic medications in the treatment of cardiac arrhythmias. ALI phy~
sicians, should have available atropine and lidocaine, or other appro-
priate medications if these are superceded in the future by more

effective therapeutic agents. (Reference to Bethesda Conference)

If the patient does not have a personal physician, or if his
response is not immediate, other mechanisms for entry into the system
of coronary care must be available. The patient may contact an
emergency room, an ambulance system, or a coronary care emergency
telephone number for immediate assistance. Each community should de-
velop its ow response system, but it is suggested that a local tele-
phone information center and community information service be developed,
When an individual experiencing symp toris calls the center, he would be
advised by a professional person about the need and availability of
medical care. If the patient needs prompt attention, he will be di-

rected to the nearest hospital or life support unit by the best avail-

able transportation. In the future a generally desirable option may be

that of a national telephone network with a single number, such as that
presently used to obtain information regarding telephone numbers in

various cities. -

~ ”

Other approaches to the problem of prevention of arrhythmias during

the first hours after onset of symptoms are currently being explored.

One rational and promising concept is the use in high risk groups of

 

 
‘ ~10-

self-administercd atropine or lidocaine, preferably under a physician's
telephone direction, as soon as symptoms are recognized. This approach
merits further investigation,
C. EMERGENCY TRANSPORT 42ND LIFE SUPPORT SYSTR
After an individual with the symptoms of acute myocardial infarction
“has sought help, it is essential that a rapid emergency transport system
be available, and that a bed in an emergency or coronary care facility

be prepared to receive him. Otherwise, the time, effort, and money

spent on public and professional education is wasted, .

1. Emergency Transport System

 

Until recent years, the patient's emergency transportation has
been left to his own devices. In some communities the patient can
reach an emergency care system relatively quickly, while in others
traffic congestion or lack of accessible medical facilities cause
~ inordinate delay. Therefore, the emergency transport system should
provide the facilities needed for the detection and therapy of cardiac
. arrhythmias, and should have the capacity to perform cardiopulmonary

resuscitation. Two types of transport systems have these capabilities:

a. Mobile Coronary Care Units. These vehicles are designed to

 

respond only to suspected cardiac emergencies. They are staffed by a
physician (or telemetry communication), nurse, and other health person-

nel and are equipped with facilities for monitoring, recording

 
 

, ~Li-

electrocardiograms, defibrillation, cardiac pacing, and pharmacolopic
therapy. In some vehicles a two-way communications system is established
through radiotelephone, “and electrocardiograns may, be transmitted via
telemetry from the vehicle to a receiving station. These vehicles are
prepared to stabilize a patient's condition in his home and in the.
vehicle, then to transport him rapidly to a continuing care unit,

Whether Mobile Coronary Care Units should be generally recommended ox
implemented in many cities is still controversial, Preliminary observa-
tions have demonstrated the effectiveness of such units in the manage-
ment of life-threatening cardiac arrhythmias complicating acute myocardial

infarction.

b. Emergency Transport Vehicles, These vehicles respond to all
medical emergencies. They are frequently operated by allied health
personnel, and are equipped with less complete facilities for dealing
with acute cardiovascular emergencies, It is mandatory that the person-
nel who staff these vehicles receive adequate training in recognition
and be competent to treat a cardiac emergency, particularly life-
theentening arrhythmias. ~ They should be authorized to initiate drug
therapy ox defibrillation, preferably under a physician's supervision
through voice communication with a control station. Equipment should
include an electrocardiograph, a battery operated defibrillator and-
constant monitor oscilloscope, oxygen and treacheal suction apparatus,
and cardiac drugs such as atropine, lidocaine and analgesics. Telemetry

transmission of the electrocardiogram from the vehicle to a control . .

+

station is recommended,

 

 
The advantages of the Imergeney Transport Vehicle over the Mobile
Coronary Care Unit are that (1) since it is not dedicated solely to
coronary care, its cost effectiveness is Sreater, and thet (2) it does

not divert medical .and nursing personnel from other high priority duties.

Improvement of the present ambulance system in the United States
to meet the Emergency Transport Vehicle standards described above scens
a more promising approach for the future than the concept of Mobile

Coronary Care Units.

2. Emergency Life-Support Station

An emergency life-support station is a unit which is strategically
located in areas of population density in which patients afflicted with
symptoms of acute myocardial infarction can be provided with immediate
care. Its staff may include physicians, nurses, or allied health person-
nel, but a physician knowledgeable and skilled in the Management of :
cardiovascular emergencies should assume administrative and supervisory
responsibility. It should be equipped for the capability of providing
continuous electrocardiographic monitoring, performing cardiopulmonary
resuscitation, and initiating appropriate drug therapy for brady- and
tachy~arrhythmias and defibrillation. Emergency cardiac pacing is seldom

needed in these stations. The purpose of the emergency life-support

-

station is, therefore, to stabilize the condition of a patient with sus-~
pected acute myocardial infarction before transfer to a coronary care

unit for continuing therapy.

 

 
 

~13-

The Mobile Coronary Care Unit is oné type of emergency life-support
station which can be brought to a patients's home or to other locations,
Stationary life-support units might be considered for the following

locations:

a. Areas where a large number of employees work on weekdays, such

“as factories, industrial plants, or large business centers.

b. Areas where there is a constant incoming and outgoing of mass

population, such as metropolitan airports and large railroad stations.

c. Areas where there is a periodic concentration of mass popula-

tion such as sport stadiums and convention halls.

However, in most communities the logical and ideal site for an.
emergency life-support station is the emergency department of a hospital
_ or an adjacent area. Every hospital with an emergency area should meet _
the standards for an emergency life-support station specified above, and
should have these capabilities on a twenty~four hour basis. The standards

should be met regardless of whether the hospital has its own coronary

care unit.

