ICU's Gatekeepers
Critical care nurses juggle the demands of a shifting specialty

By Glen Fest
May 10, 2004

DeaAnn Martin, RN, BSN, CCRN, can’t talk right now. A respiratory technician has just arrived to help hook up the BiPAP ventilating system to one of Martin’s patients.

“Excuse me a moment,” Martin says, darting to the bedside of the man wheeled in two hours earlier in her coronary care unit at Presbyterian Hospital of Dallas. Yesterday, the man checked into the hospital for a seemingly minor breathing ailment. Floor nurses discovered he had removed his oxygen mask during the night and rushed him to the ICU, where now he’s unable to exhale on his own.

“He was a little bit confused, and we’re not sure of the reason” he removed the mask, Martin says, returning to the nurses station rotunda in the center of this third-floor ICU. “The BiPAP [bi-level positive airway pressure] buys him some time before we have to put him on a ventilator.”

Martin, as usual, is busy this morning. A charge nurse in the unit, she has only a few moments to write down updated chart information on the patient before she focuses on a potential DNR case across the room. Meanwhile, a desk secretary tells her about a pharmacy order change, and another nurse runs by to update Martin on a third patient’s status. Cardiologists and other physicians are roaming the unit, and could call for Martin’s assistance at any moment.

Over the noise of beeps and alarms from 10 different rooms, Martin gladly accepts a coworker’s offer to bring up a soda from downstairs. “I’m not sure when I’ll get a break to go down there myself,” she says.

Multitasking and quick thinking are the hallmarks of a critical care nurse like Martin. Patients who could be just minutes from death don’t always have time to wait for the physician, so nurses must work with their eyes, ears, and instincts wide open. They are the gatekeepers for patients’ well-being in the ICU, possessing the educational and technical savvy to address vital needs along with the personal skills to hold a hand or reassure a panic-stricken patient.

Striving to do this job more efficiently and more safely has been the focus of critical care nurses for decades, and recent changes in the field have stepped up those concerns. Moving toward evidence-based practice, building up specialties, and matching care to an older, sicker patient population are presenting fundamental shifts in the profession for critical care nurses.

“The need for nurses to be much more in tune, much more educated and technologically savvy ... has changed the environment so much,” said Justine Medina, RN, MS, practice and research director of the California-based American Association of Critical-Care Nurses (AACN). “I think some of our old models of the way we’ve done things in the hospital are being stressed to the limit.”

New rules

In Faster, his best-selling study of modernity and time, New York Times science writer James Gleick explained the “paradox of efficiency” in the airline industry. Deregulation, hub systems, and computerized scheduling allowed carriers to squeeze in more flights and more passengers, but simultaneously introduced problems of complex pilot scheduling and shorter delay allowances that were born as a result of the new structure.

This catch-22 is somewhat parallel to critical care, as nurses see both the miracles and the consequences of health care advancement.

Mary Carol-Ambrose, RN, BSN, didn’t work much with elderly patients during her 20-year stint in the Army Nurse Corps. But it was still a surprise when the open-heart critical care nurse, now at Sutter Medical Center of Santa Rosa, Calif., learned that a surgeon there performed a bypass on a 102-year-old patient.

“Ten years ago, I don’t think any 80-year-old would have had open-heart surgery,” Carol-Ambrose said.

Medina said critical care nurses are caring for more elderly patients with multiple ailments who require more monitoring and complex treatments, resulting in a demand for more acuity skills in the critical care nursing ranks.

“We have a greater percentage of patients who are at the most frail ages of their lives, with the most complex illnesses,” she said.

Although medical improvements increase the median age of critical care patients, managed care is putting pressure on the ICU by changing the acuity threshold of hospitalization.

“If somebody was having some sort of abdominal pains in the past, they would do all the tests in the hospital,” said veteran ICU nurse Bobbie Wiles, RN, BSN, CCRN, of Mesa, Ariz. “Now they are sent to [the] outpatient [unit].”

Managed care companies keep the lid on costly hospital stays, but the patients who are admitted are placing a greater burden on critical care departments and nurses. Hospitals have to adjust staffing and organization to handle more gravely ill and injured patients, and the expertise of nurses must increase accordingly. In 2001, the AACN convened a task force that looked at ways of delineating some critical care functions into more specialized, intermediate care proficiency — what the AACN has dubbed progressive care.

Progressive care

The crunch on ICUs has forced hospitals to consider creating services for various step-down or telemetry units, where patients recover for eventual transfer to a standard care room. Frequently, hospitals have had no choice but to keep stabilized ICU patients in the unit, such as cardiac patients being weaned from ventilators or whose anti-arrhythmic drug infusions had to be closely monitored.

For reasons of cost and patient safety goals, hospitals have started to introduce these progressive care programs.

“Progressive care is the fastest-growing area of alternative care management,” said Ray Quintero, RN, MSN, CCRN, nurse manager of the progressive care unit at Virginia Commonwealth University Health System. Patients who were admitted to critical care units five years ago are now “routinely” admitted to progressive care units, according to the AACN.

Quintero cites studies where hospitals see the potential cost savings of 50% by treating progressive care patients outside the ICU. In addition, the 1-to-1 or 1-to-2 nurse-patient ratios followed by hospitals in critical care areas can be expanded to 1-to-4 with progressive units.

For hospitals that created more step-down units, the need for more ICU-level nurses in those areas became acute. “I don’t want to say there was anything lacking [in patient care],” said Deborah Barnes, RN, MSN, CCRN, AACN’s clinical practice specialist and a member of the 2001 progressive care task force. “But it had never been brought together in a general umbrella to really identify what those [progressive care] nurses needed” in education and support.

