B&B INF93Rm^,riom & lm@E 300 @lotoic D=Ituz,*n ROULXVARD Upolacm 2077Z - us^ 0 (301) 24wal 10 CORONARY CARE TABLE 0'6 COI,\ITENTS I. GEIIERAL It,rPODUCTOPY REMARKS II. CORONARY CARE LRNITS III. l@iOBILE COROI\'ARY CARE UNITS IV. COROIARY CARE TRAINII@G 1. GE,\!EtLkL IliTRODUCTOi@Y I'@,'@NLkRKS 1. General Introductory Remarks Care for the acute coronary patient received a great impetus just prior to the enactment of the Regional Medical Pro-rams Law (PL 89-tl-39). Inasmuch as the coronary care unit embodied an entirely new concept for managina patients with acute myocardial inj'irction and the arrma- mentaria for coronary care units required special accommodations in desiali and engineering, a host of hospitals were intrigued and sought 0 financial support for local undertakings. This new source of funding gave opportunity to many community hospitals to initiate this now concept. Further, it was a way by which the local RMP could establish a community service and immediate community ex- posure in which life-tlireatening events could be managed. As a result the IOIPS became involved with a number of projects dealing with coronary care units. It became irr@7,edicately 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 FL,!PS 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 -2- Devices began to develop. Based on the hope that electronic trans- mission could provide service, attempts were made to Proliferate ECG computer s)rster@s. llere again P,ZIPS became an involved partner. A review of project funding in the- @IPS since the inception of operational procrams indicates that approximately 19 million dollars has been ai@ardeci 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 ; Illurses, 10s and $15,284,000 Allied Health (many included equipment) 87 Projects Mobile Coronary Care Facilities 789$000 7 Projects Computerized ECG Systems 3,0500000 7 Projects Total 100 Projects $19,123 000 11. CORONARY CAR13 UNITS I I Coronary Care ITnits 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 Ileart Disease Study Group of the Inter-Society Commission for Heart Disease Resources. IUQ regions are particularly encouraged to explore the following areas: A. The organizational structure to implement the system - coni- munity multidisciplinary committees concerned with acute coronary care - is non-existent in most regions. B. 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. C. 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. D. The 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. INTER-SOCIE,@' COMMISSIO'@ FOR HR@ART DISEASE RESOURCES Draft ACUTE CARE FOR CORONARY PATIEHTS Introduction Corpmunity Coronary Care Planning Components of a Stratified System of Coronary Care A. Public Education in Early Care B. Mechanisms for Rapid Entry into the System of Coronary Care C. Emergency Trarsport and Life-Support System D. Coronary Care Unit E. Rcgional Reference Centers ACUTE Ci'iRE FOR CO'aO'_,Iu@-I'l@Y PATIL'L@%'TS I. INTROD'i"@'TION It has been estimated that about one million 1-@mericans experience acute myocardial inrl-arctioii or sudden coronary heart disease-deatl-i cadli year, and that about 25'/'. of these patients dic,before reaching medical care. (Reference: Offic@Lal @JPS - U.S. Public Health Service estimate. See ICYID Atherosclerosis report for supporting documents.) The mortality in acute myocardial @Li-ifarction is highest during the' first 'Lci-i hours fol- loN.7ing the onset of sy--ptoms. (Reference: Kuller, et al Epidcmiolo-ic 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-arrliytlimias or profound pump failure manifested by sliock 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 iiifarction were approximately 30%. In the past decade, there have been significant ad\-aiaces -,'-ii the of riiost irlpc)r":ai-itly tlio C-O,-ICCPL of surveillance and therapy in the specialized of coronary care units. Ili an effective unit a reduction of 50'7. of.thc early lios- pital mortality r4tc has already been achieved, This r educed mortality is directly related to the prompt detection, effective prevention, and treatment of potentially life-threatcliin.- cardiac arrliytlimias by means specific dru- therapy, dcfibrillation, and pacem@iler insertions. llo%qever, the proan6sis of patients with other serious complications, particularly pump failure-, has not changed significantly. The results of intensive research on the pathoph3,siolo-y of pump failure, and the C) development of more successful therapy should reduce mortality in the future. Because the fatality rate from acute myocardial infarction is so high duriii- the first hours after the onset of s@,mptoms, the objectives 0 are to briny 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-tllreatenin@ complications, particularly arrliytl,@-,iias. In order to accomplish these goals, a stratified and integrated 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 iiifarction 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. Develol),-iie2i-it o--@ effective omc):cency ti:zziisl)c)rt sy t -,is fo cl r, s livorinc, patients to an ol)Li,.n.,il system of coronary cire. Establisl)--aent of er.,icr-ency life-support statiol-is N,71-iere ap- propriate, and improvement of hospital emergency areas in rencici.