The specific policies of the hospital emergency areas with regard

”

to suspected acute myocardial infarction depend on local circumstances,
- but it should be emphasized that a patient with a history compatible

with an acute myocardial infarction should not be discharged from the

emergency department on the basis of an initial "normal" electrocardio-

gram. If the diagnosis is in doubt, it is always advisable to transfer the

patient to the coronary care unit for further observation and monitoring.

 
 

Every hospitel emergency area should be able to provide life support
to patients with acute myocardial infaretion. this does not mean that
every hospital should have a coronary care unit.. The decision to cstab-
lish a coronary care unit, as discussed below, should be predicated on.

the needs of the stratified system.

D.- CORONARY CARE UNIT

1, Coronary Care Concept

 

At the present time, the coronary care unit is the most important
and effective component of the stratified system of coronary care. It
is a specialized unit within the hospital which, through continuous
surveillance of patients with suspected or proven acute myocardial in-
farction, provides for the early detection and prompt therapy of certain

complications in the initial phase of the disease. The benefits of the

coronary care unit are based on the observations that (1) the sudden or

early death of hospitalized patients after an acute myocardial infarction
is usually due to cardiac arrhythmias, most commonly ventricular fibril-
lation, and that (2) these arrhythmias are largely preventable or re-

versable.

However, even if all patients with acute myocardial infarction were
treated in coronary care units, hospital mortality would still be sig-

nificant because of additional complications such as intractable heart

failure and cardiogenic shock. Additional patients die from arrhythmias

 
~15-

... and other complications after they have been transferred from the coronary
care unit. Many of these hospital deaths outside the coronary care unit
result from disturbances in cardiac rhythm, Therefore, if the mortality
rate of hospitalized patients with myocardial infarction is to be fur-

ther reduced, more effective therapeutic measures for these complications -

particularly pump failure - will have to be developed, and the period of _.

~ Continuous monitoring of patients transferred from the coronary care

unit will have to be extended,

Prolonged monitoring of hospitalized patients can be accomplished
by step-down units for continued observation, preferably located near
the coronary care unit, After the initial period of approximately five

days in the coronary care unit, patients can be continually monitored

in this progressive step-down system.
2. Establishment of the Coronary Care Unit

Hospital size alone should not be the determining factor in the
decision to establish a coronary care unit. The issues bearing on this
important decision should be the availability of qualified and dedicated
physicians, nurses, and allied health personnel, the number of patients
admitted annually with suspected myocardial infarction, and the adequacy

- - |

of other area facilities,

For many small hospitals having fewer than fifty beds and admit-

ting less than twenty-five patients annually with suspected or proven

 

 
- 16 -

myocardial infarction, it does not seem feasible to designate specific
beds for definitive coronary care. In these hospitals a life-support
station as previously described should be provided in the emergency
department or adjacent to a nursing station on a medical floor. As soon
as the patient's condition is stabilized, expeditious and safe transfer

to the coronary care unit of a nearby Larger hospital can be performed.

Paragraphs 3 (Staffing); 4 (Physical Spreifications); 5 (Organization and
Operation); and 6 (Step-down Units) omitted - not particularly pertinent

to Council at this time.

E. REGIONAL REFERENCE CENTERS

 

Many institutions, often hospitals associated with medical schools,
have full-time house staff, trained cardiologists, cardiac surgeons and
training programs in coronary care for physicians, nurses, and allied
health personnel. These institutions also have specialists in all
medical fields, facilities fer cardiac catheterization and angiographic
studies, and programs in cardiovascular surgery. Often they have active
research programs in areas which bear on the problems associated with
coronary artery disease. Such institutions may be designated as regional
reference centers. The functions and capabilities of these centers

within the stratified system of coronary care are as follows:

1. To receive patients who have serious complications and require

special diagnostic study and therapy. These complications may include:

a. Serious cardiac arrhythmias and conduction defects, particu-

 
 

- 17 -

larly in those patients with indications for insertion of pacemakers.

b, Profound cardiac failure which micht be helped by spectai-

ized medical therapy or by circulatory assist devices,

c. Suspected ruptured papillary muscle or perforation of the

ventricular septum requiring special studies and surgical intervention. |

2. To provide consulting services for neighboring hospitals such as
a physician in residence, electrocardiogram interpretation by telephone

transmission, or medical conferences by closed-circuit systems.

3. To maintain continuing education and training programs in coronary

care for physicians, nurses, and allied health personnel.

4. To assist the community in planning for coronary care. If
requested, the center might provide quality control for emergency vehicles

or for life-support stations.

5. To serve as centers for data collection, analysis, and registry
of patients with coronary artery disease or acute myocardial infarction

to facilitate epidemiologic study and evaluation.

6. To perform research in coronary artery disease in general, and

acute myocardial infarction in particular. .

IV. SUMMARY
A stratified and integrated system of coronary care is proposed to

treat patients with acute myocardial infarction. Because preventable

deaths are occurring before patients reach medical attention, each

 
 

-~ 18 -
interval of the delay period must be shortened:

(1) The patient's period of hesitation between onset of symptoms and
decision to seek medical help should be shortened by public education

programs.

(2) Entry into the medical system should be facilitated by. improved

physician response and by new information systems.

(3) Emergency transport systems and Life support stations should be
developed with the capability for treating arrhythmias and stabilizing
patients before transfer to a coronary care unit. All hospital emergency

areas should have these capabilities.

After a patient with an acute myocardial infarction has reached a
coronary care unit, he should receive monitoring and therapy for an
appropriate period of time, which may be prolonged in step-down units.
The specialized benefits of regional reference centers should be avail-

able when necessary.

The cornerstone of such a system is community planning to provide
maximum integration of personnel and resources, and to develop Local

solutions to the problems in each stage of coronary care.

 
 

111. MOBILE CORONARY CARE UNITS

 
Til.

A.

MOBILE COROSARY CARE UNITS

 

MOBILE CCU's FUNDED BY RMPS

 

1. General - RMPS funded seven Mobile Coronary Care Units between
March 1968 and February 1970. The total cost through June 1970 was
$837,000. On August 1970 we sent a questionnaire to each Project
Investigator through their respective RMP coordinators. A copy of

the questionnaire is attached as Appendix I.

