When Penn Presbyterian Medical Center in Philadelphia opened one of the first coronary care units in 1963, it pioneered the idea that nurses could successfully monitor patients whove had myocardial infarctions and, with standing orders, perform defibrillation and provide other interventions to improve patient outcomes.
“It was so new and exciting,” Janice Lufkin, RN, BSN, one of the units original nurses and its second charge nurse, said. “That was the best thing I ever did.”
Cardiologist Lawrence E. Meltzer, MD, and J. Roderick Kitchell, MD, chief of cardiology at Penn Presbyterian, led a one-year research study in 1963, funded by the U.S. Public Health Service, establishing a two-bed coronary care unit at the hospital.
A 2001 article about the evolution of the coronary care unit, published in Cardiovascular Research, indicates that investigators decided to see whether nurses could assume surveillance and emergency treatment responsibilities. According to the article, it turned out that nurses excelled at it and became “key personnel in coronary care.”
“We found out afterward that they didnt think nurses at the time could handle things on the unit without a doctor being there, and they found out we could act on our own,” Lufkin said.
Before the unit opened, the cardiologists personally trained Lufkin and the nurses how to read ECGs and how to respond to cardiac events, including how to defibrillate. It was believed sudden unexpected deaths from acute MIs, particularly during the first 72 hours, could be prevented with careful monitoring and defibrillation.
The patients, primarily, were men, since at the time it was thought younger women did not have MIs, Lufkin said. The nurses had to tape electrodes to patients, as self-adhesive electrodes hadnt been invented. They also collected data hourly for the study. Lufkin said she liked it and gained more experience by accepting other nurses shifts on the coronary care unit.
Patients had IV lines, and nurses had standing orders to start a Lidocaine drip after defibrillation.
“It was a wonderful experience, and I was glad to be a part of it,” Lufkin said.
Sandy Hicks, CRNP, MSN, a cardiology nurse practitioner at Penn, began working as a staff nurse in the CCU in 1973, after the research was completed and the then four-bed unit was incorporated into the nursing department. At that time, one RN cared for four patients, with either a nursing assistant or an LPN.
“We continued to do what the nurses in the original research unit started,” Hicks said. “The roots of the nurse-patient relationship changed so drastically in the CCU, took hold and became a springboard for all of nursing, especially critical care nursing.”
Hicks indicated medical research “exploded” during the 1970s and nurses took part in it and understood the value. “The 70s brought a tsunami wave of change,” she said. New equipment and medications arrived. Cardiac patients received beta blockers, aspirin and calcium channel blockers, but nurses still counted IV drops to calculate rates.
“The relationship we had with physicians continued to grow and deepen,” Hicks said. “We were told that we would never be seen as a widespread model. But that was the beginning of the end of the old school.”
There was a sense that nursing would destabilize and some nursing administrators “were incredulous that nurses would have the communication and interaction with physicians that we had,” Hicks said. “Some were not okay with it.”
She added that those are the best memories she has. “The early nurses took some chances, but without the support of the physicians, it never would have been able to work,” she said.
Today, patient acuity has increased, Hicks said. No longer are all acute MI patients admitted to the CCU. Often, patients are sent directly to the cath lab for intervention.
“Patients are much sicker now, but those sick patients that may not have made it [in the past], walk out of here,” added Karen Moore, RN, BSN, CCRN, who joined the CCU 15 years ago and Presbyterian 35 years ago. Hypothermia treatments, ventricular assist devices and other innovations have improved outcomes and increased patients odds of returning home with a good quality of life.
“Weve been a trailblazer,” Moore said.
Lise Bauman, RN, a staff nurse in the Presbyterian CCU, joined the unit in 1985, when it was expanding, and reported having experienced many changes. She credited a culture of genuine caring and excellent patient care with keeping her at the bedside for more than a quarter century. During that time, the hospital transitioned from a small, community facility to part of a large system.
More evidence-based practices are part of patient care. Information technology has arrived on the scene. Paper order forms and Kardexes are gone.
At first, the CCU nurses cared for many acute MI patients who now would typically go to cardiac cath labs for early interventions. Those admitted to the current 13-bed CCU are more unstable. Many are in heart failure.
“I find the job more stressful than it used to be, largely because of the constant new information,” said Bauman, who reports there also are more meetings to attend.
Despite the stress, Bauman enjoys her practice and the CCUs collegiality, saying, “The relationship among the nurses is a positive one, and that makes it a wonderful place to work.”