-in,- immediate coronary care. e. Increase in the nur@ber and improvement of coronary care units to provide continuous monitoring and capacity for definitive therapy. f. Desi-nation of ro-ional reference centers i,?ith capabilities for providing.comi)rehensive cardiovascular care. g. Establishment of continuous training programs for medical, nursing, and other allied 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 plannin- the pro- posed system can be developed into a coordinated network in which medical facilities perform different functions according to a system- atic analysis of the needs and capabilities of each community. CI"17 pi To ii@-plcincnt the stratified care system, it is rccoi.@unc-@nrleci t:llit a standing P,-,-ulti-disciplinary cor,-jni'L-tee be established in each com- muiiit3r for the planning, organization, intcoratioil, evaluat ion, and necessary) the revision of the co-@nLnity coronary care syst(L The method of function of this co=@ ittc-.c N,7ill var@, depending upon local circumstances. The committee should include physicians, nurses, hospital administrators, representatives of ei-ne3--ency services, and consumers of medical care. Tiie 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. P\.econ@nendatioli of- policies concerning the criteria for patient admission to various levels x-7@Lthin the system of coronary care, and sug- gestion of criteria for the len-th of stay and the time of discharge. c. Planning, development, and coordination of an effective public and professional educational pro-ram. d. Development of mcchaiiisms_for facilitating the prompt entry.of patients into the system,. e.g., centralized screening telephone centers. e. Definition of policies regarding the responsibility and authority for patient management i.,@ithin various components of the.systcm. 1 -5- Evaluation of LI@ic, ir@,,"),Ict> c@ffici-c",ICII, and cost ef f Cct:ivenc-@ss of the systoia. 9. Coordination of other co--,.unity -facilities for coronary care, e.g., Iservices for the identification and treatment of individuals at hioli risk of developing coronary heart disease, early detection units C> for heart disease, rehabilitation centers, work evaluation units, etc. Each conThunity should reco--iiize its responsibility to p@ovide 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 the symptoms of acute myocardial goal is to place the patient with infarction into an optimal system of care. CO'pjpO',@r.'-@TS OF A SU.-i,/iTTFTED SYSTEI-I Or CO--@10-'@,@,-PY C,'@pE A. PUTL!C EDUCATIO'_Q TN Et,-T',LY C,,,PE The first few hours after the ailset of- symptoms suggestive of acute myocardial infarctioli are-critical, since the high mortality associated with this time period is presumably due in most cases to the preventable and treatable occurrence of ventribular fibrillation. Ideally, indi- viduals with these symptoms should be placed under competent medical surveillance within one ])our after the onset of symptoms. -6- The most ziiid -r @requent cause for delay is the patient',, indecision Nq'iien lie dc@vel-op@- oppressive chest (Reference: Olin and llacl@ett: Denial of chest pain in 32 patients x,ii.th acute myocardial infarction. Ji2,11@ 190:977, 1964.) This indecision may be related to: 1. Lack of information regarding the significance of the s3Til@toj-.is 2. Denial of-.tlie importance of chest discomfort because of the fear of myocardial infarction and its consequences. 3. @'Lisinterprei:ation of s3,m,,,)to-,.ns as reflecting disorders of other oraan systems. 4. Failure to establish a relationship N,.,ith a personal physician, or-to disturb a physician at an i,-icon\renicnt time, such as night hours or N-7eel-,ends. 5. Failure of relatives or co-N.@orlcers to encoura-e the patient to seek medical help. 6. Psychologic, socioeconomic, and physical barriers barring rapid entry into the system. I-lany of these problems can be- mitigated by a major educational program directed at the publi c 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 @,71io are -7 - of should seel@ ii-,c-.)c-diatc-@ entry into the system of coronary care if they develop severe paiii or oppressive disco,-,fort in the retros ternal rei,ion, especially if'it radiates to the irnis or neck ii-id does not promptly disappear,--, Al tli oL, (,h acute myocardial infai-ction can present x.?ith other symptoms, the cliarac- te3:istics noted above are sufficiently sensitive and specific to @erve a warning message dir-ected to the general public. Iiidi,,ridiials at high risk for coronary artery disease, such as those with hypertension a history of cigarette smokin- liyperlipideraiag. or diabetes should C>.