Four of these Units provided comprehensive services and account for

$781,000 out of the total of $837,000. These Units are located as

follows: -
New York City, New York
Columbus, Ohio

Seattle, Washington

Montgomery County, Maryland

The remaining three Units accounted for $56,000 out of the total of
$837,000. None of these Units represents a full scale operation,
each for different reasons. These Units will be described separately
below, They are located as follows:

Mason city, Towa

Portland, Oregon

Waynesville, North Carolina

2. The Four Units with Comprehensive Services

 

a. New York City, New York

 

The MCCU team consists of a physician, nurse, technician, and driver

who are on duty at various parts of St. Vincent's Hospital. On calls

 

 
~2.-

from the Police Department they board an ordinary hospital ambu-
Lance with portable equipment. It takes the team 4% minutes or
less to board the ambulance and start on the way. Patients are
taken to St. Vincent's hospital but there are plans to include

other hospitals.

In nineteen months of operation, the Unit transported 729 cases,
89 of which were MI‘'s. Of the 7 cases of cardiac arrest that were
resuscitated and brought to the hospital alive, two Lived to be
discharged from the hospital alive. The median age was 65 and the

.median time to reach the patient was 8 minutes.

b. Columbus, Ohio

The MCCU team consists of a physician, technician, and two mem-
bers of the Columbus Fire Dept. Emergency Squad. The vehicle is
specially equipped like a Coronary Care Unit adapted to conditions

in a mobile vehicle. Patients are taken to 5 hospitals.

In 15 months of operation, the Unit transported 699 cases, 160 of
which were MI's. Of the 13 cases of cardiac arrest that were resus-
citated and brought to the hospital alive, 5 lived to be discharged
alive. The median age was .59 and the median time to reach the pa-

tient was 11 minutes. - -

c. Seattle, Washington

The MCCU team consists of a physician, technician, and a driver.

There are two specially ecuipped ambulances. Patients are taken to

21 hospitals.

 
 

In 4 months of operation, the Unit transported 185 cases, 88 of
which were MI's. Of the 23 cases that were resuscitated and
brought to the hospital alive, 8 lived to leave the hospital alive.
The median age was 59 and the median time to reach the patient

was 7 minutes.

d. Montgomery County, Maryland

The MCCU team consists of a nurse, technician, and a driver,
working under orders of a physician via 2-way telemetry. The
physician also monitors the ECG on an Oscilloscope via the tele-

metry. Patients are taken to 3 hospitals.

In 3% months of operation the Unit transported 98 cases, 36 of which
were MIi's. Of 5 cases that were resuscitated and brought to the
hospital alive, 1 lived to leave the hospital alive. The median

age was 65 and the median time to reach the patient was 6 minutes,
e. Summary (Also see Appendix IT)

The cost per MI transported averaged $1,200 at the three loca-
tions and ranged from $690 in Seattle to $1,500 in New York City.
The cost per case that was resuscitated and left the hospital alive
averaged $29,000 at the three locations and ranged from $7,000 in

”

Seattle to $60,000 in New York City.

These differences are accounted for in part by the fact that Seattle

differs significantly from the other locations in two ways:

 
 

~4&-

1. the high proportion cf transported cases that were MI's
2. the large number of cases per month that were resuscitated

and brought to the hospital alive.

If we omit Seattle from consideration for a moment, we note that
the cost per MI transported averaged $1,400 and varied only from
$1,300 in Montgomery County to $1,500 in New York City. The cost
per case that was resuscitated and left the hospital alive averaged
$50,000 and varied only from $45,000 in Columbus to $60,000 in New

York City.

3. The Remaining Three Units

 

a. Mason City, Iowa

The staffing consists of a nurse, attendant, and a driver, using
a specially equipped vehicle. The Unit serves 7 hospitals within
a 35 mile radius in a rural area. At pressnt, only calls from ‘
physicians are accepted, usually for transferring patients from
hospitals to other hospitals with CCU's. The project had only been

in operation for 12 days as of June 30, 1970,

b, Portland, Oregon

This was only intendedas a feasibility study. The crews and
vehicles were those of a regular Fire and Rescue Personnel, Two-way
telemetry was added to three emergency ambulances for monitoring of |
cardiac emergency patients by a nurse at the hospital in order to

demonstrate the need for on-site defibrillation by attendants acting

 

 
~5-

under verbal orders through telemetry. The demonstration was
considered a success and a full scale operation is planned with

local funding.

ec. Waynesville, North Carolina

This was a feasibility study for rural Appalachia. Portable
equipment was provided for two ambulance, one Stationed at |
Waynesville and another at Canton. This project did not charge
‘RMP for the ambulance. Also, they charged the patient a fee.
For this reason, no attempt was made to estimate the cost per case.
During the one year period from July 1969 through June 1970, there
were 100 cases transported, of whom 25 were MI's. A physician was
at the scene or arrived shortly after the call in 30% of the cases,
There were three cases who were resuscitated and who reached the
hospital alive. Of these, two left the hospital alive. The indi-

vidual case reports have not as yet been submitted for review.

B. AMERICAN HEART ASSOCIATION SURVEY

At our request, the American Heart Association surveyed their 125
‘Chapters and Affiliates during September 1970 to determine the number of
Mobile Coronary Care Units in operation and the number planned throughout
the country. The findings from the chapters and affiliates that responded

show 26 Units in operation and 21 more being planned.

”

Appendix III shows that 7 of 26 MCCU's in operation around the country used

a physician. Sixteen of the 26 used either a nurse or a physician. However,

 
 

of 12 MCCU's not now in cperation but with plans formulated for the future,

only two include a physician or nurse.

