Tuesday, July 5, 2011

Patient centered care

In creating a new ICU many changes are occurring from the design and set up to the vision and mission. Now that the physical aspect of the unit has been discussed now it is time to look at the social aspects. Our hospital has adopted a patient center of care approach when caring for our patients.  This model was developed by the Institute of Medicine (IOM), focuses on engaging the patient and their family as active members of the medical team and coordinating care around the goals of the patients.
This means exactly as it sounds, it is keeping the patient and family informed and involved in all the decisions affecting the patient. It gives patients autonomy and empowers them to choose what is best for them in their lives.  From the family perspective this is including them in rounds with the physicians, presence during resuscitation, open visiting hours, spiritual support, support groups, and consults from other specialties such as palliative care when appropriate.
There are quite a few studies published and more coming out daily that show the positive effects of patient centered care outcomes.  In order to make this initiative a success it is essential for the physicians and nurses to have excellent communication skills. Recognizing cues as to how the patient and their family members are coping with the diagnosis and stress. And be open to the questions that are presented to them. Through open communication and understanding this will make our unit a positive experience for our patients and families and staff. 

Tuesday, June 28, 2011

The best nursing staff

Nursing certifications and designations for the unit are important in providing the best care to our patient, recruitment and retention of staff, and in maintaining a healthy work environment (Weeks, Ross & Roberts, 2006). We are fortunate enough that the hospital has already achieved magnet status, however we will be a part of future renewals of that status. As a team, the physicians and nurses have set a goal to obtain the Beacon award status within 3 years of the unit opening. This status has many benefits and has only been designated to two other units in the entire institution.

Magnet and Beacon status are based on a set of criteria that must be met. The magnet award has 14 forces of magnetism. The Beacon award has 6 categories where there must be 42 standards met. One study comparing nurses perception that work in  Magnet hospitals, Beacon units and non Magnet/Beacon hospitals showed a significant difference in work satisfaction. In fact the magnet/beacon award units scored higher in healthy work environment standards, communication and collaboration, shared governance, recognition, skills and confidence in management, and support for continuing their education and completing certifications. These positives are what led to a higher satisfaction in their work environment and higher quality of care of their patients (Ulrich, Woods, Hart, Lavandero, Leggett & Taylor, 2007)

As part of a new ICU it is the commitment of the management and physicians to encourage all nurses to get certified. Some of the common barriers to certifications include cost, resources, and time. In order to offset these barriers we have included money in our budget to purchase review books, flash cards and computer programs to assist staff in studying for the CCRN and CNRN exams. To help with cost the hospital does provide an 80% reimbursement for successful completion of the exams and a $0.25/hour raise. That is $468 per year for a 36 hours/week person and $520 per year for a 40 hour/week person.  We will also be sending out emails of opportunities for staff to take review classes offered through the hospital and/or the local chapters of AACN and AANN.

Ulrich, B., Woods, D., Hart, K., Lavandero, R., Leggett, J., and Taylor, D.(2007) Critical care nurses’ work environments value excellence in beacon units and magnet organizations. Critical Care Nurse, 27; 68-77.
Weeks, S., Ross, A., and Roberts, P. (2006) Certification and magnet hospitals. American Journal of Nursing, 106 (7), 74-76.

Wednesday, June 22, 2011

Creating a healing environment

In building a new unit it is important to have the correct technology to optimize patient care. However, it is equally important to create a healing environment that will also improve the patients healing abilities. Environmental factors have been acknowledged for having a significant impact on patient outcomes since Florence Nightingale’s time.  She discussed added stress of being in a hospital could have a negative impact on the immune functions of patients body (Fontaine, Briggs & Pope-Smith, 2001; Rubert, Long & Hutchinson). Rest and maintaining patients circadian (day/night) rhythm is vital to proper healing.
Patient rooms will always be filled with technological devices and monitors however they can still have a warm feel.  Pastels provide a cheerful effect.  Blues, greens and violets are known to have calming and relaxing effects. Simple artwork on the walls allow for a more homely feeling, which can be reassuring to the patients as well as their visitors (Fontaine, Briggs & Pope-Smith, 2001).   Other resourceful things in a patient’s room include a clock and calendar which they can see. A white board with daily activities, nurse’s and physician’s names will also be beneficial.  These items can also decrease the risk of confusion and delirium from being in the hospital.

The room should be positioned near a window so the patient can see the outdoors. Natural lighting is the best and limiting the bright neon lights. Even turning the lights down in the nurses’ station and hallways is beneficial for patients.  Studies have shown leaving bright lights on for extended amounts of time can lead to visual fatigue and headaches (Fontaine, Briggs & Pope-Smith, 2001; Rubert, Long & Hutchinson).    Windows that have some tint to them are the best option as it decreases the glare patient’s experience.
Noise is all too common within a hospital especially an ICU. However these disruptive noises can be decreased with simple steps. To start close the patients door if it is safe, turn off unnecessary alarms, and remind staff to keep their voices down when they are talking (Fontaine, Briggs & Pope-Smith, 2001).  Investing in pillow speakers and head phones that can not only reduce noxious noises but can emit calming sounds (Rubert, Long & Hutchinson).  The engineers can also look into installing sound absorbent carpet, acoustic ceiling and floor tiles that will be less noisy in high traffic areas (Rubert, Long & Hutchinson).
As you can see there are many options of items we can request to be installed into the new ICU and things we can do on a daily basis to improve the quality of the environment and enhance the healing of the patients. The more cognizant we are of the noxious stimuli the more we will be able to create the environment our patients need. Also understanding different perspectives from different hospital executives the better the unit will become.

Fontaine, D., Briggs, L., Pope-Smith, B. (2001). Designing humanistic critical care environments, Critical Care Nursing Quarterly, 24 (3), 21-34.
Rupert, R., Long, L., and Hutchinson, M. Creating a healing environment in the ICU. Retrieved from: http://www.jblearning.com/samples/0763738638/38638_CH03_027_040.pdf

Wednesday, June 15, 2011

Building from the ground up

In envisioning the Neuromedicine ICU that is being created many aspects of care must be discussed and agreed upon. There will be an intensivist covering the unit with a combination of the neurology and neurosurgical residents and midlevel providers for 24 hour coverage of the unit. The unit will be managed by a nurse manager and three nurse leaders. The nurses will follow a nursing care model that involves the use of Licensed Practical Nurses (LPN) in conjunction with Registered nurses (RN). There will be a team of ancillary staff including but not limited to dieticians, physical and occupational therapists, speech pathologists, and social workers. Columbia University is well known for their state of the art Neuro critical care ICU. The nurse manager of the Neuromedicine ICU had the opportunity to tour and speak with the nurse manager at Columbia to gain more insight into building the best ICU possible.

A common question asked is why does a large university medical center need another ICU?   There are currently four that care for the critically ill patients currently. Not to mention the astronomical costs of building and staffing a new unit. Emory University did a wonderful job of explaining why their medical center chose to add another ICU within their facility. A study done in 2001 by Mirski, Chang, and Cowan compared patient’s length of stays and the cost of care between a neuroscience ICU and a generic Surgical/Medical ICU. The results showed a decrease in the length of stay, decrease in costs and a decrease in imagining tests ordered on patients with intracranial hemorrhages.  The decrease in laboratory test, imagining (such as MRI and CT scans) and pharmacy needs is related to specialized knowledge of the neurologist and neurosurgeon.  Another, older, study noted a decrease in length of stay in a neuromedicine ICU versus a surgical ICU. This study did not evaluate the costs in relation to the decrease length of stay.