% constitute a particular target population for this educational message. Patients with a history oj' an-ina pectoris should not enter the system of coronary care after every episode of' ancina. Tliey,sl-iould be instructed that more frequent or more severe ancina, or a change in pattern, may herald acute myocardial infarction. Ifore 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. @MC@qIS,',IS T,'O"ll @T@PID EI\IMY II@TO TIIE SYSTE@L OF COTZO""L-I,.PIY 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 personal is to contact Iiii,.i iiir-..icdiatel),. pl)y- sici,all delay often result-,,;. J'roTi difficulty in reaching the personal I C> physicians t)ICI. P1117SiCiall'., IIC!Sil@-atiC)I-l in imaging, the presuiiiT,)tivc@ diig- nosis of acute myocardial infarction over the telephone, or his lack of information about coir.,munity facilities and resources for.coron-,Iry care. It should be emphasized that almost t@,7o-tliirds of the patients x,7ith acute myocardial infarction have prodrom@il symptoms including pro- gressive or crescendo chest pain i-7itlain one i.@eek before the onset of the acute attack and frequently consult a physician durina this time. To improve the response to the individual seekiii- help, physicians and other health personnel likely to make primary contact x-iith the patient c>,perienciiig symptoms of acute myocardial infarction should be educated in the follo,,7ing areas: 1. Recognition of the si-ns and symptoms of impending acute myocardial infarction. 2. Familiarity with community resources and facilities so that the patient can be advised hoi.7 to reach a monitored bed as rapidly as possible. 3. The ability to perform cardiopulmonary resuscitation. (Reference:. Definitive Therapy in Cardiopulmonary Resuscitation, ARA, 1965.) -10- 1)i.-cfcribly under a I)li),si.cial)ls teleplioi-ic direction, -,s soon as s3@-t.@,pto,.iis irc recognized. This approach raerits further ii.n-vcsti-ation. C. D LIF17 SLI:-'PORT SYSTJl',@,i After an individual @,7itli the symptoms of acute myocarciiil infarctioii "--Ii,as sought help, it is essential that a rapid emergency transport system be available, and that a bed in an emergency or coronary car.e facility be prepared to receive him. Otherwise, the time, effort, and money spent on public and professional education is N..@asted. 1. Emergencv Transport S@rste-@!l Until recent years, the patient's emergency transportation has been left to his oi,-n devices. In some comunities the patient can reach an emergency care system relatively qu@Lckly, i-7hile in others traffic congestion or lacl@, of accessible medical facilities cause inordinate delay. Therefore, the emergency transport system should provide the facilities needed for the detection and therapy of cardiac arrhytlimias, and should have the capacity to perform cardiopulmonary resuscitation. Two types of transport systems have these capabilities: a. I-lobile 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 c I ccLroca@.-dioc,r@iiis, clcfibrill@itj-cii, cardiac 1),-,cill- and plia-,:i-,iacolc)<,ic o - - I 0 5i 0 therapy. Ii-i some vehicles a t@,.-o-i7,iy co:riE)Liiiica t4 O)-,S sysLc.T- i5 established through racii-otel(-,plioric,, -@incl e-Icctrocardio,,rii-i-is i7.,iy be transmitted vii telcr,ietry from the vehicle to a receivin- station. These vehicles are 0 prepared to stabilize a paticnt's condition in his laoi-ic and iii the vehicle, then to transport him rapidly to a con@uijiuin- care unit. I!@lliethcr 'vlobile Coronary Care Units should be generally r-cco,.n.-,Ic@i-ided or implemented in many cities is still controversial, Preliminary observa- tions have demonstrated the effectiveness of such units in the manaae- meiit of life-threatenin- cardiac arrliytliraias c@-aplicatinc, acute myocardial infarction, b. Emerge7icy Transport '%7chicles. 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 iql-io staff Lhose-veliicl.es receive adequate trainiii- iii recognition C> and be competent to treat a cardiac emergency, particularly life- threatening arrhytliiiias. They should be authorized to initiate druc, therapy or de'Librillation, preferably under a physi cian's supervision throu-Ii voice communication N-iitli a control station. Equipment should include an electrocardiograph, a battery operated defibrillator and. constant 7fionitor 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 statioii is recommended. The -icl@,antiL@c.@s of- the ET-,,,orr-c)icy, \7clii C ilc 0 -cic over tll 2.,.C,I) Coronary Care Unit are that (1) silicc@ it is not cl(-,dicatcd solely -Lo coronary care, its cost effectiveness is greater, and that (2) it :iocs not divert medical and nursing personnel from other. high priority duties. 'lance system in the Improvement of the present arrbu United States to meet the Emerc,(-,iicy Transport Vehicle standards described above seems C> a more promising approach for the future thin the concept of @lobilc Coronary Care Units. 