 

 
 

APPENDIX TI
EVALUATION OF MOBILE CCRONARY CARE AMBULANCE
RMPS Operational Project Grant

From date RMPS Grant authorized to June 30, 1970

I. General Information
A. Sponsoring Institution
B. Project Director
C. Service area of Mobile Coronary Care Unit
1. Number of hospitals to which patients are customarily transported
by Mobile CCU

2. Square miles covered by service

 

3, Estimated population residing or working in area served

D. Date RMPS grant authorized

 

Mo / Day / Year

E. Date Mobile CCU began operating

 

Mo / Day /. Year

II. Operating procedures

A. Hours Mobile CCU scheduled for service
(Show initial schedule and subsequent changes thru June 30, 1970)

 

Dates Number of

 

From To hours per week

 

 

 

 

 

 

o

 

 

 

B. Under the most current protocol of standard operating procedure, who
is privileged to call the Mobile CCU? (Check one)

[7 Anyone

[7 Physicians only

[7 Other groups (Specify)

 

 

 

 
Ill. Fiscal Data through June 30, 1970

‘A. First fiscal year actucl expenditures, from

»

to

 

Mo /Day’ Yr Mo
(From date RNPS grant authorized to end of first fiscal year or
June 30, 1970, whichever is earlier)

hay / Yr

 

Estimated allocation of total expenditures

 

Item of expense

Before initiation of
services

After initiation of
services

 

nes Funds

I
Other Funds

RMPS Funds

ae
vas

Other Funds :

 

2
Personnel “Vescccesacee,
: 2
Training of personnel .~

Equipment

2

a, Special equipment .”.

b. Ambulance vehicle ..

c. Ambulance equipment

d, Other equipment .,,

SUPPLLeSS oo eee ese eeecees
. 4

Other direct costs %\...

Indirect costs ...cecces

i

 

 

 

 

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 

1, Include estimated value of all services, equipment, ete., donated to

the MCCU project.

2. Include ali services paid for either directly or by subcontract,
3. Include ECG, defibrillator, mechanical CPA, telemetry, and voice
communication equipment.
4, Include consultant services for other than training of personnel.

*

 

 
 

B.

Cc.

~

3

Second fiscal year actual expenditures, from to

Mo /Day /Yr Ho /Day/Yr
we x
; )

 

Item of expense

Extimated allocation of
total expenditures

 

RMPS Funds Other Funds *

 

Personnel 2 cece e ee nse ccnres

Training of personnel 2.,

Equipment

a. Special equipment 3,

b. Ambulance vehiecle....

c. Ambulance equipment...

d, Other equipment......

SUPPLIES. ccc cece eee ec ccee

Other direct costs 4...
Indirect CostS.. cece eee ence

 

 

 

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 

Third fiscal year actual expenditures, from to

Mo /Day /Yr Mo /Day / Yr

(To end of third fiscal year or June 30, 1970, whichever is earlier)

 

—-

Item of expense

Extimated allocation of
total expenditures

 

RMPS Funds Other Funds +

 

Personnel 2 lececccceces

Training of personnel 2.

. Equipment

a. Special equipment 3..

b. Ambulance vehicle ...

c. Ambulance equipment..

d. Other equipment......

Supplies. ccccccceccccsece

Other direct costs.“

eoeteee

.

Indirect cosStS...ccececces

.

€

 

 

 

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 
 

~

IV. Operating Problens
A. Describe difficulties with:

1. Vehicle

 

 

 

2. Electronic equipment

 

 

 

3. Other special equipment

 

 

 

4. Personnel

 

 

 

B. Estimated total number of scheduled hours Mobile CCU was not in

operation ("down time') during each fiscal year.

 

Reason Fiscal Year

 

First 5 Second 5 Third 5

 

Personnel or staffing problems

 

Other reasons

 

 

 

 

TOTAL

 

 

 

5 To end of fiscal year or June 30, 1970, whichever is earlier

 

 
 

V. Operational Statistics through June 30, 1970

 

 

 

A. Number of calls answered. ..... cc cee eee cee wee

 

1. Number of calls cencelled en route........

 

 

2. Number of arrivals on scene.........06-. 1.

 

a. Number of individuals not transported : . '
to hospital by Mobile CCU....... i

(1) Dead on arrival of Mobile CCU....

 

 

 

(2) Died at scene after arrival......

 

(3) No need to hospitalize......ceeee

 

(4) Transported to hospital by other
than Mobile COU. ccc cer ecccceces

(5) Other reasonsS...... ccc secs ccecece

 

 

bk. Number of individuals transported to

hospital by Mobile CCU..........

(1) Died en route... cece eee ee ceees

 

 

(2) Avrived at hospital alive.......

 

(a) Died in emergency room.....

 

(b) Discharged from ER (not
requiring hospitalization)

 

(c) Hospitalized. .... cece eee eed

 

(la) Admitted to CCU........

 

(1b) Admitted to ICU.......4

(lc) Admitted to other
-hospital bed........4

 

 

B. Total Hospitalized (Same as (c) above)........

 

Principal discharge diagnosis:

1. Myocardial infarction. ..cecccccvces

 

Other coronary diseaseé......cecceceed

 

SCrOk@. . i ccc cece ccc cccetccccceeveced

 

Other cardiovascular disease........

 

Non-cardiovascular disease.........4

 

. Discharge diagnosis not known......4

 

“SO ON & Ww Bh
eo

 

Still in hospital... cc... ccc ewe e eee

 

 

 

 

 
- 6 =

VI. Therapy Statistics through June 30, 1970

 

Fiscal Year

 

First? | Second? | Third

 

A. Number of individuals who received CPR and
one or more defibrillations Total...

 

 

1. Reached hospital alives....ccccccevccens

 

2. Died before reaching hospital...........

 

B. Number of individuals who received CPR {-
ce only Total...

 

1. Reached hospital alive....ccccccececcoes

 

2, Died before reaching hospital....ccceees

 

C. Number of individuals who received one or
more defibrillations without CPR Total...

1, Reached hospital ALIVE. Leese cece cc cenen

 

2. Died before reaching hospital....csseees

 

D. Number of individuals who received CPR
and/or one or more defibrillations and
who reached hospital alive.
(Sum of lines A-1, B-1, and C-1) Total...

