By Patricia A. Blissitt Ph.D., ARNP-CNS, CCRN, CNRN, SCRN, CCNS, CCM, ACNS-BC
Harborview Medical Center (HMC) in Seattle, Washington, is an exceptional place to practice neurocritical care nursing. The 413 bed academic medical center is one of four University of Washington Hospitals. Critically ill neuroscience patients from Seattle and beyond receive neurocritical care in the 30 bed neuro ICU or the medical cardiac, trauma surgical or burn pediatric ICU depending on their primary needs. HMC is the only Level I trauma center for a four state area — Washington, Alaska, Montana and Idaho — and the only Joint Commission Certified Comprehensive Stroke Center in Washington State.
Nurses that provide care to the patients at HMC have an active voice in the care of the patient, from presentation of the patient during interdisciplinary rounds to the development of the plan of the day for each patient. Nurses may independently request ethics consults and also have access to palliative care service as needed.
The two neurocritical care teams consists of physicians and nurse practitioners from neurocritical care, neurology and neurosurgery, a respiratory therapist, registered dietician, rehabilitation therapists, a physiatrist, a social worker, and the direct care nurse and charge nurse. Neurohospitalists and acute care neuroscience nurse practitioners also round with the neurocritical care teams to ensure a smooth transition to acute care. The neuroscience clinical nurse specialist is available as needed for nursing or interdisciplinary consults.
The neurocritical care nurses actively participate in a number of continuous quality improvement activities and scientific studies, some nurse-led and others directed by other team members. The neuro ICU nurses recently participated in an international nurseled study to validate a behaviorally based observational tool to assess pain in critically ill cognitively impaired neuroscience patients. More recently, they provided input for the development of a “smart,” non-gravity-based, external ventricular drainage system and will be trialing the device to evaluate its performance and safety.
Several physician-led investigations to improve the outcome of critically ill stroke patients involve the HMC neurocritical care nurse. One of those studies looks at the efficacy and safety of intraventricular administration of a biodegradable polymer-based sustained-release microparticle containing nimodipine versus standard administration of Intraventricular administration may lessen the hypotension associated with enteral nimodipine. The nurse is key to the early recognition of deterioration related to delayed cerebral ischemia as it may or may not occur in this study.
Another study involves the neurocritical care nurse in the intravenous administration of deferoxamine mesylate (DFO). Deferoxamine is thought to facilitate the removal of the iron accumulation in the brain from intracerebral hemorrhage and improve outcomes. A multicenter randomized controlled trial, involves the intravenous administration of natalizumab, a monoclonal antibody that is currently used in the management of multiple sclerosis and Crohn’s disease but has been postulated to reduce infarct size in acute ischemic stroke.
The neuro ICU nurses at HMC have led the way in a quality improvement initiative regarding early mobility. The nurses were awarded a grant from the American Association of Critical Care Nurses Clinical Scene Investigator initiative to design and trial an early mobility program with patients in the neuro ICU.
Physician partners, physical and occupational therapists, patients and families were involved in the development of the mobility program. The daily shift report sheet was modified to include the patient’s mobility status. A daily huddle between the neuro ICU charge nurse and the lead rehabilitation therapist was initiated. This information is presented to the interdisciplinary team during daily rounds to facilitate early mobility. Benefit versus risk is carefully considered in patients with actual or potentially unstable intracranial dynamics.
At three months post-implementation of the early mobility program, the Neuro ICU had an 11 percent increase in the number of eligible patients mobilized. A 35 percent reduction in falls and a 33 percent reduction in readmission to the ICU also occurred. A culture of early mobility has been established and is now addressed each day for each patient in the neuro ICU.
Another area of study in the neuro ICU came out of a need expressed by a neuro ICU nurse and respiratory therapist dyad following an emotionally laden transition to comfort care. A survey was developed by multiple disciplines including nursing, neurocritical care and neurology and distributed to neurocritical care attending physicians, residents, nurse practitioners, respiratory therapists and nurses. The survey revealed that only 9.5 percent of the nurses and respiratory therapists felt included as part of the comfort care decision-making process and 78 percent felt that they had experienced at least one transition to comfort care that was less than ideal.
A checklist was developed to encourage communication among all interdisciplinary team members prior to initiating comfort care. Education is ongoing as house staff and new team members from the various disciplines become part of the interdisciplinary team. This checklist provides an opportunity to ensure that each member of the interdisciplinary team, including the nurse and the respiratory therapist, is in agreement with the plan of care. This initiative has been viewed as successful in the neuro ICU and discussion is currently under way to embrace this initiative throughout the hospital.
The nurses in the neuro ICU at Harborview have an active and essential role in the work of neurocritical care. From direct patient care to continuous quality improvement and research, the nurses are integral members of the neurocritical care team.The author would like to thank Kellie Hurley, Cory Kelly, Rebekah Marsh and Pat Tanzi for their contributions to the development of this article.