2. Eme e-Support Station An emergency life-support station is a unit which is strategically located in areas of population density in N@hich patients afflicted with symptoms of acute myocardial ii-ifarction can be provided with immediate care. Its staff may include physicians,.nurses, or allied health person- nel, but a physician Knowledgeable and sl@illed 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 dru- therapy for brady- and tachy-arrliythmias and defibrillation. Emergency cardiac pacing is seldom needed in these stations. The purpose of the emergency life-support station is, therefore, to stab]-liz.e the condition of a patient with sus- pected acute myocardial infarction before transfer to a coronary care unit for continuing therapy. The Coroiiiry Care unit is one type of c,,,,tcr-ciic3, life-support 0 station N,.,hicli can be brought to a I)ationts's lio-o-io or to other locations, Stationary li'Le-support units rii-lit be considered for the followii-ic, 0 locations a. Areas x..,herL- a lar-c number of c-,Qployees i,,orl, on weeldays, such -a@'lactories, industrial plants, or large business centers. b. Areas i,-Iiei:e there is a constant incomin- and outgoin' of mass population, such -s metropolitan airports and large railroad stations. c. Areas i-7here there is a periodic concentration of mass popula- tion such as sport stadiums and convention lialls. Hoiqever, in most communities the logical and ideal site for an emergency life-support station is the cLier-ency department of a hospital or an adjacent area. Every hospital x-7itli an emergency area should meet the standards for an emergency life-support station specified above, and should have these capabilities on a tN.7enty-four hour basis. The standards should be met regardless of i-7lietlier the hospital has its oi-ni coronary care unit. The specific policies of the hospital emergency areas i-7itli regard to suspected acute myocardial infarction depend on local circumstances, .but it should be emphasized that a patient x-7ith a history compatible N,7itli an acute myocardial infarcti-on should riot be discharged from the emergency department on the basis of an in-L'L',ial "normal" electrocardio- gram. If the diagnosis is in doubt, it is al@,7ays advisable to transfer the patient to the coronary care unit for further observation and monitoring, E\,c@i.-y c-,,:i(,).-(Iclicy L@rc.@a siotild be able to P-j:c)\Tici@, life support to patients N-7itli acute ii3roc@tudial ilif,.ii:ct-'-on. This does not tli,-tt: every hospital should have i coroiii3.-y care unit.. The decision to estal)- lisli a coronary care- unit, as discussed below, should be predicated on the needs of the stratified system. D.. COR03\lx'Q--',@jr Cl@T-,);,' IT@@IT 1. Coroiiiry Care Conccl)t 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 arrliytlimias, most commonly vciitricular fibril- lation, and that (2) these arrhythmias are largely preventable or re- versable. Ilowever, 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 cardiog(@nic sliock. Additional patients die from arrliytliriiias -15 - and L@fLer other cGnlplicaLiOlIS they 11@IV(@ been transferred fr iii Llic@ corollary care unit. 1-1,-ny of these lik-)spital deaths outside the coronary care unit result from disturbances in cardiac rhythm. Tlic-@rc@j'ore, if the mortalit,, rate of hospitalized patients with myocardial infarction is to be fur- ther reduced, more @f@tive therapeutic measures for these complications particularly pump failure - will have to be developed, and the period.of Eontinuous monitoring of patients transferred from the coronary care unit will have to be extended. Prolonged monitoring of hospitalized patients can be accomplished by step-doi..,n 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-do,,qn system. 2. Establishinent of the Coronar@, 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. ror many small hospitals having fewer than fifty beds and admit- ting less than txqenty-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 ad4acent 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 l@irger hospital can be performed. Paragraphs 3 (Staffing); 4 (Physical Sprcifications); 5 (Organization and Operation); and 6 (Step-do@vm Units) omitted - not particularly pertinent to Council at this time. E. REGIO@NtiL IIFFERFNCE CENTFRS 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 for 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 ari-liythmias and conduction defects, particu- 17 larly in those patients with indications for insertion of pacemakers. b. Profound cardiac failure which mif-ht be helped by special- 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 interval of the delay period must be shortened: (1) The patient's period of hesitation between onset of svmptons and decision to seek medical help should be shortened by public education programs. (2) Entry into the medical system should be facilitated I)y.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. 