 

1. Died in Emergency RoOm...iscccsceccecece

 

2. Died in hospital.... cece esc ec cccccccecs

 

3. Discharged from hospital alive..........

 

E.. Number of individuals who received
medications Total...

 

1. For disturbances of rhythm........eee--4

 

2. For discomfort or pain..cscccccccccceccs

 

3. For acidosSiS....cc ccc cccccacccccccccecce

 

4. For Anxiety. .ccccccccccsccccvcccececeves

 

 

 

 

 

 
 

VIL. Observetions on beneficial effects other than individual therapy
resulting from the existance of the Mobile ccUuU. (Briefly list
events such as (1) activities by other organizations, (2) problems
the medical community became aware of, (3) upgrading of medical or
hospital services, (4) talks, seminars, or training sessions,

(5) public education programs, etc.)

7 A.

 

 

 

 

 

 

 

 

 

 

 

 

i

 

 

 

 

 

Prepared by: Date:

 

 

 
 

CASE HISTORY FOR CARDIAC ARREST PATIENTS
WHO REACHED THE HOSPITAL ALIVE
I. General Information

A. Initials or other identification of patient

 

B. Date of episode
. Mo / Day / Year

C. Age
D. Sex: {7 Male [7 Female
TI. Pre-Hospital data

A. Date and time of first symptoms [7] AM
Mo / Day / Yr Hr / Min LL] PM

B. Date and time call for Mobile CCU received [7] ix
Mo / Day / Yr Hr / Min [/?

 

C. Time Mobile CCU arrived at scene
tir. / Min °

D. Condition of patient on arrival at scene

 

Clammy or sweaty

 

f/f Stable {[] No heart beat (Pulselessness)
{7/7 Unconscious {/] Not breathing

{-] Semi-comatose L/ Pupils dilated

[7 Shortness of breath © [] Other

£7

T7

Abnormal pulse

 

E. Was cardiac arrest validated by ECG monitor or tracing? (J ves // No
F. If "Yes", was it § £-/ Ventricular standstill?

f/ Ventricular fibrillation?

G. How long was CPR applied?

 

‘ H. How many times was defibrillation applied?

 

 
Tit.

IV.

~2-

I. Complications and therapy at scene or during transport

ECG changes

Clinical [oe cpanes RX Therapy / Medications

 

 

 

 

 

 

 

 

 

 

 

 

 

Known to be alive 6 months after discharge from hospital

Time
Emergency Room
A. Was patient taken to Emergency Room? J / Yes l/ No
B. If "Yes", did patient die in ER? [7] Yes [7] No
Hospitalization
A. Was the patient admitted to the hospital? [7] Yes £7 No
B. History of prior cardiovascular disease
f£] Myocardial infarction
f£] Other cardiovascular disease (Specify)
C. Hospital discharge diagnosis
Outcome
A. Surival (Check all applicable items)
[7] Discharged from hospital alive
. (Date)
{-] Died after admittance to hospital °
| a . (ate)
(7 Died within 6 months after discharge from hospital
(Date)
[7
£7

Survival not known 6 months after discharge from hospital

 

 
 

 

B. Gause of death on death certificate:

 

 

 

VI. Remarks:

 

 

 

 

 

 

 

red by: Date:

 

 

 
000‘ S#s

 

000‘62$ 000“ L$ 000‘ZS 000‘09s
002‘ ooe ‘I$ 0698 0O0#‘T$ 00s ‘I$
OLz$ oss OES. Oz€$ osts
000‘ S9%S 000°L45 000‘19$ 000‘92z$ 000‘TETS
000‘ 9TES 000‘06$ 000‘ €0T$ 000‘ €6$ 000‘0E$
BEE Z0Z “SE “BE “87
91 Tt 8 S z
eT 7°T B's 6°0 7°0
847 S €? et ZL
“£00 DLE “89 LES 421
“ELE 9€ 88 091 68
ou aed Ty ‘ou aed 97 ‘ow aed gy ‘ow rod fy ‘ow aed g¢
TtZ*T 86 SBT 669 62L
"say 08 *siy got "say OT "say COT
"sow &Ly *sou &E ‘sow "sow CT *sOoul 6T
[BIOL {*pH f°0D Arzowosquoy! ‘ysem ‘ezTaqees | oTYO ‘snquinjog] °A°N ‘4919 YAO MON

 

 

 

 

 

 

II d.unddadv

 

SNOILVOOT y LV LT

GNV SLSOD ONILVUado

OATTe Tejtdsoy azet zeuy
uopzjIeAyosnsera rzvd 4ysoo Burqezsdg

pejztodsueiy *[°W aad qsoo 3upjeaado
pejaodsuezz asvo aad ysoo ButTqerz3do
$3809 3utqeredo

$3809 [eTI TUL

 

$3s09
SATLTE [eVAtdsoy Buyaesy, Jusorzed
BATTS [TBATdsoy BuyAesy, *ON

BATTS TeItdsoy of 4Y8norq pue
paszezzosnsaaz yQuow asd saseo jo °ON

@ATTe TeatTdsoy oF WYyBsNoAg
pue pezejyosnsea saseo Fo “ON

$,°I°W a1em 3eu3
peqaodsue1z, saseo yo Zusorag

pejaodsuerzy s,°I'W °ON
yquow aad pejiaodsuez3 soseo °oN
pajiodsurez3 seseo °ON
yeem aed uoyyearedo ut *say *ON

uoyfjzertadg yo syQuOW

 

 

SLINSAa

 
APPERDIX IIT

SURVEY OF MOBILE CORONARY CARE AMBULANCES

IN OPERATION

 

