Complacency in coronary care.

From modest beginnings in 1962 in Kansas City, Philadelphia, and Toronto, the coronary care unit has become at once an institution and a revolution in the treatment of acute myocardial infarction. The CCU was synthesized from now well known innovations in resuscitation, monitoring, and in the electrical treatment of arrhythmias. Its early history was written by small units of three to four beds which monitored patients for two to four days. Occasional successful defibrillation improved mortality statistics. As in most revolutions, change was rapid. The nurse quickly evolved into an integral member of the medical team, proficient in recognition of ar-rhythmias and in electrical defibrillation. Aggressive management of arrhythmias replaced watchful waiting for ventricular fibrillation. The new role of the nurse, coupled with the anticipatory management of electrical problems, combined to reduce the mortality in acute myocardial infarction to less than 20 percent from perhaps 35 percent in the pre-CCU era. While mortality data are difficult to assess , there seemed little doubt that the CCU represented a better way to manage acute coronary disease. The proliferation of units was rapid. By 1967, physicians and nurses representing hundreds of coronary care units assembled in Washington for a national conference. They heard the CCU pronounced indispensable in the treatment of acute myocardial infarction. Today it may be difficult to find a hospital of more than 200 beds without a CCU. There are few with less than 200 beds not at least planning one. But in the current groundswell of enthusiasm for the CCU, there are signs of reaction and complacency which may impede its ultimate evolution. The CCU is developed in a hospital at great financial cost to administration and with great effort by its medical staff. Once the unit has been established, changes in instrumentation, number of beds, and operational policies are made with difficulty. Corn-placency tends to follow even limited successes. For this reason, it may be well to examine signs of inertia which are becoming apparent in coronary care. The monitoring of patients from three to four or even seven days is inadequate in the light of developing data that fatal arrhythrnias continue to occur throughout the hospital course of acute myocar-dial infarction. At the Good Samaritan Hospital in Dayton, Ohio, post-CCU deaths approach 15 percent even though the average length of stay is nine days. Recent thinking suggests that patients should he monitored for five to ten …