By Aarti Sarwal (left), Janet Crumpler (middle) and Terri Gordon (right)
Wake Forest Baptist Medical Center built a 24-bed neuro ICU in 2016 to accommodate a growing census and acuity of patients housed in the older 11-bed ICU that was an open bay design with limited space or privacy for family presence. In addition to learning from designs of other new ICUs built across the country, the hospital leadership partnered with former patients and family members to understand their perspective and experiences in care. The new unit design incorporated their feedback to ensure we created a healing, nurturing environment that highlight the advancements in critical care technology as well as our emphasis on patient and family centric care.
The unit provides several accommodations that encourage family presence and participation in patient care. A common family lounge provides eating space, lockers, showers, a kitchenette, a washer/dryer and other amenities for families and caregivers of patients. This allows for families to have some normalcy in their life if they are anxious about leaving the premises. Two conference rooms are built for private discussions with family with teleconference and audiovisual capabilities to allow sharing important medical information with family long distances away and sharing images and pertinent information from medical records to help them understand the complexities of neurocritical care issues such as stroke, hemorrhage, seizures or surgery.
The clinical areas populate the periphery of the unit allowing natural sunlight in each patient room. Each room also has a builtin shower and a sofa that is transformed into a sleeping couch at night for family present within the patient room. Ambient lighting in the rooms is intensity controlled, limiting bright light only for procedures. The acoustics of the room allow minimal dispersion of noise from alarms in between neighboring rooms. Such strategies prevent circadian rhythm disturbances and serve as delirium prevention strategies.
For clinical providers, the unit provides latest infrastructure for nursing and respiratory care that improves patient care as well as provider wellness. Three hundred sixty degree “booms” in each room provide all electronic, nursing and gas connections. These can move around the bed and avoid any connections for wires, lines and tubing to the walls enabling the nurses to efficiently care for patients. Infection prevention strategies like copper-enhanced surfaces eliminate bacteria and reduce hospital acquired infections. Ceiling lifts in each room allow efficient and safe early mobilization of each patient.
A nursing station between each pair of rooms is equipped with computers and paired live monitors. This allows nursing staff to keep a close eye on both patients while charting. With the unit hallways spanning one quarter of a mile and 36,000 square feet, double padded surface floors protect feet during walking. Separate clinical areas like an ICU workroom, a staff lounge, two academic conference rooms and call rooms allow clinical providers working facilities to incorporate academic activities and personal wellness into day-to-day clinical care within the premises of the unit. A designated staff respite room for non-physician staff with attached showers allows nurses, respiratory therapists and nursing assistants to take a break on a busy day.
The move into the newly built unit brought several new technological features and created the need for new workflows for daily patient care activities. While the training for new technology is standard practice for clinical providers, Wake Forest neuro ICU took innovation to a new level and created a systemized program to test the new clinical facilities and train the providers for using the new space. A three-stage simulation program was designed with multidisciplinary team input. Real clinical providers participated in these scenarios in their real clinical roles with high-fidelity simulators or standardized patients used to create clinical situations.
The first stage was built in a “scavenger hunt” approach to train providers in “where is what?” for their relevant clinical needs. A labeled colored map of the unit was created with an “operation manual” of the new unit and a fully staged patient room with self-guided tours to familiarize providers with new workflow and equipment.
The second stage of simulation tested the ergonomics of a patient room with regard to provider and equipment workflow in an acute clinical crisis. A high-fidelity simulation was used to create an acutely deteriorating patient progressing to cardiac arrest requiring escalating need for equipment like airway, code and vascular access carts.
The third stage was conducted with several clinical scenarios in series using actors as standardized patients and high-fidelity simulation to create a “typical busy in the neuro ICU.” These scenarios captured major high-risk events like ED to ICU admission with neurological change during transit, acutely seizing patient requiring pharmacological management and patients having an acute ICP crisis with need for airway, external ventricular drainage and emergent neuroimaging. All healthcare systems that are integrated into routine clinical care like pager systems, ASCOMs, medical records; pharmacy dispensing, environmental services, bed assignment and triage were tested as a part of this final stage. The “presence and recognition” of the unit and designated patient space was verified in all electronic environments. A multidisciplinary team including clinical providers and representatives of hospital systems like risk management, triage coordinators, facilities and planning, information technology, etc. participated as observers.
Each stage of simulation was followed by a debriefing that allowed an open forum of discussion of observations, concerns identified and suggestions for improvements by observers as well as participants. Several safety and workflow issues were identified and addressed prior to the actual move. This led to a much safer and efficient move into the new unit.
The new unit recently celebrated its first year anniversary in February 2016. We continue to build a committed and confident neuro ICU program with several new additions to our unit including nurses, neurointenvists and advance practice providers. Simulation, quality improvement and clinical research are now closely knit into our academic program. We are proud of how far we have come. We hope to continue providing excellent clinical care to our patients in a manner we will like our family members to be taken care of.
We would love to share more details about our simulation program or opportunities for employment. Please contact us:
Aarti Sarwal, Medical Director, email: firstname.lastname@example.org
Janet Crumpler, Clinical Nursing Manager, email: jcrumple@ wakehealth.edu
Wake Forest Baptist Medical Center is a comprehensive stroke center with a level 1 trauma center and a growing neurosciences program that provides all subspecialty support in neurological and neurosurgical care of patients.
The new neuro ICU was built with several patient- and family-centric features in spacious private rooms and hallways. Several enhanced features like booms and ceiling lifts help provide infrastructure for all nursing and respiratory care. Calm colors and artwork of natural scenes from around North Carolina create a nurturing, healing and peaceful environment.
The neuro ICU celebrated its first year anniversary in February 2017. The unit holiday card celebrated the hard work and camaraderie of the staff members in helping continue to build a strong program and an innovative new unit.
Wake Forest Baptist Team using high-fidelity simulation in neuro ICU to teach airway management and cardiac resuscitation in patient rooms with real staff and real equipment
Aarti Sarwal MD, medical director, Janet Crumpler RN, MSN, CNRN, clinical nursing manager, and Terri Gordon RN, BSN, CCRN, clinical nursing educator work in the Wake Forest neuro ICU in North Carolina and are all invited guest writers for Currents.