Date Physi- Trained M.D,

Started cians Nurses Personnel Meets a b c d

No. City and State Mo, Yr. (See below)
1. Inglewood, Calif. 8/69 - x x - x x x
2. La Jolla, Calif. 8/70 x x x - x x xX xX
3. Rancho Santa fe, Calif. ~/67 - - x - x* - x
4, San Francisco, Calif. 6/70 - - x - x x x Xx
5. Tulare, Calif. 10/70 - x x - “ - x* «x
6. Hartford, Conn. 2 - ~ x - x - x x
7. Jacksonville, Fla. ? - x - - x x x x
8. St. Petersburg, Fla, ? - x x - - x - x
9, Marietta, Georgia 6/70 - - x - x x x Xx
10. Chicago, Illinois 9/69 x x - - - x x* x
li. Champaign County, I11.* 9/70 x x x ~ - x - x
12, Mason City, Iowa 6/70 x x x x x xX xX xX
13. Bethesda, Maryland 3/70 - x x - xX xX x Xx
1’ Columbia, Missouri 6/58 - - x - x x x x
1 Newark, New Jersey 7/69 x - x x - x* xX Xx
16. Alburquerque, New Mexico 8/70 - x x x xX - = =
17. Elmira, New York 9/70 - - x - x x x
18. Winston-Salem, N. C. 1/68 - - x - KH = = -!
19, Akron, Ohio 11/69 - - x x x X -
20, Columbus, Ohio 4/69 x + x - x x x x
21. Oklahoma City, Okla. 11/69 - x x - x x - Xx
22. Portland Oregon %** 1/70 - - x - x -xX x -
23. Greensburg, Penna. 10/69 - - x - x xX -
24. Ligioner, Penna. 1/70 - x - - x x - «
25. Hanover, Penna. ~ -/69 - x x x x xX xX X
26. Seattle, Wash. 3/70 - x - x x x x
TOTAL 7 13 23 6 21 22 17 23

“Ambulance equipped with:
a. voice communication to obtain professional guidance -
b. portable electrocardiogram
c. telemetry to monitor the ECG
d. portable defibrillator

* Football games only
* (2 Ambulances)

 
 

SURVEY OF MOBILE CORONARY CARE AMBULANCE

PLANNED TO OPERATE

 

. Date Physi- Trained M.D.
Will Start cians Nurses Personnel Meets a b c d
No. City and State Mo. Yr. (See below)
1. Los Gatos, Calif. 1/71 - x - x x x
2. Orange County, Calif. -/71 x x - - - So - ox
3. San Francisco, Calif. -/71 - - x - x xX KX xX
4&4. Miami Beach, Fla. 4/71 - - x - x - x x
5. Honolulu, Hawaii 4/71 - - x - x x jx Xx
6. St. Louis, Mo. -/71 - - x - x xX x Xx
7. Middlesex County, N.J. ~/71 - - x - x oc XK -
8. Nassau County, New York 11/70 - - x - x x x x
9, Jeannette, Penna 1/71 - - x x x x x= x
10. York, Penna -/70 - - x x x x XxX Xx
ll. Columbia, S.C. (2 Units) 7/71 - - x - x x xX Xx
12. Worris, Minn. -/71 - - - - - = x =
13. Tulsa County, Okla Not Yet Formulated
14. Hartford, Conn. " " u
15 WN. E. Florida " " We
1. tampa, Florida " " u
17. Atlanta, Georgia " " "
18. Mississippi nt mt "
19. Winston Salem, N. Cc. " " "
20. South Dakota " " "
21. Utah it tt tt
TOTAL 1 2 9 3 10 9 1 10

a.
b.
c.
d.

Ambulance equipped with:

voice communication to obtain professional guidance

portable etectrocardiogram

telemetry to monitor the ECG

portable defibrillator

 
 

iV. CORONARY CARE TRAINING

 
iv. CORONARY CARE TRAINING
A. BACKGROUND TNFOSMATION

Among the categorical diseases specified in the PL 89-239, heart
disease is currently receiving the greatest emphasis in Regional Medical
Programs ag it did in the early phase of the program. This legislation
reflected a growing national interest in accelerating progress in the.
care of patients with heart disease. In response to this interest, the’
American College of Cardiology and the Heart Disease Control Program in
1965 sponsored the "Second Bethesda Conference on Training Technics for
the Coronary Care Unit." Proceedings of this Conference with recommenda-
tions regarding training were subsequently published. In 1967 and 1968,
additional publications became available from the Public Health Service

on coronary care units and physician and nurse training programs.

The proceedings from the 1968 conference, "The Outlook for Coronary

 

Nursing," contain recommendations for training. These recommendations
are further reinforced in the findings of the Cybern Education, Inc. whose
two-year evaluation (Xerox Report) study was recently completed. .This
study of eleven nurse training programs funded by the Heart Disease and
Stroke Control Program highlights the following findings:
1. that attention be given to more careful selection criteria for
students with specific emphasis‘on the selection of those students

who will be returning to already established units.

2. that programs be geared to a greater degree to adult learners’!

needs and previous experience when possible such as providing special

 
B..

units of study for those learners who will be responsible for teaching
or administration of the coronary care unit. The findings further
suggest that those students without experience and those with previous
experience should be taught separately when possible to adapt to

their varying needs.

~ 3. that communication between the training center and sponsoring

hospital be formalized so that a regular flow of information be
facilitated regarding trainee expectations, responsibilities and
capabilities of trainees among: Medical Staff, Nursing Administration,

Hospital Administration, and Trainees,

4, that the curriculum include more concentrated preparation in the
area of fluid and electrolyte balance, non-coronary complications,

EEG interpretation and renal aspects of coronary care,

5. that each training center should have access to facilities where

the patient population is adequate for clinical practice at all times.

(This was the most universal complaint expressed by trainees and

their sponsoring hospital's supervisors.)

RMP CONTRACT ACTIVITY

It is anticipated that by early next year, training guidelines will

-

be available from the Inter-Society Commission for Heart Disease Resources

funded by a Regional Medical Program contract with the American Heart

Association. Additional training specifics will probably continue to

emanate from within regions or states such as the enclosed guidelines for

 
-3-

curriculum and the use of multimedia instructional systems produced by

the New York Heart Assembly. (see Attachment A) The majority of

committee members responsible for the work were RMP staff people from

throughout New York State.

