Overview

Health care is undergoing dramatic change at a speed that makes it almost impossible to remain current and be proactive. The chaos and many challenges facing health care providers and consumers are evident in critical care, in which new treatment modalities and technology interface with the continuing effort to strive for quality care and positive outcomes. Efficiency and cost-effectiveness in relation to health care services are frequently discussed and are emphasized to all health care providers. To some, it appears that quality patient care has taken a back seat to the emphasis on cost containment and that quality and cost-effectiveness are not congruent. It is incumbent on all critical care health care providers to face these challenges from their individual discipline’s scope of practice and collectively from collaborative and interdisciplinary approaches.

The ever-changing health care environment creates many challenges for providers and consumers of care. Sensitivity to the appropriate time to eliminate or modify practices and adopt innovations is key to maintaining quality, cost-effective care delivery. Willingness to step outside of traditional structures and roles is the first step in making necessary changes. Change is constant. Flexibility and adaptation to change are essential to maintaining personal and organizational balance and to surviving in today’s health care environment.

This chapter provides an overview of the evolution of critical care and describes the trends and current issues affecting critical care nurses and interdisciplinary team. The information in this chapter serves as the framework for the remainder of the book in the areas of professional nurse decision making, holistic care, interdisciplinary collaboration, evidence-based practice (EBP), quality, and safety.

History of Critical Care

Critical care evolved from the recognition that the needs of patients with acute, life-threatening illness or injury could be better met if the patients were organized in distinct areas of the hospital. In the 1800s, Florence Nightingale described the advantages of placing patients recovering from surgery in a separate area of the hospital. A three-bed postoperative neurosurgical intensive care unit was opened in the early 1900s at Johns Hopkins Hospital in Baltimore. This was soon followed by a premature infant unit in Chicago.¹

Major societal issues have affected the development of intensive care as a specialty. During World War II, shock wards were established to care for critically injured patients. The nursing shortage after the war forced the grouping of postoperative patients into designated recovery areas so that appropriate monitoring and care could be provided. The technologies and combat experiences of health care providers during the wars of the 20th century also provided an impetus for specialized medical and nursing care in the civilian setting. The 1950s brought the new technology of mechanical ventilation and the need to group patients receiving this new therapy in one location.

Critical Care Nursing

Critical care nursing was organized as a specialty less than 60 years ago; before that time, critical care nursing was practiced wherever there were critically ill patients. The development of new medical interventions and technology prompted recognition that nursing was important in the monitoring and observation of critically ill patients. Physicians depended on nurses to watch for critical changes in the condition of patients in the physicians’ absence, and they sometimes depended on the nurses to initiate emergency medical treatment.

As sophisticated technology began to support more elaborate medical interventions, hospitals began to organize separate units to make more efficient use of equipment and specially trained staff. Postoperative care, once provided by private duty nurses on general nursing wards throughout the hospital, was moved into recovery rooms, where nurses with specialized knowledge regarding anesthesia recovery provided the patient care. Medical and surgical intensive care units segregated the most critically ill patients in locations where they could be cared for by nurses with specialized knowledge in those areas of care. By the 1960s, nurses had begun to consolidate their knowledge and practice into focused areas such as coronary care, nephrology, and intensive care. In the hospital units established for patients needing such specialized care, nurses assumed many functions and responsibilities formerly reserved for physicians, and they assumed a new authority by virtue of their knowledge and expertise.

Contemporary Critical Care

Modern critical care is provided to patients by a multidisciplinary team of health care professionals who have in-depth education in the specialty field of critical care. The team consists of physician intensivists, specialty physicians, nurses, advanced practice nurses and other specialty nurse clinicians, pharmacists, respiratory therapy practitioners, other specialized therapists and clinicians, social workers, and clergy. Critical care is provided in specialized units or departments, and importance is placed on the continuum of care, with an efficient transition of care from one setting to another.

Critical care patients are at high risk for actual or potential life-threatening health problems. Those who are more critically ill require more intensive and vigilant nursing care. There are more than 500,000 nurses in the United States who care for critically ill patients.

