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Critical Care Collaboration

One hospital's successes caring for patients in critical care

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The oldest Catholic hospital in Baltimore, Saint Agnes Hospital was founded 150 years ago by the Daughters of Charity. The 314-bed facility is undergoing a $200 million plus expansion with an emphasis on patient safety in high-quality healthcare.

In critical care, nurses face unique challenges where even minor issues can quickly become very significant. The Saint Agnes approach and a comprehensive, dependable team minimize the uncertainties with clinical knowledge, consistency and communication, according to Karen Cepero, MSN, RN, CCRN, CEN, NEA-BC, director of critical care at Saint Agnes.

To demonstrate the teamwork, the hospital's stroke center received accreditation nationally by the Joint Commission and the Maryland Institute for Emergency Medical Services System. It has been recognized by U.S. News and World Report as a "Best Hospital" for stroke care for three consecutive years and has earned the "Gold Plus" award from the American Stroke Association - the highest recognition awarded for stroke programs.

Nursing Success

Nurses play a huge role in establishing and maintaining this environment, with a strong commitment to competency, collaboration, responsibility, authority and accountability. Saint Agnes has gone to great lengths to employ nurses who demonstrate the highest integrity and clinical qualifications, and supports each nurse with a climate that nurtures clinical expertise, education, shared governance, research and, most importantly, a value system focused on respect.

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"All nurses must demonstrate successful completion of a critical care course and ongoing competency validation," said Cepero. "Critical-thinking skills, lifelong learners and a passion for patient family are necessary skills."

The critical care division, which often sees patients presenting with a significant number of comorbidities, consists of an adult intensive care unit (AICU) of 16 beds; an intermediate medical care unit (IMCU) of 20 beds; a coronary care unit (CCU) comprised of 12 beds; cardiac telemetry with 32 beds; and neurotelemetry housing 30 beds. In total, the division has more than 200 full-time equivalents.

Nurses serving the critical care unit at Saint Agnes face many challenges in maintaining high quality, expeditious, safe care in a highly technological and advanced environment. "Length of stay reduction and throughput reduction in the division are imperative to afford available beds for other critically ill patients," explained Cepero.

The IMCU throughput team has reduced throughput time - from door to bed - by 25 % in the past year. The AICU team boasts a collaborative effort with a dedicated pharmacist, rehabilitation and respiratory therapist all who are critical for patient healing. The telemetry department serves more than 250 admissions monthly. To stay on top of treatment, nurses and care providers conduct a weekly review of high-risk patients, safety events and quality concerns such as pressure ulcer development, self-extubations and central line-associated bloodstream infections (CLABSI), which helps keep quality high, Cepero said. The Maryland Hospital Association recently presented an award to the department for its CLABSI reduction.

Embracing Technology

Critical care at Saint Agnes also employs a number of state-of-the-art technologies such as non-invasive cardiac output monitoring, a method of hemodynamic monitoring that assists in stabilizing patients and optimizing outcomes. "Our AICU was the first intensive care unit in Ascension Health - that's our parent company - to use therapeutic-induced hypothermia for in-comatose survivors of out-of-hospital cardiac arrest caused by ventricular fibrillation," said Cepero.

"Radial artery approach in the wrist instead of the femoral artery in the groin for catheter access in angiographic procedures has resulted in fewer vascular complications for patients. We have also found success with continuous veno-venous hemodialysis as an effective treatment for all critically ill unstable patients with complicated acute renal failure," Cepero reports.

Best Practices

In daily safety huddles among managers and the executive team, staffers review safety events and near misses that could potentially cause patient harm. "Any employee who identifies a near miss or takes measures to avoid a mistake receives a 'Swiss cheese award,'" Cepero said. "We also complete amazing service cards to recognize outstanding performance by our associates."

The nursing division is also transitioning the care model to relationship-based care, built around relationships with yourself, others and patient/family. Further best practices have resulted in no ventilator-associated pneumonia in either AICU or CCU in over one year. Cepero also reports the IMCU staff identified that noise seemed to be deterring their patients healing. "An assessment of evidence-based practice guidelines and implementation of a noise-reduction program resulted in substantial decrease in noise levels as evidenced by feedback on the patient experience scores."

Finally, critical care nursing staff enacted the Amaryllis program - inspired by the flower that symbolizes success won after a struggle - to provide added support to the families of dying patients. A flowered bag containing a quilt, flameless candle, sympathy card, prayer book and funeral arrangement information are given to the family. Amidst dimmed lights and quiet surroundings, the quilt is placed over the patient during their last moments.

"We'd like to recognize our patients' constant struggle for life, and that shifting gears from the curative path to palliative care doesn't mean losing in the battle for life. It is being brave enough to face the inevitable time of death without discomfort and misery," Cepero noted.

Kerri Reeves is a freelance writer.


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