1/14/09 2:18 PMNurse.com - New Tech-niques

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During an inservice on theAbiomed heart assistdevice, Rosemary Dunn,RN, (left) and DanettDurphy, RN, watch closelywhile Nicole Melino, RN,(kneeling) demonstrateshow to check the tubingfor clots. Photo by DavidDeBalko Photography

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Home Philadelphia Tri-State

New Tech-niquesWendy J. MeyeroffMonday October 4, 2004

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High-tech monitoring systemsin ICUs and CCUs help nursestrack patients' conditions sonurses can spend more time atthe bedside.

Imagine an ICU where alarmsrarely sounded. Or a hospitalthat never worried about nothaving enough intensive carebeds. Consider what could beaccomplished if nurses had anextra set of hands or eyes - oreven eight more of each.New technology in the ICUimproves patient care, not onlythrough more sophisticatedmonitoring systems and treatment options, but by freeing nurses to focus on bedsidecare. It also creates opportunities for nurses to grow in their profession as they learnnew skills and hone clinical expertise using state-of-the-art techniques and equipment.The FlexNet system installed at Christiana Care Health System, Wilmington, Del., givesnurses that extra set of eyes. Specially trained technicians, called "tech monitors," helpnurses monitor patients' vital signs from beyond the bedside. Elizabeth Wykpisz, RN, vicepresident 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 thecare."

Lunchbox-sized devices, called Propaq flex monitors, are placed beside each hospital bed and record a patient's vitalsigns. The monitors' compact size makes them easily portable for when the patient needs to leave the room for testing orother procedures. Smaller monitoring devices can be attached to the patient's body to allow freer range of motion, forexample, to use the bathroom. Data from each of these devices feeds through a wireless network into a centralmonitoring system called Acuity. Tech monitors at Christiana track this data through Acuity and alert the nurse on duty ifthere'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 "nurseextenders." 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'thave to be in specific beds; they can be anywhere in the hospital, as long as they have a portable monitoring unit withthem.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, theradiologist and other staff members must understand the equipment.Help from afarAt Lehigh Valley Hospital and Health Network, Allentown, Pa., critical care nurses participate in a different kind ofelectronic monitoring through the remote ICU (rICU). Staff members include a couple of regularly assigned clerks, oneRN, 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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"The 12 nurses I have right now work out a flex-time schedule for the hours they can work during the week, along withtheir 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 banksof eight monitors each - one for the nurse on site, one for the intensivist - provide access to extensive data about thepatients 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 havea 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 bedsidecaregivers - 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 andask, 'Can I help you?' "Eyes and ears in patient roomsThe different types of audio and video setups allow for different levels of interaction between the rICU staff and thepeople in the hospital. The two-way audio link in each patient room on the CCU and the ICU allows the rICU staff tocommunicate with the patient through an overhead speaker. For example, if a patient calls for help when a floor nursehas stepped away, the nurse at the remote location can answer him. If the patient is in the ICU, the rICU nurse can seewhat'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 inthrough the ER, there's been a lot that had to be left undone. It's amazing what people forget in a crisis," she says. Usingthe communication links, the rICU nurse can help family members attend to these needs, for example, calling a sitter towatch the children, setting up a bed for the night, or arranging for pastoral care. The rICU nurse can even help finish allthe 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 delicatetopics 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 watchthe Glasgow coma score on one with a heart problem and program a warning if the sugar level drops on another whoalso has diabetes."Enticing for nursesNew technologies such as these can be a draw for nurses into a unit, says Rosemary Dunn, RN, director of cardiothoraciccare/neurology at Hahnemann University Hospital, Philadelphia. "It's exciting for the nurses," Dunn says. "They're drivento 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. Toan experienced CCU nurse, that might be a relatively simple orientation, but Dunn is training many brand-new nurseswho 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 bedeployed to assist staff on any floor as the patient's acuity changes," Wykpisz says. If the heart rate of a patient in themed/surg unit changes, for example, the STAT nurse will arrive with a portable monitor. The STAT nurse's critical careexperience helps because "they need to be proficient at managing unstable patients and able to pull a whole teamtogether," no matter where the patient is, Wykpisz says.Recognizing potentialIt's this respect for the skills and abilities of critical care nurses that led Baker to establish the rule that rICU nurses musthave 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 skillsand 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 atHahnemann. "Less than three years ago," she says, "I wouldn't even look at a resume without critical careexperience." 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 changingand improving.Opportunities for growthOne way Wykpisz keeps current is by meeting with a multidisciplinary committee twice a month to go over the datagathered with the FlexNet system. "We look at volume statistics, such as how many monitor days were there, how manyarrhythmias detected?" she says. She'll also look at specific data pertaining to STAT nurses: "How long did it take themto respond to a call, the number of calls they had, and what were they doing on those calls? If I find that 90% of recentcalls 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 amajor 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 isparticularly important in an era in which those patients are likely to be more critically ill with various comorbidities. "Theacuteness of patients today demands a hands-on approach," she says. "You're the front-line caregiver."

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