Royal AlexandraHospita I

CARDIOLOGY DIVISION

Coronary Care Rotation - Royal Alexandra Hospital

Welcome and Orientation Letter

We extend a very warm and sincere welcome on behalf of all the Cardiologists, nurses,pharmacists, and other health care professionals in our Division. The next four weeks of yourtraining program will be busy and rewarding. You will gain knowledge and skills to assess andmanage patients with acute cardiac problems. The majority of patients you will be exposed towill presenl with an acute coronary syndrome (ACS) including myocardial infarctions (Mls).There will also be many patients suffering primarily from valvular heart disease, cardiacarrhythmias, chronic congestive heart failure and cardiomyopathies. During the rotation therewill be frequent exposure to both indications and contraindications for fibrinolytic therapy,interventional reperfusion therapy. The reasoning behind the rationale for use of beta blockers,Aspirin, Heparins, angiotensin converting enzyme inhibition and lipid lowering therapy in thepatient diagnosed with an ACS will also be explored. A working knowledge of anti-arrhythmicsand inotropic therapy will also be gained over the four-week period. Significant exposure tomechanical ventilation is to be expected; as well as exposure in certain instances tohemodynamic monitoring by pulmonary artery catheters, intra-aortic balloon pump (IABP)therapy, and temporary pacemaker therapy.

You will further develop time management and prioritization skills, and learn to efficiently andeffectively assess the critically ill patient. The Division is complemented with resources andknowledgeable health care professionals who you are encouraged to approach and utilize toensure you get the most during your four weeks with us.

IN ORDER FOR THE CCU TEAM TO FUNCTION EFFICIENTLY AND SAFELY, IT ISIMPERATIVE THAT ALL PAGES, PARTICULARLY CODE PAGES, BE ANSWEREDPROMPTLY.

Coronarv Care Unit (CCU) Desiqn

The CCU has:

> eight acute beds (patients requiring intravenous nitroglycerine, inotropic support, invasivemonitoring/intervention, temporary pacemakers),

) four step-down beds (observatory, awaiting transfer to patient care units [PCU]),> a procedure room with fluoroscopy capability (insertion of temporary pacing wires.

pulmonary artery catheters, IABP.

Patients admitted to the CCU primarily have a single system illness, and accordingly arepresented with a focus on their cardiac illness, with other pertinent information added- The initialpresentation provides details related to the admission with subsequent presentations providing athumbnail introduction ofthe patient, new changes in clinical status, and relevant diagnosticresults. A'problem list'should be utilized to address the issues involving your patient; with morecomplex patients a 'systems approach' may be more functional. Please see handout entitledPresenting on Rounds for a more detailed explanation of what is expected.

revised July 2006RGWRAS/IM

Capita lHeal th

RAH CCU Welcome & Orientation Letter

Rounds and Dav Flow Desiqn

CCU rounds begin at 0830 hrs. (unless otherwise specified ) at which time a review of thepatienVassessment, progress note, and a tentative plan for your patient should be completed.You are encouraged to join the morning nursing report which takes place daily between 0700-0715 to find out about the events ofthe night and concerns which have arisen. lt istheexpectation that you follow the patients who you admit during their CCU stay. Some patientassignments may be redistributed to equalize workload. Once transferred out to a PCU, theattending CardiologisUPhysician assumes care and rounds on them independently. You areencouraged to follow the patient through his/her convalescence on the PCU to discharge to bettergain an appreciation for the management of their cardiac illness.

Upon completion of reviewing your patient with the CCU attending Cardiologist, plans and goalsneed to be documented, orders written, and consults/requisitions completed. Every patient in theCCU requires a progress note daily, and a clear, complete, concise transfer note whentransferred to a PCU to help the receiving CardiologisUPhysician understand the patient's courseduring his/her CCU admission, and the plans which were discussed and implemented.

Following CCU rounds, x-rays are reviewed in the main Radiology Department and anyadjustments to therapy are made and communicated to the CCU bedside nurse caring for thatparticular patient. Time permitting, a teaching session follows when the Cardiologist will discussa topic pertaining to some aspect of the management of the cardiac patient. After the teachingsession the group disperses for lunch and begins assessment of the consults. At this time areview of any left over consults from the previous night also takes place. Review of the consultsbegins, typically, around 1400 and sign-out rounds in the CCU are planned for 1600. Variationsin this schedule may occur depending upon workload or staff preferences.

