New Tech-niques

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Philadelphia Tri-State

New Tech-niques

Wendy J. Meyeroff Monday October 4, 2004 E-mail to a friend | Print This | Select Text Size:

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High-tech monitoring systems in ICUs and CCUs help nurses track patients' conditions so nurses can spend more time at the bedside.

Imagine an ICU where alarms rarely sounded. Or a hospital that never worried about not having enough intensive care beds. Consider what could be accomplished if nurses had an extra set of hands or eyes - or even eight more of each.

New technology in the ICU improves patient care, not only During an inservice on the Abiomed heart assist through more sophisticated device, Rosemary Dunn, monitoring systems and treatment options, but by freeing nurses to focus on bedside RN, (left) and Danett care. It also creates opportunities for nurses to grow in their profession as they learn Durphy, RN, watch closely new skills and hone clinical expertise using state-of-the-art techniques and equipment. while Nicole Melino, RN, The FlexNet system installed at Christiana Care Health System, Wilmington, Del., gives (kneeling) demonstrates how to check the tubing nurses that extra set of eyes. Specially trained technicians, called "tech monitors," help for clots. Photo by David nurses monitor patients' vital signs from beyond the bedside. Elizabeth Wykpisz, RN, vice DeBalko Photography president of cardiovascular/critical care services, describes this flex monitoring system as "bringing the care that's required to the patient, instead of bringing the patient to the care."

Lunchbox-sized devices, called Propaq flex monitors, are placed beside each hospital bed and record a patient's vital signs. The monitors' compact size makes them easily portable for when the patient needs to leave the room for testing or other procedures. Smaller monitoring devices can be attached to the patient's body to allow freer range of motion, for example, to use the bathroom. Data from each of these devices feeds through a wireless network into a central monitoring system called Acuity. Tech monitors at Christiana track this data through Acuity and alert the nurse on duty if there's a change in the patient's condition or an abnormal reading.

'Nurse extenders' Wykpisz emphasizes that the tech monitors are not intended to replace the nurses; instead, she calls them "nurse extenders." They handle tasks related to equipment, such as hooking up patients to the monitors and changing batteries.

They also are trained to watch the data coming through Acuity for easily recognizable conditions, such as arrhythmias, while nurses maintain personal patient care.

FlexNet expands the reach of intensive care outside the walls of the ICU, says Kathy Johnson, RN, MICU manager.

"Initially, if a patient had to be on a heart monitor, they had to be on a specific floor," Johnson says. Now, patients don't have to be in specific beds; they can be anywhere in the hospital, as long as they have a portable monitoring unit with them.

Communication and education among hospital employees has been vital in the four years since FlexNet was implemented.

If a patient with a flex monitor goes to another department for diagnostic testing, such as an x-ray or MRI, the radiologist and other staff members must understand the equipment.

Help from afar At Lehigh Valley Hospital and Health Network, Allentown, Pa., critical care nurses participate in a different kind of electronic monitoring through the remote ICU (rICU). Staff members include a couple of regularly assigned clerks, one RN, and one intensivist - a physician specially trained in critical care who oversees the unit. All work in 12-hour shifts, but the doctors and nurses who staff the unit vary; working in the rICU is an assignment everyone wants.

"The 12 nurses I have right now work out a flex-time schedule for the hours they can work during the week, along with

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Nurse.com - New Tech-niques

1/14/09 2:18 PM "The 12 nurses I have right now work out a flex-time schedule for the hours they can work during the week, along with their regular critical care or ICU work," says Kathy Baker, RN, a critical care nurse and nurse manager of the rICU. The rICU is located in an office building, a former lab, 3 miles away from Lehigh Valley's Cedar Crest campus. Two banks of eight monitors each - one for the nurse on site, one for the intensivist - provide access to extensive data about the patients in the ICU. Each professional can monitor, via audio only in the Critical Care Unit or audio and video in the ICU, 25 to 30 patients each. Or they might use several screens to monitor different aspects of a single patient. "I might have a video of a patient on one screen and look at his current EKG on another," Baker says.

The rICU staff also has access to patient medical records, including all updates and modifications made by bedside caregivers - nurses, physicians, or pharmacists. Having an electronic record of care helps minimize mistakes, Baker says.