These nurses practice in a variety of settings: adult, pediatric, and neonatal critical care units; step-down, telemetry, progressive, or transitional care units; cardiac catheterization laboratories; and postoperative recovery units.² Nurses are now considered to be knowledge workers because they are highly vigilant and use their intelligence and cognition to go past tasks in order to quickly pull together multiple data to make decisions regarding subtle and/or deteriorating conditions. Nurses work technically with theoretical knowledge.³

A growing trend in acute care settings is the designation of progressive care units, considered to be part of the continuum of critical care. In past years, patients who are placed on these units would have been exclusively in critical care units. However, with the use of additional technology and monitoring capabilities, newer care delivery models, and additional nurse education, these units are considered the best environment. The patients are less complex, more stable, have a decreased need for physiologic monitoring, and more self-care capabilities. They can serve as a bridge between critical care units and medical-surgical units, while providing high quality and cost effective care at the same time.⁴ Additionally, these progressive units can be found throughout the acute care setting, thus leaving critical care unit beds for those who need the highest level of care and monitoring.⁵

Critical Care Nursing Roles

Nurses provide and contribute to the care of critically ill patients in a variety of roles. The most prevalent role for the professional registered nurse is that of direct care provider. The American Association of Critical-Care Nurses (AACN) has delineated role responsibilities important for the critical care nurse⁵ (Box 1-1).

Critical Care Professional Accountability

Professional organizations support critical care practitioners by providing numerous resources and networks. The Society of Critical Care Medicine (SCCM) is a multidisciplinary, multispecialty, international organization. Its mission is to secure the highest quality, cost-efficient care for all critically ill patients.¹ Numerous publications and educational opportunities provide cutting-edge critical care information to critical care practitioners.

The organization most closely associated with critical care nurses is the AACN. It is the world’s largest specialty nursing organization and was created in 1969. AACN is focused on “creating a healthcare system driven by the needs of patients and their families, where acute and critical care nurses make their optimal contribution.”⁷ The top priority of the organization is education of critical care nurses. AACN publishes numerous materials, evidence-based practice summaries, and practice alerts related to the specialty and is at the forefront of setting professional standards of care.

AACN serves its members through a national organization and many local chapters. The AACN Certification Corporation, a separate company, develops and administers many critical care specialty certification examinations for registered nurses. The examinations are provided in specialties such as neonatal, pediatric, and for those who practice in diverse settings, such as critical care, progressive care, “virtual” ICU, or remote monitoring (e-ICU). Certification is considered one method to maintain high quality of care and to protect consumers of care and services. Research has demonstrated more positive outcomes when care is delivered by health care providers who are certified in their specialty.⁸ AACN also recognizes critical care and acute care units who achieve a high level of excellence through its Beacon Award for Excellence. The unit that receives this award has demonstrated exceptional care through improved outcomes and greater overall satisfaction. It reflects on a supportive overall environment, teamwork and collaboration, and distinguishes itself with lower turnover and higher morale.⁹

Critical Care Nursing Standards

AACN has established nursing standards that provide a framework for critical care nurses. Nursing practice varies depending on the setting in which the nurse is employed and the patients cared for in that setting. The standards set forth by AACN describe the practice of the nurse who cares for an acutely or critically ill patient in the health care environment. The standards are authoritative statements that describe the level of care and performance by which the quality of nursing care can be judged. They serve as descriptions of the expected roles and responsibilities, describing the standards of care and the standards of professional practice.

Evidence-Based Nursing Practice

Much of early medical and nursing practice was based on non-scientific traditions, intuition, and traditions. These traditions and rituals, which were based on folklore, gut instinct, trial and error, and personal preference, were often passed down from one generation of practitioner to another. Examples of non–scientific-based critical care nursing practice include Trendelenburg positioning for hypotension, use of rectal tubes to manage fecal incontinence, gastric residual volume and aspiration risk, accuracy of assessment of body temperature, and suctioning artificial airways every 2 hours—to name a few. In order to deliver the highest quality of care, EBP is essential and must be embraced by all nurses.¹⁰

The dramatic and multiple changes in health care and the ever-increasing presence of managed care in all geographic regions have placed greater emphasis on demonstrating the effectiveness of treatments and practices on outcomes. Emphasis is on greater efficiency, cost-effectiveness, quality of life, and patient satisfaction ratings. It has become essential for nurses to use the best data available to make patient care decisions and carry out the appropriate nursing interventions.10–11 By using an approach employing a scientific basis, with its ability to explain and predict, nurses are able to provide research-based interventions with consistent, positive outcomes. The content of this book is research-based, with the most current, cutting-edge research abstracted and placed throughout the chapters as appropriate to topical discussions.