House Staff Responsibilities

There are typically three or four senior residents (Cardiology fellows, Anesthesia, Emergency,General Internal Medicine, Cardiovascular Surgery), four junior residents, with one or two studentinterns. Intermittently, there will be international medical graduates joining the CCU team for anobservational period of a week.

l. Senior Resident Call

The senior resident numbers are variable and not guaranteed. The Monday to Fridaydaytime duties of the senior will vary depending on their program of origin andexperience. Anesthesia and Emergency Medicine residents are expected to spend themajority of their time with the CCU team organizing and assisting with the management ofmore complex patients and coordinating the consult service. Senior Cardiology residentsare expected to spend the majority of their time in CCU and on consults, however theymay choose to spend time in the catheterization, stress, and echocardiographylaboratories, for example, and also follow their own 'adopted' patients.

Based on the 2006 PARA contract, maximum home call frequency is 1 in 3 nights.

There will be certain days and nights where there will be no senior resident available. Theteam will be aware of who is on call at sign-out rounds. At no time does senior call involvedirectly handling outside calls.

revised July 2006RGWRAS/IM

RAH CCU Welcome & Orientation Lefter

Seniors will also be responsible for presenting at one 'Senior Rounds'during their rotation.'Senior Rounds'are scheduled on Tuesdays between 1200-1300 in Room ATC 2315(Ophthalmology Library). The topic needs to be relayed to the CCU attending Cardiologistand Marie Schneider, (Cardiac Administration Secretary - 735-5677), within the first2 weeks of their rotation.

Junior Resident Call

Junior resident call can be a very busy time during the CCU rotation; additionally it can beone ofthe most beneficial and educational components ofthe rotation. During call, theresident will learn to assess and treat acutely ill patients in a lertiary care centre and learnto prioritize actions when multiple requests are encountered. The junior resident issupported by both senior residents and attending staff. Before calling either ofthe afore-mentioned physicians, the junior resident should have made an assessment ofthe case inappropriate detail to convey first an idea of the suspected diagnosis, followed by theimportant details of the case and, finally, a planned course of action. Timelypresentations are necessary to allow efficient implementation of further strategies, ifrequired. Further details regarding call can be discussed during orientation.

Junior residents divide the daily activity schedule into four different areas:

1) CCU/ ER - This resident is responsible for consults coming from the ER during thedaytime and then is responsible for the whole hospital during the night. The mostimportant phone call heishe will receive is a patient who is in the ER presenting with asuspected ST elevation myocardial infarction (STEMI) and the attending physician isassessing which treatment modality to implement. The current trend in acutemyocardial infarction (AMl) is towards emergent angiography and primarypercutaneous coronary intervention when appropdate. This applies to large, high riskMls, cardiogenic shock associated with Ml, and most Mls presenting during regularcatheterization laboratory hours. Due to the time delays for staff returning during 'offhours', fibrinolysis is most often considered at these times. These patients need tobeen seen and assessed promptly. During evening and night, CCU is the primaryresponsibility of the junior resident. Although many things (ie. electrolyte imbalancesand anticoagulation) are set up to be managed as per protocol, issues/concerns doarise and your attention to the concerns of the CCU bedside nurse helps ensurewholistic management of the patient, as well as support teamwork skills. The residentmust maintain timely communication with the nurse in charge to inform them ofadmission or possible admissions so that staffing can be adjusted to the acuity of theCCU. THE POST CALL RESIDENT, PRIOR TO LEAVING, MUST ENSURE THATTHE SENIOR RESIDENT IS AWARE OF ANY OUTSTANDING ISSUES FROM THEPREVIOUS NIGHT.

