The hectic pace of innovation radically changed the function and acuity of the CCU. It had evolved from managing AMIs with monitoring and defibrillation/CPR in the event of ventricular tachycardia (VT)/ventricular fibrillation (VF) to actively managing relatively acute and unstable patients with active hemodynamic, cardiovascular, and respiratory complications. In the first 30 or so years, remarkable improvements in survival were noted, as close monitoring and early resuscitation became ubiquitous. Killip reported that the mortality in MI in his CCU decreased from 26% to 7% over a 2-year period from January 1965 to 1967.
Treatment of myocardial infarction in a coronary care unit: a two year experience with 250 patients.
Patients were no longer dying from sudden arrhythmias but from pump failure. However, the low hanging fruit had been picked. In their remarkable review of the changing epidemiology in their CCU
- Katz J.N.
- Shah B.R.
- Volz E.M.
- et al.
Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes.
over a 17-year period from 1989 to 2006, Katz and colleagues were unable to replicate this reduction in mortality. At the same time that rapid advancements in technology were leading to a decrease in AMI mortality, the burden of patients with ischemic cardiomyopathy and advanced heart failure was increasing. This was reflected in the increase in such patients in their CCU. To manage these patients, improved therapies, both pharmacologic as well as mechanical circulatory support, were being increasingly utilized. These patients were older and sicker and had many more comorbid medical conditions requiring a broader knowledge and experience base and a wider therapeutic armamentarium. This was clearly shown in Katz’s study of the changing trends in pathophysiology of CCU patients. He documented a pattern of increasing patient complexity, evolving critical illness, and accelerated resource utilization. Over the 17-year period, he noted a significant decrease in patients with STEMI, and a significant increase in patients with non-STEMI (NSTEMI) and cardiogenic shock. There was a significant increase in the number of patients with pneumonia, sepsis and septic shock, acute and chronic kidney failure, acute and chronic respiratory failure, and prolonged ventilation. More invasive procedures such as central venous catheterization, gastrointestinal endoscopy, bronchoscopy, and renal replacement therapies were performed. Interestingly, despite the increased case mix and Charlson comorbidity indices, there was no significant increase in CCU length of stay or unadjusted in-hospital and CCU mortality. This was attributed to a better understanding and prophylaxis of potential complications of ongoing critical care.
Practitioners at Mount Sinai have noted a similar increase in severity of illness in the CCU. Most PCI patients today are discharged the same day, and those who are admitted go to a step-down monitored unit. Increasingly the CCU of today is becoming more like a general ICU with a focus on cardiac patients. Table 1
highlights this severity and complexity in 1370 admissions in 2012.
The coronary care units of the 1970s have evolved into the cardiovascular ICUs (CICUs) of the 21st century and this evolution will certainly continue. As the modern CICU develops, it must follow the trends that have been evolving in the more organized general critical care realm. The principles of the approach to intensive care are evidence-based and can be examined in the context of 3 domains, which will be discussed in the next sections.
Quality, Safety, and Resource Utilization
The modern patient safety movement began with the Harvard Medical Practice Study (MPS), which was published in 1991 and found that 3.7% of hospitalized patients suffered an adverse event, of which 69% were preventable, and 14% were fatal.
- Brennan T.A.
- Leape L.L.
- Laird N.M.
- et al.
Incidence of adverse events and negligence in hospitalized patients.
Although this study also ran as a front-page article in the New York Times, it was essentially ignored. Only in 1996 did the American Medical Association (AMA) join the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the American Academy of Arts and Sciences, and the Annenberg Foundation to host the first ever conference on medical errors in California.
Scope of problem and history of patient safety.
The patient safety movement gathered further steam after the 1999 Institute of Medicine report “To Err is Human,” which estimated that medical errors were the cause of up to 98,000 preventable deaths per year.
The focus also shifted from a culture of blame to a problem of defective processes and systems. Since then, various agencies have established organizations focused on increasing patient safety and improving the quality of care. Some of these agencies are the Centers for Medicare and Medicaid Services (CMS), the National Quality Forum (NQF), JCAHO, the Agency for Healthcare Research and Quality (AHRQ), the AMA, through its National Patient Safety Foundation, and the Institute for Healthcare Improvement (IHI). The Society of Critical Care Medicine (SCCM) collaborates with most of these organizations to promote evidence-based care in the ICU. The SCCM also collaborates with the National Institutes of Health’s (NIH) United States Critical Illness and Injury Trial (USCIIT) Group, to study organizational structure, processes of care, use of protocols, and outcomes in ICUs and determine which of these structures and processes of care and other factors might be associated with patient outcomes.
- Cobb J.P.
- Cairns C.B.
- Bulger E.
- et al.
The United States critical illness and injury trials group: an introduction.
To date, more than 200 USCIIT Group investigators have enrolled more than 10,000 patients from more than 30 academic and community hospitals in studies during the last 3 years.
- Blum J.M.
- Morris P.E.
- Martin G.S.
- et al.
United states critical illness and injury trials group.
The modern CICU must be cognizant of and incorporate these structures and processes into daily work flow. These processes will be discussed briefly.
The Centers for Disease Control and Prevention (CDC), The Joint Commission (TJC), the IHI, and several state departments of health all have rigorous protocols for the prevention and monitoring of central line-associated blood stream infections (CLABSIs). Similar protocols and requirements exist for the prevention of catheter-associated urinary tract infections (CAUTIs), Clostridium difficile-associated diarrhea (CDAD), ventilator-associated pneumonia (VAP), and coronary artery bypass grafting (CABG) surgical site infections.
The IHI promotes comprehensive protocols such as the ventilator bundle, central line bundle, and methicillin-resistant Staphylococcus aureus (MRSA) prevention and best practices to reduce patient harm from sedation, immobility, and delirium. All of these are germane to the practice of modern cardiac critical care.
TJC and the CMS collaborate to monitor core measure sets that standardize the use of evidence-based interventions to maximize patient safety and outcomes. Some of the core measure sets relevant to cardiac critical care include
Surgical care improvement project
Pneumonia and influenza vaccination
Acute Myocardial Infarction
On its Web site www.medicare.gov/hospitalcompare
, CMS posts various data points relating to care delivered to its Medicare recipients. Some of these are
Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS), which collects patient feedback on 10 important hospital quality topics in recently discharged hospitalized Medicare patients
Measures of timely care such as for heart attack, heart failure, pneumonia, and surgical management
30-day mortality and readmission rates
The CMS also has the authority to deny payment to hospitals for hospital-acquired conditions (HACs, also known as “not present on admission”), which obviously has implications for resource management for the hospital and its ICUs. For 2013, there are 14 HACs for which CMS can deny payment (http://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ HospitalAcqCond/Downloads/FY_2013_ Final_ HACsCodeList.pdf
). Those relevant to cardiac critical care are
Foreign object retained after surgery
Stage 3 and 4 pressure ulcers
Falls and trauma
Manifestations of poor glycemic control
Catheter-associated urinary tract infection
Central line-associated blood stream infection
Deep vein thrombosis/pulmonary embolism
Surgical site infection and mediastinitis following CABG
Surgical site infection following implantable cardiac electronic device