1.11. YOBILE CORONARY CARE UNITS MOBII,T,', CO@?,,O@IAPY-C@IR-F@ UNITS A. MOBILE CCU's FM@DED BY R-KIPI,; 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, Iowa 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 IACCIJ team consists of a physician, technician, and a driver. There are two specially equipped ambulances. Patients are taken to 21 hospitals. 3 In 4 months of operation, the Unit transported 185 cases, 88 of which were @II'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. MontgoTery County, liarviand 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 3k months of operation the Unit transported 98 cases, 36 of which were MI'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 II) 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 S7,000 in Seattle to $60,000 in New York City. These differences are accounted for in part by the tact that Seattle differs significantly from the other locations in two ways: 4 1. the high proportion of transported cases that were YLI's 2. the large number of cases per month that were resuscitated and brou-ht to the hospital alive. C, 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 -,,chicle. 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.intended-as a feasibility study. The crews and vehicles were those of a r-egular Fire and Rescue Personnel. Tx,7o-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. C. Waynesville, North Carolini 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 froii 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. AL-TERICAN HEART ASSOCIATION SURVEY At our request, the American Heart Association surveyed their 125 Chapters and Af.filiates 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 mcculs in operation around the country used a physician. Sixteen of the 26 used either a nurse or a physician. However, 6 of 12 MCCUts not now in operation but %.jith plans formulated for the future, only two include a physician or nurse. APPENDIV. I EVALUkTlOi\l OF MOBILE CORO@\TAPY CARE A@ir)Tj7,Ai",CE P@IPS Operational Project Grant From date r\,'@fP'o 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 @IPS grant authorized Mo / Day / Year E. Date Mobile CCU began operating lio / 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 B. Under the most current protocol of standard operating procedure, who is privileged to call the Mobile CCU? (Check one) Anyone Physicians only Other groups (Specify) 2 III. Fiscal Data throu,.h June 30, 1970 A. P-irst fiscal year actu,@l expenditures, from to @io Da@,' Yr lio /Ja,, Yr (From date P-1,@iPS grant authorized to end of first ;Lliscal year or Jur@e 30, 1970, i-fiiicliever is earlier) Estir..iatcd allocation of total expenditures Before initiation of After of Item of expense services serv-@ces 1 Pd'L'il'S I.-'tindol Other Funds j,,Ilpc@ Funds Otli er Funds 'I. Per-oLinel @ ............ 2. Trainin- of personnels 3. Equipment ai Special equipments b. Ambulance vehicle.- C. Ambulance equipment d. Other equipment 4. Supplies ............... 5. Other direct costs 6. Indirect costs ......... TOT,@L 1. Include estimated value of all services, equipment, etc., donated to the @ICCU project. 2. Include all 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. - 3 - B. Second fiscal year actual expenditures, from to @io /Day /Yr 1-io 1970, r') (To end of second fiscal yc@,@r o,- June is ea,-@", Extim.ated allocation oL total Item of expense @,-IPS Funds r Funds Ottic 1. Personnel 2 ................ 2. Trainino of personnel 2..... 3. Equipment a. Special. equipment 3 b. Ambulance vehicle .......i C. Ambulance equipment ..... d. Other equipment ......... 4. Supplies .................... 5. Other direct costs 4 ........ 6. Indirect costs ............... TOTAL C. Third fiscal year actual expenditures, from, to Mo /Day /Yr tlo /Da Yr (To end ol@' third fiscal year or June 30, 1970, whichever is earlier) Extimated allocation of Item of expense total expenditures PI,'.rPS Funds Other Fundsi 2 1. Personnel ................. 2 2. Training of personnel ..... 3.-Equipment a. Special equipment 3..... b. Ambulance vehicle ...... c. Anbulance equipment ..... d. Other equipment .... .... 4. Supplies .................... 4 5. Other direct costs., ........ 6. Indirect costs .............. TOTAL 4 IV. Operating Proble-,,is A. Describe difficulties i,7itli: 1. Vehicle 2. Electronic equipment 3. Other special equipment 4. Personnel B. Estimated total number of scheduled hours ijobile CCU was not in operation ("down time") durin- each fiscal year. Reason Fiscal Year First Second Third Personnel or staffing problems Other reasons TOT,@L To end of fiscal year or June 30, 1970, whichever is earlier 5 V. Operational -otiti,'3tiCS tlirou-h June 30, 1970 Fi.scal Year E' irs t Second A. I'Nur@iber of calls answered ...................... 1. Number of calls cancelled en route ........ r 2. Number of arrivals on scene ............... a. Nun,oer of individuals not transported to hospital by '.,Iobilc CCU ....... (1) Dead on arrival of 1-iobile CCU.... (2) Died at scene after arrival ......I (3) No need to hospitalize ........... (4) Transported to hospital by other than Mobile CCU ................. (5) Other reasons .................... b. Number of individuals transported to hospital by mobile CCU .......... (1) Died en route ................... (2) Arrived at hospital alive (a) Died in emergency room..... (b) Discharged from ER (not requiring hospitalization). (c) Hospitalized ................ (la) Admitted to CCU ........ (lb) Admitted to ICU ........ (1c) Admitted to other -hospital bed ......... B. Total Hospitalized (SameF as (c) above) ........ Principal discharge diagnosis: 1. Myocardial infarction ............... 2. Other coronary disease .............. 3. Stroke .............................. 4. Other cardiovascular disease ....... 5. Non-cardio'vascular disease .......... 6. Discharge diagnosis not kno@qn ....... 7. Still. in hospital ................... 6 VI. Tl-.crapy Statistics tl,.rou,.Ii June 30, 1970 Fiscal Year First Second5 Thirc]5 A. !lumber of individuals who received CPR and one or more defibrillations Total ... 1. Reached lios-,)ital alive .................. 2. Died 'before reaching hospital ........... B. Number of individuals who received CPR only Total ... 1. Reached hospital alive .................. 2. Died before reachin- hospital ........... C. l@umber of individuals i.@ho received one or more defibrillations without CPR Total ... 1. Reached hospital alive .................. 2. Died before rea--Iiing hosrital ........... 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 .................. 2. Died in hospital ........................ 3. Discliarced from hospital alive .......... E.. Number of individuals who received medications Total ... 1. For disturbances of rhythm ............. 2. For discomfort or pain .................. 3. For acidosis ............................ 4. For anxiety ..... ....................... 7 VIl. Observations on beneficial ef.'Lec.@@s ozher individual ti-ierair.,, restiltin,- from the existence of the @lobile CCU. (Briefly list events such as (3.) 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.) A. B. C. D. E. Prepared by- Date: CASE HISTORY FOR CAiUlAC AR@EST Pt'iTIE@N'TS WHO RF-KCTI@ED TTIE !IOSPITI@L AI,IVE General Information A. Initials or other identification of patient B. Date of episode Mo Day / Year C. Ace D. Sex E7 @iale E7 Female II. Pre-Ilospital data A. Date and time of first symptoms L7AM l,lo Day Yr Hr @lin LJ Pi.-i B. Date and time call for Mobile CCU received Mo Day Yr llr llin C. Time llobile CCU arrived at scene llr. n D. Condition of patient on arrival at scene Stable L7 No heart beat (Pulselessness) Unconscious ID Not breathing Semi-comatose Pupils dilated E3 Shortness of breath E7 Other E7 Cia,@iiy or sweaty L7 Abnormal pulse E. Was cardiac arrest validated by ECG monitor or tracing? E7 Yes No F. If "Yes", was it Ventri-cular standstill? E7 Ventricular fibrillation? G. How long was CPR applied? H. How many times was defibrillation applied? 2 1. Complications and therapy at scene or durin- transport Er-C7 c@iangcs Clinical n(>c.@ssi'-t'af--in@ P-X T'@ieraov Dedications Time III. Emergency Room A. Was patient taken to Emergency Room? E3 Yes No B. If "Ybs", did patient die in ER? Yes iD No IV. Hospitalization A. Was the patient admitted to the hospital? Yes No B. History of prior cardiovascular disease Myocardial infarction Other cardiovascular disease (Specify) C. Hospital discharge diagnosis V. Outcome A. Surival (Check all applicable items) Lj Discharged from hospi.tal alive (Date) L7 Died after admittance to hospital (Date) /-7 Died within 6 months after discharge from hospital (Date) Known to be alive 6 months after discharge from hospital LJ Survival not knoA-n 6 months after discharge from hospital 3 B. Cause of Cteall-h on dc-att, certificate: VI. Remarlcs: red by: Date: 14 0 $4 CD CD 14 E (D C,4 (N C) 4i 0 C,4 E-4 C,4 CC) m C,4 C,4 P4 P4 rz 0 C:) 0 0 0 C:) 0 00 0 C:) rz 0 It CT C) o 14r4 C) 00 co %D r- tr) to CV) co IN m CY) cli 0 Ct) co 0 o C:) C:) rA co Le) co Cl) tD co %D co 00 m CC) tn 'IO (1) co cq cn 0 la 0 C) C) in C:) C) C> C,4 C) C) 04 0 C:> CY) C) 00 a% kD r_ %D cn cn Lt) 00 cn %D tn 0 rn p 0 cn >1 C) 4i 0 $4 C> C> 0 C) a) 0 CD m C) CD 0. C) 0 C) tn H p 0 co m m C) l@ cn co C) cq cn cn P-4 (1) 0 z I Cd > c: 0 0 0 .M 0. 0. .,4 0) 0 10 Q) u Cd ;> to El) 4i 0) 0 0 > rn r. r. co C) rz Cd -H :3 r-q %t . 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C) Cd (5 -A 0 4i $4 $4 0 4j rA O') C= 0 4i 0 $4 $4 $4 @ 44 Cd 0 0 H 0 0 4i a) 4-i ;4 m CL (D U) U) C $4 rJ4 co co z 0) (1) w 4-) bD ri) $4 c: ei m $4 0 0 a 4i 4J -W 4.J (i) 0 Cd Cd $4 ct (i) -W ri) U) U) rn 4i $4 $4 4i C) $4 0) 4i 0 0 0 0 44 0 4i 4.J 0) 4) -Li C) 0 bD fi) u ci C) u 0) U2 44 U) x fi) $4 c la) 0 ,-4 44 to 0 0 Cd tz Cd .0 r-) 60 14 00 60 0 4) a) 4i u 0 u ;> CZ r- 4.J m rA tri 4-i Cd 0 10 tv 4i "4 -r-4 Cl co $4 tt w z = 44 14 t44 C: (Li z Cd 4.J 4.J 4J LJC 10 C) C) (1) 4i 0 o 0 co rA (L) r.4 Cd 0 Ca 0 -W r-) u 4J 14 $4 $4 ;4 14 4 4 0 $4 .,i 0) (1) (1) (D 0 0 0 0 a) 0 0 0 a) 0. 