The increasingly complex and changing health care system presents many challenges to creating an EBP. Appropriate research studies must be designed to answer clinical questions, and research findings must be used to make necessary changes for implementation in practice. Multiple EBP and research utilization models exist to guide practitioners in the use of existing research findings. One such model is the Iowa Model of Evidence-Based Practice to Promote Quality Care, which incorporates evidence and research as the bases for practice.¹² Cullen and Adams describe a framework with four key phases to implement EBP: 1) create awareness and interest; 2) build knowledge and commitment; 3) promote action and adoption; and 4) pursue integration and sustained use. Each step has multiple strategies that will facilitate successful progression to the next phase. The authors indicate that this model is particularly suited to complex static organizations.¹¹

Just as there has been such an exponential growth of EBP literature, reports, publications and acceptance, others are posing the question, “But at what cost?” Newhouse describes this as a complex issue to address and states that economists would go beyond the costs of human labor and materials in their analysis. Another way to evaluate this is to examine “whose” cost is being considered.¹³ More recently, a published article reported estimates of costs per event for several health-acquired conditions (HACs). The estimated cost of care for one catheter-associated urinary tract infection (CAUTI) was $758. A patient fall was estimated to be $4,233 per fall; and a surgical “never event” cost $62,000 per event. These are most likely underestimated; but it is easy to realize the tremendous impact of situations that should not occur because there is sufficient evidence to prevent such outcomes.¹⁴ Thus, inquisitive practitioners who strive for best practices using valid and reliable data will demonstrate quality outcomes-driven care and practices.

Evidence-based nursing practice considers the best research evidence on the care topic, along with clinical expertise of the nurse, and patient preferences. For instance, when determining the frequency of vital sign measurement, the nurse would use available research, nursing judgment (stability, complexity, predictability, vulnerability, and resilience of the patient),¹⁵ along with the patient’s preference for decreased interruptions and the ability to sleep for longer periods of time. At other times the nurse will implement an evidence-based protocol or procedure that is based on evidence, including research. An example of an evidence-based protocol is one in which the prevalence of indwelling catheterization and incidence of hospital-acquired catheter-associated urinary tract infections in the critical care unit can be decreased.¹⁶

The AACN has promulgated several EBP summaries in the form of a “Practice Alert.” These alerts are short directives that can be used as a quick reference for practice areas (e.g., oral care, noninvasive blood pressure monitoring, ST segment monitoring). They are succinct, supported by evidence, and address both nursing and multidisciplinary activities. Each alert includes the clinical information, followed by references that support the practice.¹⁷ An example of one of the alerts is found on in Box 1-2.

Box 1-2   Aacn Practice Alert

Family Presence During Resuscitation and Invasive Procedures

Expected Practice:

• Family members* of all patients undergoing resuscitation and invasive procedures should be given the option of presence at the bedside. [Level B]

• All patient care units should have an approved written practice document (i.e., policy, procedure, or standard of care) for presenting the option of family presence during resuscitation and bedside invasive procedures. [Level D]

*Family members are those individuals who are relatives or significant others with whom the patient shares an established relationship.

Scope and Impact of the Problem:

Evidence is mounting that family presence during resuscitation and invasive procedures is beneficial to patients, families, and staff. Meeting psychosocial needs in a time of crisis exemplifies care driven by the needs of patients and families.

Supporting Evidence:

• Research1–11 and public opinion polls^12–14 have found that 50% to 96% of consumers believe family members should be offered the opportunity to be present during emergency procedures and at the time of their loved one’s death.