Cc.

RMP PROJECT ACTIVITY |

 

1. Some coronary care training programs have attempted to increase
their impact on patient care by identifying and overcoming barriers
to implementation of new knowledge and skills. One such example is
that of the Intensive Care Training Project in Area I of California.

(see Attachment B)

2. From the paucity of information available, the turnover of RMP
trained coronary care nurses in units appears to vary considerably.
Professional leadership in regions need to be encouraged to adopt a
common Language in defining turnover and in determining the length
of time after training when follow-up will be done in order to pro-

vide data for evaluation.

3. As more health personnel are provided coronary care experience,

the demand for short-term refresher training will increase.

4. The rate of adoption of new knowledge into the basic education
of the health professional seems to be occurring at a slow pace. If
integration of coronary care is to occur in basic preparation, it

will be the responsibility of the professional leadership in the

 
 

-4-

educational institutions and in the coronary care training centers
to cooperate in bringing about accessibility to ali health profes-
Sionals. It appears that the educational structure for the intern/
resident physician allows him greater access to coronary care
training/education than is true for other health professionals at

this time.

D. RECOMMENDATIONS = a
The following recommendations have been developed, based upon the
findings of the Cybern Report (Xerox Report) and on the three years of
RMP experience in the funding of intensive coronary care courses: |
1. The training project application should include an indication
of the importance of the project's contribution to the cardiovascular
program of the Region as well as how it contributes to the overall

Program goals of the Regional Medical Program,
2. It should include well defined selection criteria for students.

3. -The educational design of the course should recognize the needs
of adult learners; such as in providing special units of study for
those who will be responsible for teaching or administration of a

unit,

4, The project should include assurance of planned formalized
communication between the training center and the sponsoring hospital
im before and after the training period to facilitate the flow of infor-

mation regarding expectations, responsibilities and capabilities of

trainees.

 

 
 

5. The training program should have documented its access to a
sufficient number of facilities with available patient population

to assure adequate clinical experience.

6. If courses of differing lengths are provided in the same Region,
the rationale for each course should be identified and in some

Regions an evaluation made of their relative effectiveness.

7. Assurance of planning for the ultimate phasing out of the RMP
funding support should be included such as by integrating coronary
care training into the basic preparation of students by the educa-
tional institutions of the Region or funding by some other community

agency.

 
THE CORONARY HEART DISEASE COMMITTEE'S

TOPICAL OUTLINE OF NURSE TRAINING CONTENT

NEW YORK STATE HEART ASSEMBLY, INC.

 
—_. LL PFOPICAL OUTLINE OF NURSE TRAINING CONTENT

 

Statement: The content, both essential and contributory, as defined meets the
requirements of the Joint Position Statements regarding the role of the registered
professional nurse in the care of patients with Cardiovascular Disease in the
coronary care or intensive units as presented by the Medical Society of the State
of Now York, New York State Nurses Association and the Hospital Association

of New York State. This is intended as a basic preparation for the nurse ata
staff level, Continuing education is considered essential to maintain nursing
expertise and proficiency in coronary nursing.

eee

ESSENTIAL CURRICULUM CONTENT

 

I. Orientation to the Program:
A. Course Objectives
B. Course Format/Plans

Il, Coronary Care Concepts:
A. Administrative Aspects of
Coronary Care Unit

hn. Anatomy and Physiology of the Heart
IV. Epidemiological Factors of Coronary Heart Disease:

A. Risk Profile

V. Care of the Patient with Myocardial Infarction:
A. Pathophysiology

B. Diagnosis

C. Complications

D. Medical Management:
“(l) Rest
(2) Drugs

» (3) Dietary
Nursing Care:
(1) Admission of the patient
(2) Routine Nursing Care in Coronary Care Unit .
(3) Transfer of the patient
(4) Psychological aspects of care
(5) Rehabilitation and Teaching of patient/family

Vv Fluid and Electrolyte Balance

 

 
 

ake

Viti,

IX,

Electrophysiology of the Heart:

A. 12L ECG - normal heart function
B, Cardiac monitoring concepts
C. Arrhythmia recognition and treatment:
(1) Identification, interpretation, treatment
(2) Drug management
(3) Caxrdioversion and Defibrillation
(4) Pacemakers (temporary and permanent) .
(5) Cardiopulmonary resuscitation:
(2), Principles of ventilation
(b)! Definitive therapy

Care of the Patient with Congestive Heart Failure:
A. Normal anatomy and physiology of respiratory system
B. Pathophysiology ,
C. Diagnosis:
(1) Auscultation
(2) Early recognition
D. Medical management:
(1) Drug therapy
' (2) Other therapics
E, Nursing Care:
(1) Nurse's. role in early detection
(2) Subsequent care:
(2) Rotation of tourniquets
(b)} Positioning of patient
(3) Evaluation of therapy:
(a) C.V.P. monitoring
(b) Intake and Output
(c) Daily weights

Gare of the Patient with Cardiogenic Shock:

A. Pathophysiology

B. Diagnosis

C. Medical management:
(1) Drug therapy |
(2) Other therapies

D, Nursing Care:
(1) The role of the nurse in early detection
(2) Evaluation of therapy

 

 
ii.

IV.

Vi.

Vil.

CONTRIBUTORY CONTENT

 

Defribrillation:
A. Didactic instruction/demonstrations:
(1) Dog defibrillations
(2) Use of Resusci-Anne with lead vest chest liner
(3) Other training devices .
(4) Elective cardioversion~-participation

ECG Experience:

A. Practice with ECG Technicians in routine taking
of 12 lead tracings

B. Knowledge of various lead systemk, for instange

, hexaxial, vector, etc.

Care of Patients with Pacemakers:
A. Knowledge of principles involved
B. Assist with catheter-pacer insertions, etc.
C. Awayvreness of electrical hazards

Skills in treatment of congestive Heart Failure:
A. Rotation of tourniquet .