0. 04 z z P4 0 0 0 I PrEl%7DIX iii SURVEY OF MOBILE CORO'@-@IAP.Y 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 b c 1 ox-q) 1. Inglewood, Calif. 8/69 x x x x x x 2. La Jolla, Calif. 8/70 x x x x x x x 3. Rancho Santa fe, Calif. -/67 - x x - x - x 4. San Francisco, Calif. 6/70 - x - x x x x 5. Tulare, Calif. 10/70 - x x - x - x x 6. Hartford, Conn. - 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 x 10. Chicago, Illinois 9/69 x x - - x x x 11. Champaign County, Ill.* 9/70 x x x - - x - x 12. Mason City, Iowa 6/70 x x x x x x x x 13. Bethesda, Maryland 3/70 x x x x x x I' Columbia, Missouri 6/58 x x x x x I qewark, New Jersey 7/69 x x x - x x x 16'. Alburquerque, New Mexico 8/70 - x x x x - - 17. Elmira, New York 9/70 - - x x x x x 18. Winston-Salem, 14. C. 1/68 - - x x 19. Akron, Ohio 11/69 - - x 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 x 22. Portland Ore-on 1/70 x x -x x 23. Greensburg, Penna. 10/69 x x x x 24. Ligioner, Penna. 1/70 x x x x 25. Hanover, Penna. -/69 x x x x x x x 26. Seattle, Wash. 3/.70 x - 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) SUR@7EY Ol-- MOBILE CORO@'@'APY CAPE zUi"IDJMkl@C]3 PLA',N'I\IED TO OPE@TE Date Physi- Trained M.D. Will Start cians Nurses Personnel I/ieets a b c d No. City and State Mo. Yr. (See below) 1. Los Gatos, Calif. 1/71 x x x x x x 2. Oranae County, Calif. -/71 x x - x x 3. San Francisco, Calif. @/71 - - x - x x x x 4. Miami' Beach, Fla. 4/71 - - x - x - x x 5. Honolulu, Hawaii 4/71 - - x - x x x x 6. St. Louis, Mo. -/71 - - x - x x x x 7. Middlesex County, N.J. -/71 - - x - x - x 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 x x 11. Columbia, S.,C. (2 Units) 7/71 - - x x x x x 12. l,forris, Minn. -/71 - - x 13. Tulsa County, Okla Not Yet Formulated 14. Hartford, Conn. of 11 of 15 l@, E. Florida It it 1 .@ampa, Florida I-/ - Atlanta, Georgia 18. Mississippi 19. Winston Salem, N. C. 20. South Dakota 21. Utah It it it TOTAL 1 2 9 3 10 9 11 10 Ambulance equipped with: a. voice communication to obtain professional guidance b. portable electrocardiogram c. telemetry to monitor the ECG d. portable defibrillator I IV. CORONARY CARE TLUINING I i I .. -k IV. CORONARY CT,.RE T@KINING A. Among the categorical diseases specified in the PL 89-239, heart disease is currently receiving the greatest emphasis in Regional Medical Programs as it did in the early phase of the program. This legislation reflected a growing national interest in accelerating progre ss 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 2 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.) B. @IP CONTRACT ACTIVITY It is anticipated that by early next year, training guidelines will be available from the Inter-Society Cor=ission 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 PDAP staff people from throughout New York State. C. RMP PP..OJECT 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 RY.P 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 all 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. RECO',WiEl\'DATIONS 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 before and after the training period to facilitate the flow of infor- mation regarding expectations, responsibilities and capabilities of trainees. 5 5. The training program should have documented its access to a sufficient number of facilities with available patient population to assure adequa.te 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. TI-IE COROI\TARY HEART DISEASE COMMITTEE'S TOPICAL OUTLINE OF NURSE TRAII\'I-@\G COI\"!"ENT NEW YORK STATE HEART ASSEMBLY, INC. TOPICAL OUTI,l@,Tli- OF TIZAII@,INC'T CO',r\ITENT Statei-iient: The contents both essential and contributory a-, (lefi)-ied ia-.Ccts the recluircn-icnts of the Joint Position Statements the role of the reris@tcred professional nurse in the care of patients with C@.rdioviE;cul-CL3: Diiease in the coronary care or intensive units as presented by the, 1%letlical Society of the State of I\Ic@%, Yorl-., Ne\v Yo3:k State Nurses Association -and the 1-jo@,1)4,"al AC@.goCiatiol-i of I\Tcvi Yorl@ State. This is intended as a basic preparation for tire nurse at A. Risk Profile V. Care of the Patient with Myocardi-,vl Ing',--rctioi-i: A. Pathophysiology B. Diagnosis C. Complications D. ME,@dical Manaaement: (1) Rest (2) Drugs (3) Dietary Nursing Care: (1) Admission of the patient (2) Routine Nursin Care in Coronary Care Unit 9 '(3) Transfer of the patient (4) Psychological aspects of care (5) Rel-iabilita't-.ion and Teacliing of patient/farnily v Fluid and Electrolyte Balance Elcctropl.-lysiolo-y c@f the. A. 12 L ECC:- - i-ic)rm-?,l heart B. Cardiac r-ionill-or;-iig coi-iccp@-,s C. Arrhythmia recognition @nd treatment: (2) (3) C.-trdio-%,ersion ancl. Defiunillatioii (4) Pacem,--Irlcrs (5) C-,rdiopLil.monary j.