2,) Wards - This resident is responsible for PCU 24, where the majority of theresponsibilities are to address acute changes in patient's clinical status and for follow-up of investigations. You will be asked to complete admission histories and orders onpatients who are direct admissions to PCU 24. lf you are called to assess a patientwith chest pain it is because the bedside nurse has administered three sublingualnitroglycerin without relief and has completed the electrocardiogram (ECG). The otherresponsibility is follow-up of patients who are admitted post-percutaneous coronaryintervention into the post-angioplasty rooms. You will be called to assess the patientand to complete any orders for their admission after 1600.

revised July 2006RGWRASTIn

RAH CCU Welcome & Orientation Lefter

3) Consults - This resident is responsible for taking the consults from the hospital. Thenumber of consults can vary from day to day and accordingly the work should beevenly distributed among the residents and students to ensure that the consults areseen in a timely manner. The senior resident will play a key role to help delegate theconsults.

4) Post-Call - This resident is required to stay for rounds following call, including the lastday of the rotation. As per PARA, the resident needs to complete all responsibilitiesand follow-up so that he/she functions in accordance with the 2006 PARA contract.

lll Student lnterns

Student interns usually spend one to two weeks on the Cardiology service. The mainfocus will be in the CCU where the students will be involved in seeing patients and on theconsult service. They may assume a CCU patient and follow them with a junior or seniorresident in the CCU. Students are also encouraged to stay at least one evening duringthe week to shadow the junior resident.

lV International Medical Graduates (lMG)

lMGs will be joining the CCU team for a one week observational period. Similar toStudent Interns, their main focus will be the CCU where the IMG is encouraged to beinvolved in seeing patients on the consult service. They may assume a patient and followthem with a junior or senior resident in the CCU. IMG's are also encouraged to stay atleast one evening during their week to shadow the junior resident.

Academic Half-DavsiAppointmentsiMeetinqs

All residents will attend all compulsory academic half-days from their respective programs. CCUcall is discouraged on your half-day or on the night before a morning academic half-day. In otherwords, compulsory academic activities should result in minimal disruption of CCU activities.Personal appointments and meetings should be scheduled for your post call days.

Codes

The other most important phone call you will receive, besides a patient having an AMl, is a code.The CCU junior is responsible for the management of the code and must review and sign thecode sheet once the code has been completed. It can be stressful, but during lhe daytime therewill be more than ample amount of resources and assistance available to you. The IntensiveCare Unit (lCU) resident, who is usually one to two years ahead of the CCU resident isresponsible for airway management and procedures, if required. During the evening and nightsthere are far less people, but the ICU resident and nurses can provide an invaluable source ofknowledge based on experience and expertise. Once again you are encouraged to fully utilizethese resources.

Electrocardioqram (ECG) Readinq

All residents, Sl's, and IMG'S are encouraged to fine tune their skills in interpretation of ECGs byreading ECGs at every opportunity.

revised July 2006RGWRAS/lm

+

RAH CCU Welcome & Orientation Lefter

Medical Grand Rounds and Cardioloqv Rounds

On Thursdays, all residents, student interns and international medical graduates are required toattend Medical Grand Rounds from 0830 to 0930, and Cardiology rounds from 1 100 to 1200, inthe ATC auditorium, 5203. On Thursdays, CCU rounds must be completed between 0930 and1 1 00, re-enforcing the importance of seeing and assessing your patients prior to 0830. Juniorresidents are required to present a case-based group presentation on the last Thursday of theirrotation. A decision regarding the topic should be decided upon by the end ofthe second week,and can be reviewed with the Cardiologist in terms of relevance and content. (There are noMedical Grand Rounds or Cardiology Rounds in July and August).

Cardioloqv Research

On your first day you need to contact Linda Kvill, Study Coordinator (pager number 480-6223) tobecome orientated with studies which are currently recruiting at this institution. lf all of you areunable to meet with Linda, the person on call for the first day needs to meet with her.

We are here to make your learning a positive experience. Please do not hesitate, at any time, toask questions during your rotation to those in the Division. Once again we welcome you to theDivision of Cardiology and hope that you will enjoy and actively learn during your four weeks withus.

R.G. Wil l iams MD, FRCPCDirector - Coronary Care

zt fu./ 's '

R.A. Seyon MN, NP, CCN(C)Nurse Practitioner, Cardiology

revised July 2006RGWRAS/1m