Nurses working in progressive care conduct less invasive monitoring of patients who are at less risk of a life-threatening event, Barnes said, but still need the vigilance and the skill should trouble occur. “They certainly needed more education above the med/surg level,” Barnes said.

The AACN this month will hold the first exam for progressive care certification, based on the task force recommendation of core competency requirements. About 450 to 500 nurses signed up to test for the new certification.

Family issues

Of the several criteria for progressive care certification, a major distinction with ICU credentialing is being able to enhance patient involvement in the hospital-to-home care transition. Patients in the progressive care status are sometimes able to start participating in their own care, and must be taught how to properly sustain their treatment and recovery outside the hospital.

Family involvement is also a major component of progressive care and a growing factor in standard ICU care.

An April 2000 study published in The American Journal of Nursing noted that 97% of family members studied believed they had a right to be present in the ICU, even during the dire circumstances of a code. A majority of parents surveyed in 1999 wanted to be present during invasive procedures performed on their children, according to the Annals of Emergency Medicine. Organizations such as the Emergency Nurses Association and the American Heart Association support facilities providing the family presence option during resuscitation.

“I think we’ve all educated ourselves with shows like ER 85 and there are more and more people who say they want to be there when you do the resuscitation,” Medina said. “I think our structures and our processes haven’t allowed us to be as nimble with what we’re being [asked] to do.”

For good reason, many nurses do not want family present during an emergency procedure. Family members may become unsettled or argue against a procedure because they do not understand why it’s being done. Family presence may interfere in teaching and mentoring situations. But nurses understand why families want to be present, Medina said — it may be their only chance to say goodbye.

“We shouldn’t have the door closed, nor should we have it completely open,” Medina said.

Wiles understands firsthand the need for family presence and for open communication with nurses. Her first husband was fatally injured in an auto accident when they were both 21. She remembers the ICU nurses discussing with her in detail his injuries, and how much that information helped her deal with her sudden loss.

Wiles, who serves as a preceptor to incoming ICU nurses at Banner Mesa Medical Center, said critical care nurses have a responsibility to be as open with the family as possible. “We have a new grad nurse treating a patient who was not neurologically intact. She saw that the family didn’t understand that he wasn’t getting better, so she saw to it that they talked with the doctor. She learned that from me.”

Moral distress

Critical care nurses are starting to talk more about end-of-life issues and to confront the moral distress many nurses suffer from the decisions they’ve made — or have been unable to make in deference to physician or family preferences. For years, Cathy Schuster, RN, BSN, CCRN, has been troubled by a pair of DNR patients who died on her watch as a night-shift nurse at the University of California, San Francisco Medical Center.

Schuster, after consulting the staff, once continued care for a sedated elderly man against his wishes after a desperate call from a family member. The relative begged them to resume care long enough for her to arrive before he died. “My dilemma was, could I delay death for her visit? Morally and ethically, you’re torn,” Schuster said.

In the other case, Schuster was troubled by an unresponsive patient in her 40s who showed signs of agitation when Schuster began the withdrawal of care. She and the staff chose to continue withdrawal, unsure whether to contact the family.

“We sometimes feel the futility of continuing with aggressive and supportive care. 85 That becomes a dilemma for us,” Schuster said. “When death is inevitable, we need to switch our mode of life to one of comfort.”

The improvements in health care that can extend life sometimes cloud the ethics for nurses, who suffer high burnout rates because of moral distress. Ultimately, many palliative, end-of-life decisions are for families and patients to make, so nurses have to provide the guidance.

“I think there are more choices people are going to have to make,” said Chris Wesphal, RN, MSN, CCRN, with Oakwood Healthcare System in Dearborn, Mich. “The shift to patient autonomy has made the need for decisions on choices [some people] are not prepared to make.”

Instincts

Not every nurse can handle the emotional baggage of the ICU. Death happens in the ICU, and that inevitability in cases is at odds with a nurse’s determination or a family’s false hopes. Critical care nurses cannot stoke those desires for a positive outcome, no matter how much it may appear to smooth the pain.

“You don’t want to take all the hope away, but you have to prepare the family,” Martin said.

Martin said it took her nearly two years to feel “comfortable” as a critical care nurse. Those greener years of her career saw her waking up in a cold sweat after dreaming she was the only nurse in the unit, overwhelmed by the alarms, buzzers, tones, and beeps from the monitoring equipment.

“It’s really hard to come straight out of nursing school and go into the ICU,” Martin said. “Plenty of nurses can’t make the adjustment. You can’t wait for someone to tell you what to do.”

“They also find out really quickly they can’t do this without the help of their peers,” Martin said. “When there’s a code, all but one nurse will head to the room and one will remain on the floor.”

Having been a critical care nurse for nine years, Martin has honed her instincts well. She knows which patients may be on the cusp. She knows which ones will probably make it. And she only has to look at the calendar to prepare for the rush periods. Each fall brings a flood of flu and pneumonia victims. The holidays have arrived when high-cholesterol, stroke, and heart attack candidates check in after indulging on family feasts.

Martin said there’s no sign yet of the influx of spring patients who overexert themselves with outdoor activities. She’s prepared for them, as well as the “frequent fliers,” as Martin calls the chronically ill patients from nursing homes and other hospitals who could fill up the rooms today.

She looks over at the BiPAP patient again, and reads through his medical records that have just arrived nearly three hours after his ICU admission. To the layperson, he still looks near comatose, but Martin turns to walk back into his room. She knows better.

“He might be waking up soon,” and be a little confused about where he is, especially without any family members around to tell him where he is, Martin explains.

“Excuse me for just a minute.”

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