CCU vs ICU admission s/p MI

[Epo83]

So the issue has came up quiet a few times during residency, and after searching through some other hospitals guidelines I was wondering if anyone else could provide some input for what criteria should be met when deciding whether or not a pt who has undergone cardiac arrest should be admitted to the Cardiac Care unit vs the Medical ICU?

Cheers

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[gutonc]

It basically depends on what your hospital does. In mine, the difference between CCU and MICU was the attending and fellow. Same residents, same physical location (although that has since changed), same RNs.

 

[flipmd]

Depends on the fellow / attending. Sometimes they have "too many medical problems" for the CCU. Sometimes they have already "fixed the heart" and now just waiting for neurologic recovery (and goals of care discussion) on the vent...

 

[Epo83]

Yah this is the way it is at my hospital. It just sucks for the overnight resident who makes the decision where to send the patient and gets yelled at by attending in the morning for admitting to their service.

 

[Instatewaiter]

So the issue has came up quiet a few times during residency, and after searching through some other hospitals guidelines I was wondering if anyone else could provide some input for what criteria should be met when deciding whether or not a pt who has undergone cardiac arrest should be admitted to the Cardiac Care unit vs the Medical ICU?

Cheers

We need a little more information. Every troponin leak isn't a primary cardiac issue. First, what type of cardiac arrest are we talking about? The root cause of a PEA vs VF arrest are very different. Second as I alluded to above, the "MI" you are talking about, is this a little troponin leak after any arrest or a true plaque rupture MI (STEMI or type I NSTEMI)?

For instance, a really bad COPD'er who has a PEA arrest after becoming severely hypoxic from pneumonia will leak a good amount of troponin based on the down/ischemic time. That person had a cardiac arrest but shouldn't go to the CICU/CCU because the root cause is not cardiac.

If we're talking about a true plaque rupture MI that causes a VF/polymorphic VT arrest, yes that should probably go to the CICU and be managed by a cardiologist. I am of the opinion that if a patient is going to be managed primarily by a specialist, that specialty should be the patient's primary team.

 

[gutonc]

Yah this is the way it is at my hospital. It just sucks for the overnight resident who makes the decision where to send the patient and gets yelled at by attending in the morning for admitting to their service.

Congratulations on only taking 2 posts to get to your actual issue. You got bitch slapped for admitting to one service when it "should" have gone to the other. Whatever. People are douchebags and don't want to do extra work. This is an amazingly common phenomoneon among academic attendings who have to do remarkably little (clinical) work in general compared to their community counterparts.

Go have a beer, call it a day and move along.

 

[jdh71]

Where I work primary cardiac events that require a cardiologist usually go to the "CCU" - if they are intubated in the process or have a bunch of other non-cardiac problems they will consult me. Often I'll be "effective primary" until things have settled down.

Run of the mill out of hospital arrests for whatever reason go to the ICU and I'm primary. And I may ask cards to consult if it looks like the patient will make it and maybe needs a cath. Otherwise. Whatever.

Though usually I'll admit anything. And cards decides what it wants. So if they don't want the sick heart patient and they need the "CCU" I'll take care of them there too.

 

[IMreshopeful]

Where I work primary cardiac events that require a cardiologist usually go to the "CCU" - if they are intubated in the process or have a bunch of other non-cardiac problems they will consult me. Often I'll be "effective primary" until things have settled down.

Run of the mill out of hospital arrests for whatever reason go to the ICU and I'm primary. And I may ask cards to consult if it looks like the patient will make it and maybe needs a cath. Otherwise. Whatever.

Though usually I'll admit anything. And cards decides what it wants. So if they don't want the sick heart patient and they need the "CCU" I'll take care of them there too.

We actually have a separate intensivist team that manages vents and such in the CCU at my hospital should the need arise. It's pretty awesome, especially with the ones who concurrently develop ARDS/septic shock etc. Obviously as residents we are able to manage much of it but it's great having a critical care fellow and attending around when needed.

 

[leviathan]

If you think the cause was an ACS or primary cardiac issue then CCU. Other causes to the MICU. A good chunk of arrests without an obvious cause need to be cathed first and then the decision can be made after.

 

[visari]

Where I did residency, all PEAs went to MICU where almost all VFs and VTs went to the CCU. not all the time though. As residents we never had to decide between those two. The fellows had to do the fight. I think it's the norm everywhere that the MICU acts as a safety net for the critically ill pts refused by other services. The CHFs and MIs that cardiology decides over the phone it's "sepsis and definitely not cardiac related". The surgical pts who "don't need to go the OR" but they always go the next morning. The status epilepticus or massive stroke pts who neurology thinks their altered mental status is "toxic-metabolic" and definitely not neuro related.

In general, if you are given the chance of being lazy and block an admission every now and then, you're more than likely to abuse it.

 

[Gastrapathy]

Come on now, this is easy . Are you rotating on cards, if yes, they go to MICU, if no, they go to ccu. Are you on the wards, if yes, patient is either too sick for the floor or safe to discharge from th ER. This is such an easy game. Are you working in the ER - check trops on every drunk who fell down.

Then all of you can keep yelling at each other and never notice that the real winners are the folks who are purely consultants. "Sure, happy to see that pt once they are admitted. Where? Oh I don't care. Pick a service."

 

[IMreshopeful]

Come on now, this is easy . Are you rotating on cards, if yes, they go to MICU, if no, they go to ccu. Are you on the wards, if yes, patient is either too sick for the floor or safe to discharge from th ER. This is such an easy game. Are you working in the ER - check trops on every drunk who fell down.

Then all of you can keep yelling at each other and never notice that the real winners are the folks who are purely consultants. "Sure, happy to see that pt once they are admitted. Where? Oh I don't care. Pick a service."

My personal favorite service shunting is the surgical services - "uh huh they're coming in with appendicitis ... what? They've got diabetes? They're on METFORMIN?? well, we can't have that, admit to medicine". I'm glad they feel my expertise in writing sliding scale insulin and abx/pain med orders is of greater need than surgery.

 

[Gastrapathy]

The best way to handle this is to consult a different surgeon. Call your favorite colorectal fellow (during daytime) and say you think you've admitted an appy to IM. Suddenly the case disappears. When the resident gets mad, just smile, apologize and say you were under the mistaken impression they weren't interested. The Bariatric/lap team is a good option too.