-esi-,,@,citation: (a). Principles of ventilation (b)' Definitive therapy VIII. Care of the P@iti-ei-it x-,,ith Co-.iciestive lieprt Failure: A. Normal anatomy and physiology of cm B. Pathophysiology C. Diacfnoris: (1) Auscultation (2) Early recocnitio-Ti D. 1,1@dicc-LI i-n.@.nagornei-it: (1) Drug thc-il,-,py (2) Other therapies E. Nursing Care: (1) Nurse Is. role in early detection (2) Subsequent care: (a) Rotation of tourniquets (b) Positioning of pat'ient (3) @,.ll-lal@ion of therapy: (a) C. V. P. monitoring (b) Intal-,e and Output (c) Daily @%@c-,ights IX. Care of the Pat3.cnt Nvi'Lh Cardiogenic Shock: A. Patliol)hysiology B.' Diagilo,,3i.5 C.. Medical management: (1) Drug tl-icrz,,py (2) Other therapies D, Nursl-ng Care: (1) The role of the ni-irse in ez,,:cly detection (2) Evaluation of therapy -3 - CO@\ITP,!3" ITT02,Y CO'I\TTENT A. Did--ctic instruc'tioi-L/deiiaoii,-,-Lyations: (1) Dog (2) Usc- of Resusci-lir,.iie Ic@d vest, chc,-t liner (3) Other training devices (4) Elective ca2:d,@oversion-p,@rticipzLti-on II. ECG Experience: A. Practice with ECG Tcchii:Lci,-tns In routine t-@ldnf,- of 1Z lead tracin;,s C> B. Kriov%,Ic-dgc of various lead systomri, for insta-,i<-,-e hexa@zial, vector, etc. JU. Care of Patients with P,--Lcon-lakers: A. Kiiowledcye of principles involved B. Assist with c,--thc-ter-pacer insertion.-, etc. C. Awcn-rei-iess of electrical hz-zards IV. Slzills in treatment of congestive I-Tcart Failu@-e: A. Rotation of ti)uriiiquet B. Auscultation techniques C. Early portable chest x-ray D. Circulatory'assist procedures V. Slzilis in Inhalation Tlicrapy Techniques: A. Types of respiratory equipment aids B. Kiio,.T.,Iedre of special drurfs; aerosols, etc. C> C. Experience inhalation the:rapy teams 7 VI. Special Laboratory Techniques: A. Venipuncture tnd 1. V. therapy; assisting %,,iith cut-down procedures B. Urii-ialysis - urine specific gravity; ph determination VII. Sldlls in Therapy Related to Itespiratory Failure: A. Central Venous Pressure: (1) Preparation for and assisting with (2) Interpretation -4- A. Role of the NLrse ii'i Dat,,- Collec'ti,@-i B. Research Trends IX. Complei-neii'L-s of Instruction: A. Use of filmr,, video t,,p--s, records B. 1\6onitor-tez,,clii-ng machine for C. Distribution of prepared material,, froi-i-i Asz-,ocia'Lion and o-%,jn mi t-n-eo prcp,-tred ii-istrtic'tioi-ia.1 aic,@s D. Use of I\Iurr,,i.iig Round,@ as a metl-2od of teaching E. Library resources F. Animal experimentation C;LII\TICAI, l@:YPj@-RIENCE A plariii0el, supervised cliiiic@-I experience should be provided theory presentation so that reinforcement of Ic-,ri-iiii- can tal;:e place. Cliriic.-,Ll 0 practice should focus upon the attainment of specific nur,-ing.beh,,-vior.-, and ils. pw 10117/69 CO@TIONARY I-M@ ART DT@'q!,IASE CO-k@,.L\IITTr@,E T,' l'ILOA'i YOR.L@ STATE I-IEART.ASSEMBLY Multi-media coronary care instructional systems @,hould r-ot b-- used as se@,. contained teaching systems in the education of coronary care n-Lir.902. systems may be used ,-s i'lltep,,rated, flexible tools which can be a'd,%p@lod for cl-ls,,-- room teaching or independent study. Therefore, the following re@orilmenc,-,tions ave made in i-elation to the of tc-,cliinrf r, :3tr--i-n.:3 for co,-%-o care nurse training: 1. Teaching systems should emphasize the need for prepared nurres as instructors in cooperation v-,ritli the interested physician instructor as vrell as the implementation of demonstrations, discussion r.,ro-L%139, mid other teaching techniques in conjunction.-,,@ith systems; 2. Other texts, in addition to those recommended by the special teaching systems should be utilized because no oi-te teachiii" system should be depended upon; 3. Certain gaps in content are usually present in most teaclliiiry'i3yste-ino and these must be supplemented by structured course and class presentation as wall as demonstrations essential to ftiF.ill procyram excellence; 4. Local hospitals @tilizing multi-media instructional systci-iis to prepare ntirses'in coronary caze nursinri should provide co-,iclirront nnod clinical i-,istiLucci,@n in adequate. facilities for clinical practice tr,%In.111g; C'kiiiical rirac:ticc should focus upon the attainment of specific bohavio@z; And skills under qualified. supervision; -z- iNurse teachers uti-liziii(f be tatif,li',, course prec:ent'atioii and evaluation slzills; 7. Individual nurse replacements for thc, Coronary Care IJ2iit 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 -@djurct5.-,,,e tool for training coronary care nurses if the follovrii-ig essential components are provided @'or: 1. prepared physician-nurse teams for instruction and supervision of trainees; 2. the -.vail,-tl:)ility 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 eval.L,--ted prior to purchase and implementation. .cbw R-t'C Oi'@IMPiiN DA T IO !ITS TO C.HliPTFi-IS It is recommended that: 1. Clarification is needed of all costs of i-nulti-ined;-a instructional systems other than initial exponditure. 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 %@.,orkbooks, instructor wo@rl