. Auscultation techniques

. Early portable chest x-ray

: Circulatory assist procedures

lewen

wens

Skills in Inhalation Therapy Techniques:
A. Types of respiratory equipment aids
B. Knowledge of special drugs; aerosols, etc,
Cc. Experience inhalation therapy teams

Special Laboratory Techniques:
A. Venipuncture end1,V. therapy; assisting with
cut-down procedures
B. Urinalysis - urine specific gravity; ph determinatior

Skills in Therapy Related to Respiratory Failure:
A. Central Venous Pressure: ,
(1) Preparation for and assisting with
(2) Interpretation

 

 
yail, Instillation of Research Responsibilities:
A. Role of the Nurse in Data Collection
B. Research Trends

IX, Complements of Instruction:

. . Use of films, video tapes, records

. Monitor-teaching machine for arrhythmia recognition

. Distribution of prepared materials from Heart Association
and own mimeo prepared instructional aids

Use of Nursing Rounds as a method of tezching

Library resources

Animal experimentation

.

Seo AWD

 

CLINICAL EXPERIENCE

A planned, supervised clinical experience should be provided concurrently with

theory presentation so that reinforcement of learning can take place, Clinical

practice should focus upon the attainment of specific nursing behaviors and
‘Us.

pw

10/17/69 - | : | ;

 

 
 

CORONARY HEART DISEASE COMMITTEE
NEW YORK STATE HEART ASSEMBLY

Multi-media coronary care instructional systems should not bs used as selfe
contained teaching systems in the education of coronary care nurses. Instructlozal
systems may be used as integrated, flexible tools which can be adapted for clasd+

room teaching or independent study. Therefore, the following recornmendations ave

‘

made in relation to the proper utilization of special feaching systems for coronary

 

care nurse training:

 

1, Teaching systems should emphasize the need for prepared nurses ag
instructors in cooperation with the interested physician inctructor as
well as the implementation of demonstrations, discussion groups, and
other teaching techniques in conjunction with systems}

2. Other texts, in addition to those recommended by the special teaching

“systems should be utilized because no one teaching system should be
depended upon;

3. Certain gaps in content are usually present in most teaching ‘systems
and these must be supplemented by structured course and class
presentation as well as demonstrations essential to fulfill program
excellence;

4. Local hospitals utilizing multi-media instructional systems to prepare
nurses in coronary care nursing should provide concurrent planned
clinical instruction in adequate, facilities for clinical practice tryaining;

5. Clinical practice should focus upon the attainment of specific behaviors

and skills under qualified supervision;

 
~2~

_. Nurse teachers utilizing systems be taught educational techniques in
course presentation and evaluation skills;

.7. Individual nurse replacements for the Coronary Care Unit should be
trained primarily by physician-nurse teams in conjunction with multi«
media instructional systems,

in summary, multi-media instructional systems can be an effective adjunctive
tool for training coronary care nurses if the following essential cormponents are
provided for:
1, prepared physician-nurse teams for instruction and supervision of
trainees;
2. the availability of clinical facilities for the concurrent reenforcement
of didactic instruction;
3. utilization of supplementary educational experiences,
It is advised that any multi-media instructional system be evaluated priox to

purchase and implernentation.

cbhw

 

 
RECOMMENDATIONS TO GHAPTERS
It is recommended that:
1, Clarification is needed of all costs of multi-media instructional
systems other than initial expenditure, .
a) investigate maintenance costs of hard equipment
b) investigate maintenance and/or repair costs of
tapes, film strips, and films
c) investigate updating of content; tapes. costs, etc,
d) investigate cost of needed replacement materials
such as pre and post tests, evaluation sheets,
student workbooks, instructor workbooks, etc.
2. Evaluate distribution, transportation, and insurance costs ito
borrowing agencies. |
3. Development of policies for lending of systems to requesting
agencies,
4, Development of an orientation program for nurse teachers who

will use the instructional system.

cbw

 
 

EVALUATION OF CORONARY CARE TRAINING: SOME DIRECT OBSERVATIONS OF PERFORMANCE

 

It HOSPITAL PRACTICE

 

. Rodger Shepherd, M. D.
Associate Director ‘
Intensive Care Training Project
RMP, Area I of California

The objective of our Intensive Care Training Program is to enable physicians
in cadres from small general hospitals to perform certain intensive care skills in
their own hospital settings. These skills include: use of central venous catheter,
use of intra-arterial monitoring catheter, interpretation of blood gas data, continus:
EKG monitoring, airway care, controlled ventilation, cardioversion, and others.
The staff of our ICU had visited small hospitals and identified these skills as
feasible, but underused in smaller hospital ICU's.

The training program is conducted in three phases. During the first phase,
the cadre and project clarify mutual objectives. During a second phase, each
physician from the cadre undergoes a week-long program of one-to-one instruction
at a metropolitan medical center. During a third phase, an instructor-in-residence
is maintained in the cadre's own intensive care unit around the clock for 10-12
days.
The direct observations of these instructors have provided valuable anecdotal
data on both the project and the resulting student performance:

1. Standardization of Technique: The same single standard technique for insertion
of central venous catheter is advocated during each individualized instruction.
The mastery of this technique is certified by the instructor. However, the
student may not implement this technique in his own hospital setting. It has
been observed that the failure of some physicians to support standardized
technique has a disruptive effect and reduces the tendency of other physicians
to implement the advocated procedure at all.

2. Availability of Equipment: Standardized technique depends on standard
materials. Instructors have observed the lack of certain critical materials
or instruments during introduction of a new technique. The attendant
frustration during this critical phase may abort or seriously retard the -
adoption of the new practice in spite of adequately trained personnel,

3. Supporting Services: Interpretation of blood qas data depends on complete
confidence in the data. We have encountered one hospital setting where the
Student's training in interpretation of blood gas data was not implemented
until we had rectified certain analytical problems in the clinical laboratory.

Arcn. B