My husband just had a liver resection for cholangiocarcinoma. Major, major surgery. He is 67 and has CAD. He was taken to the 14 bed oncological surgery ICU and got outstanding care. The hospital is Johns Hopkins and it is no wonder they are #1 in the country. The care he got from EVERYONE during his stay was superb. And the staff was so nice and pleasant and helpful. I am an NP and I was impressed.

JoJo,

I have worked in a total of at least four Open Heart Surgery Units. Sometimes they were called different names. Some of the units were "controlled/covered" by anesthesia or critical care intensivist--which is usually advanced educated anesthesia for critical care. Others were completely controlled by the OH Surgeons/team or a combination of the CT surgeons/fellows, etc as wells as unit cardiologists. It all depended. In all of these units, however, the nurses always received the patients straight out of the OR--whether it was for peds OH or adult OH or, in one unit, it was a combination of both ped and adult OHS--they also had other kinds of intensive vascular surgeries, etc in these kinds of units. And the children's hopsital unit received post-op heart and lung or heart/lung transplantation.

In one state in particular, the standard of care for receiving a fresh open heart patient directly out of the OR was, upon "receive" 2 RNs--one receives, the other assists. After anesth. signout and, if adults, the first shooting of the cardiac index/profile, etc, (The receives were involved b/c often the lines coming out of the OR were like this nightmare of a bird's nest--especial w/ adults in some places--OY. So there was this whole protocol at this one excellent facility. You systematically went through your initial post-op assessment, again, hemodyn profile, blood draws, gases, etc, turned pt as part of the assessment--much like you would in surgical trauma. Of course VS are way frequent q 15 at first--if there is greater instability, IABP, or something of that nature, it may be even more frequent--assessment and clearing of CT's. In the ped's CT unit, we had to do sterile suction of the chest tubes, etc. Every place had their own particular way, but it all basically is to be systematic and continuous very close assessment--I mean, you really don't leave the patient post-op for quite sometime--sometimes not at all depending on how things are going, how much blood products you have to give, etc. Critical documentation is part of it all. And most of these kinds of units that I have had the privilege of working in had people there almost all the time. You have to accept being in a fishbowl. Some nurses were a pain, in that rather than being supportive, they would watch a nurse receive post-op and just hope he or she might miss one little thing and jump all over them--or they would feel that there way is THE only way to manage the kid post-operatively--even though, in my experience at the kid's hospital, at least at that time, many of the nurses didn't really know a whole heck of a lot about hemodynamics or rhythms, or looking at CXR's etc. So, if you had gotten a lot of those pieces w/ the adults, even though kids are different for many reasons, certain hemodynamic principles, especially post-operatively are similar. That is, if the kid is intravascularly dry, even though you don't have a swan-ganz in place, you can look a LA & RA pressures, systems outputs--all the way down to their u.o., and circulating BP and HRs, and their Blood Ct's, as well as they full assessment--and guess what? If they need some volume, they need volume post-op or they are going to circle the bowl. You just have to be very exacting and careful w/ what and how you give it. And we tended to treat h/h's more readily w/ kids, in general, then in adults, in general.

Getting back to your question. . .it all depends on how the unit and nurse and med/surg staff is set up. Generally if a unit is going to receive straight from the OR, the unit policies and protocols, environment, and staffing should be set up to meet the requirements of a post-anesthesia setting w/ the specifics for the kinds of critical post-ops the units will be receiving.

Don't know if that is helpful. Haven't been doing it for a while, but will probably go back from general ICU/CCU and PAR to that setting, after being a part of working and inputting for a whole new unit for kids. Still want to stay in it at least part time. Eventually my school demands will make so it would only be weekends and per diem I think. . .it depends. Since my advanced degree is in education, and I am teaching PT now, I think it will be hard to go back into it full-time for a very long tour--like years. You can't do everything you like and want forever. I hope to work in it at least part time as long as I can.

Look for Post Anesthesia Recovery UNIT Standards for Open Heart Surgery and other Critical Surgeries. Look into the various certificate of needs information for such projects. You will get more of an idea of what's expected--especially as it pertains to your state.

Please try to pardon my rough and very unedited above response.

I wanted to say that some OHU's required q 5 min vitals when you first receive. You move up to q 15, etc. The one place was cool, b/c it ran like a tight military operation. Not being a military person, at first I thought some things were too rigid. What I learned was they had mostly excellent rationales for their "rigidity." And if the area is going to treat pt's right off the table, then they have to function like a post-anesh area--w/ the extra specialization. I hated to leave that place, even though it was a big of a cuture shock at first. It wasn't until I was working in similar units elsewhere that I was able to fully appreciate their seemingly inflexible approach to, well, almost everything. I was able to be a part of and witness changes in terms of making certain things more flexible--not leaving every fresh heart sedated and intubated all night, etc.

We only one patient fresh open heart first 12 hours and right off the table it was 2 RNs to 1 pt for the first 1/2 to hour or so if they were more or less stable. If they came back w/ an open chest, on a pump or a h/l circuit, then of course the ratio stated 2RNs to 1pt. If a kid was on ECMO and very unstable, of course there were be the ECMO specialist or the perfusionist and then two RNs. Needless to say, regardless, most places don't like to keep that kind of ratio to pt for too long. And, in some of those units (not so much the first one I spoke of), you would get two really unstable kids/babies and sometimes three. Running concurrent codes, or one baby coding while the other kid is skating w/one foot on a banana peel is just wrong in my view. If I had a baby or kid in a unit like that, under those circumstances, they'd really be hearing about it.

Anyway if we're talking a fresh heart post-op, it should at least be 1:1 for no less than 12 hours if stabalized. I am not sure what state you are in, but in NJ, at least that was the standard. The first hospital I refer to in this reply followed that standard. But they were exceptional compared w/ what happens in a lot of other places. I hope you are able to find out about these standards in your state, etc. The situation you describe seems to fall short. Unless they are willing to follow tried and proven protocols of safe practice, I'd say, yes. Let the go to the PAR. But many PARs I know don't really deal w/ fresh heart, etc, so if that is the case, they'd have to get up to speed on that as well. You can't treat fresh hearts as wake up and ship out kinds of clients. There's a lot more specialized intensive care to it, if it is to be done well.

My short answer... I think every single patient coming off the OR table should go to a Post Anesthesia Care Unit or Recovery Room for close monitoring immediately post op.