"It [also] helps us train the residents," she says. "The nurse in the remote ICU can see if an attending seems unsure and ask, 'Can I help you?' " Eyes and ears in patient rooms The different types of audio and video setups allow for different levels of interaction between the rICU staff and the people in the hospital. The two-way audio link in each patient room on the CCU and the ICU allows the rICU staff to communicate with the patient through an overhead speaker. For example, if a patient calls for help when a floor nurse has stepped away, the nurse at the remote location can answer him. If the patient is in the ICU, the rICU nurse can see what's going on via a one-way video hookup.

Baker says the rICU also can interact with family members in the patient's room. "Lots of times when a patient comes in through the ER, there's been a lot that had to be left undone. It's amazing what people forget in a crisis," she says. Using the communication links, the rICU nurse can help family members attend to these needs, for example, calling a sitter to watch the children, setting up a bed for the night, or arranging for pastoral care. The rICU nurse can even help finish all the necessary paperwork by asking questions through the speaker.

"We also have an end-of-life room with a two-way audio and video in which - if the family desires - we discuss delicate topics outside of the patient's earshot," Baker says.

The rICU capabilities go beyond conversation. Baker can program the equipment so alarms sound only in the rICU. Unique criteria can be assigned for each patient's monitors to determine when alarms should go off.

"I might have a general parameter I set for every patient in the unit, such as 'alert us if any heart rate drops below 60,' " she says. Or if three patients are fighting intracranial pressure, Baker can set specific parameters for each. "I can watch the Glasgow coma score on one with a heart problem and program a warning if the sugar level drops on another who also has diabetes."

Enticing for nurses New technologies such as these can be a draw for nurses into a unit, says Rosemary Dunn, RN, director of cardiothoracic care/neurology at Hahnemann University Hospital, Philadelphia. "It's exciting for the nurses," Dunn says. "They're driven to learn the advanced technology that will help them in patient treatment."

Nurses working in high-tech units must have - or develop - special skills, Dunn says. For example, flexible monitoring "requires a nurse with higher assessment skills." It's critical that a nurse is able to not only read the patient's monitor, but she also must integrate that information with all the other equipment readouts and the patient's physical signals. To an experienced CCU nurse, that might be a relatively simple orientation, but Dunn is training many brand-new nurses who can be somewhat overwhelmed by all the data.

One solution Christiana Care developed for implementing the FlexNet system was creating another level of supervision: the STAT (stability, teaching, assessment, and telemetry) nurse. "The STAT nurse is a critically trained nurse who can be deployed to assist staff on any floor as the patient's acuity changes," Wykpisz says. If the heart rate of a patient in the med/surg unit changes, for example, the STAT nurse will arrive with a portable monitor. The STAT nurse's critical care experience helps because "they need to be proficient at managing unstable patients and able to pull a whole team together," no matter where the patient is, Wykpisz says.

Recognizing potential It's this respect for the skills and abilities of critical care nurses that led Baker to establish the rule that rICU nurses must have at least three years of critical care experience. "They may be overseeing 25 patients, instead of two," she says, pointing out that all the patients are critically ill. It's important, then, that rICU nurses "have good decision-making skills and feel comfortable tracking a lot of data."

Finding nurses with all the desired skills is not easy. So Dunn instituted a new approach for hiring nurses for her unit at Hahnemann. "Less than three years ago," she says, "I wouldn't even look at a resume without critical care experience." Today, Dunn looks for other qualities in her applicants: "the drive to be successful, a sense of excitement, and a willingness to learn," she says. The latter is especially important, she says, since technology is constantly changing and improving.

Opportunities for growth One way Wykpisz keeps current is by meeting with a multidisciplinary committee twice a month to go over the data gathered with the FlexNet system. "We look at volume statistics, such as how many monitor days were there, how many arrhythmias detected?" she says. She'll also look at specific data pertaining to STAT nurses: "How long did it take them to respond to a call, the number of calls they had, and what were they doing on those calls? If I find that 90% of recent calls were to answer questions about a medication, I know we need to hold educational seminars on that medicine," Wykpisz says.

Many opportunities exist for critical care nurses trained in ICU technology. "They go on to be NPs or CNSes; this is a major stepping stone in their careers," Dunn says.

But no technological bells or whistles could ever replace a skilled nursing professional with a hand literally on the patient.

"There's nothing like touching - visually checking - the patient," Baker says.

Dunn agrees that nurses must continue to be vigilant and not rely too much on the equipment to assess their patients.

"You always have to look at the patient in the bed, no matter what the machine says," she says. A physical assessment is particularly important in an era in which those patients are likely to be more critically ill with various comorbidities. "The acuteness of patients today demands a hands-on approach," she says. "You're the front-line caregiver."

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