Transition to Intermediate Care
Once patients have initially recovered from cardiac surgery in the intensive care unit (ICU), they are usually transferred to an acute care or step-down unit until discharge. Throughout this chapter, these types of units will be referred to as intermediate care units. This transition is a critical step in the recovery process. There are many pitfalls possible in this process, including breakdowns in communication, rushed transfers, and lack of comprehensive discharge planning. Collaboration is critical in successfully transferring patients.
Objectives
In this chapter, you will learn:
1. How to prepare patients for transfer out of the ICU
2. Key information that must be communicated upon transfer
3. Steps to take to ensure transfer is as smooth as possible
PATIENT READINESS FOR TRANSFER
Patients should not be transferred out of the ICU until they are hemodynamically stable enough for a lower level of care. Each intermediate care unit has its own admission criteria depending on staffing levels and the training and expertise of the nurses on the unit. Typically, these requirements include a stable respiratory status and blood pressure and the absence of intravenous medications required to support blood pressure or cardiac output. Chest tubes and epicardial pacing wires may or may not be removed prior to transfer from the ICU.
Cardiovascular Status
A pulmonary artery catheter must be removed prior to transfer from the ICU. Patients who still need cardiac output readings, pulmonary artery pressures, or other measurements gathered using a pulmonary artery catheter also still require ICU care. In general, arterial lines must be removed, although some intermediate care units have the capability of caring for patients with these lines. Typically, patients should be stable on oral medications before transfer. Some patients may require low doses of certain vasoactive medications (e.g., dopamine at 5 mcg/kg/min or less) or other intravenous medications that require little titration.
Cardiac surgery patients require continuous electrocardiographic (ECG) monitoring. On an intermediate care unit, this typically involves a telemetry monitor. After cardiac surgery, patients are at high risk for the development of atrial fibrillation or other arrhythmias. Atrial fibrillation often develops around postopertative day (POD) 3. Typically, epicardial pacing wires remain in place until about POD 4. At that point, if they are not needed they will be removed. If patients have experienced bradycardia, heart blocks, ventricular arrhythmias, or atrial fibrillation requiring intravenous amiodarone, pacing wires may remain in place longer in case they are needed.
Vital signs and assessments are performed less frequently on an intermediate care unit than in the ICU. Vital signs may be assessed every 2 hours if required, but usually every 4 hours is routine. Physical assessments typically occur every 4 hours.
Respiratory Status
Patients transferred to an intermediate care unit should have a stable respiratory status. They often require oxygen therapy but should not be in distress when transferred. On transfer out of ICU, chest tubes may remain in place if drainage is stable, a pleural effusion remains, or there is an air leak. Chest tube output is typically monitored less frequently than in an ICU.
If required, some intermediate care units will accept patients who need continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP). Some units are trained and staffed to care for patients who are stable on a mechanical ventilator. These patients must have an established tracheostomy prior to transfer. Patients with an endotracheal tube require ICU care.
Neurological Status
Many cardiac surgery patients experience neurological complications after surgery (see Chapters 13 and 14 for more information). Patients should not be transferred to intermediate care during the acute phase of a stroke. However, many patients are transferred while still confused or otherwise neurologically impaired. These patients often require very close monitoring to maintain their safety. Staffing levels and the ability of the intermediate care unit to closely monitor these patients should be taken into account prior to transfer.
NURSING IMPLICATIONS: It is the responsibility of nurses, both in the ICU and on an intermediate care unit, to advocate for patients if their stability and readiness for transfer are in question. If a transfer must take place, the patient should be assigned to an experienced nurse on the intermediate care unit or, if assigned to an inexperienced nurse, assistance should be made available to ensure appropriate care for the patient. See the section “Special Circumstances” later in this chapter for a discussion about transferring patients who may not be quite ready for transfer.
FAST FACTS in a NUTSHELL
Patients need to be stable upon transfer from ICU to an intermediate care unit. The receiving unit must have the knowledge and skills to care for a patient who is transferred.
PATIENT AND FAMILY EDUCATION
It is important that patients and families are prepared for transfer out of ICU to a lower level of care. Some patients and their families are very anxious about leaving the security of the ICU. This is especially true if complications have been experienced or the ICU stay has been prolonged. Having a nurse in sight at all times can be very comforting for some people. The highly technological character of the ICU, while initially overwhelming, may provide comfort and security to patients and families. A move to another unit where staff are not known and monitoring equipment is not readily apparent can be frightening. This phenomenon has been called transfer anxiety.
Patients and families are often unprepared for the change in staffing ratios and have feelings of abandonment. They may have unrealistic expectations of care in the intermediate care unit, which can create feelings of insecurity and mistrust. These problems are created and exacerbated by a lack of communication between ICU and intermediate care nurses and a rushed transfer process, which lead to a lack of adequate preparation for transfer. If resources in the intermediate care unit are inadequate (staffing, knowledge, and clinical skills to care for high-acuity patients), this may compound the problem.
FAST FACTS in a NUTSHELL 
To avoid transfer anxiety, patients and families should be given a realistic idea of what to expect on the intermediate care unit. Communication between the ICU and intermediate care unit is critical to adequately prepare patients and families for transfer.
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