• Despite support by professional organizations and critical care experts,15–24 only 5% of critical care units in the U.S. have written policies allowing family presence.²⁵ Surveys of nurses’ practice find that most critical care nurses have been requested by family members to be present during resuscitation and invasive procedures and have brought families to the bedside, despite the lack of formal hospital policies.^25–27

• Studies find the following benefits of family presence:

• For patients: Almost all children want their parents present during medical procedures28–30; and adult patients report that having family members at the bedside comforted and helped them.^3,31–32

• For family members: Their presence at the bedside helped in removing doubt about the patient’s condition by witnessing that everything possible was being done.8,9,32–35 It decreased their anxiety and fear about what was happening to their loved one.^{7,10,29,32,36–37} It facilitated their need to be together^8,10 and the need to help and support their loved one.^{8–11,33–4,36} They experienced a sense of closure^3,8,11,34 and their presence facilitated the grief process should death occur.^{3,5,11,32–36}

• Studies show that 94% to 100% of families involved in family presence events would do so again.3,7,8,9,33,36

• Studies also find that there are no patient-care disruptions, no negative outcomes during family presence events,8,9,29,32–34,38–39 and no adverse psychologic effects among family members who participated at the bedside.^8,10,32,40

AACN Evidence Leveling System

Level A Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment.

Level B Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.

Level C Qualitative studies, descriptive or correlational studies, integrative review, systematic reviews, or randomized controlled trials with inconsistent results.

Level D Peer-reviewed professional organizational standards with clinical studies to support recommendations.

Level E Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Level M Manufacturer’s recommendations only.

Actions for Nursing Practice:

• Ensure that your health care facility has written policies and procedures that support family presence during resuscitation and invasive procedures.

• Policies and procedures, and educational programs for professional staff should include the following components:

• Benefits of family presence for the patient and family.²³

• Criteria for assessing the family to ensure uninterrupted patient care.9,20,23

• Role of the family facilitator in preparing families for being at the bedside and supporting them before, during, and after the event, including handling the development of untoward reactions by family members.21–22,34,41 Family facilitators may include nurses, physicians, social workers, chaplains, child life specialists, respiratory care practitioners, family therapists, and nursing students.^20,23,41

• Support for patient’s or family members’ decision not to have family members present.²³

• Contraindications to family presence (for example, family members who demonstrate combative or violent behaviors; uncontrolled emotional outbursts; behaviors consistent with an altered mental state from drugs or alcohol; or those suspected of abuse).9,20,22–23

• Develop proficiency standards for all staff involved in family presence to ensure patient, family, and staff safety.

• Determine your unit’s rate of compliance in offering families the option of family presence during resuscitation and invasive procedures. If compliance is ≤90%, develop a plan to improve compliance:

• Consider forming a multidisciplinary task force (e.g., nurses, physicians, chaplains, social workers, child life specialists) or a unit core group of staff to discuss approaches to improve compliance.

• Re-educate staff about family presence; discuss the intervention as a component of family-centered care and evidence-based practice.

• Incorporate content into orientation programs as well as initial and annual competency verifications.

• Develop a variety of communications strategies to alert and remind staff about the family presence option.

• Develop documentation standards for family presence and include rationale for when family presence would not be offered as an option to family members.

Need More Information or Help?

• Go to www.aacn.org and select Practice Resource Network.

• The guidelines for “Presenting the Option for Family Presence,”²³ developed by the Emergency Nurses Association and endorsed by AACN, are suitable for adaptation to critical care units and include educational slides and handouts, a family presence department assessment tool, a staff assessment tool, an educational needs assessment tool, a sample family presence guideline, and other supporting documents. This resource (Product #120632) is available online at www.aacn.org or by calling (800) 899-2226.

• AACN endorses the American College of Chest Physician’s Critical Care Family Assistance Program. This toolkit empowers you and your team to create a family-friendly critical care environment at your hospital. This resource (Product #120631) is available online at www.aacn.org or by calling (800) 899-2226.

References:

1. Bauchner, H, Waring, C, Vinci, R. Parental presence during procedures in an emergency room: Results from 50 observations. Pediatrics. 1991; 87(4):544.

2. Sacchetti, A, Lichenstein, R, Carraccio, CA, et al. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care. 1996; 12(4):268.

3. Belanger, MS, Reed, S. A rural community hospital’s experience with family-witnessed resuscitation. J Emerg Nurs. 1997; 23(3):238.

4. Barratt, F, Wallis, DN. Relatives in the resuscitation room: their point of view. J Accid Emerg Med. 1999; 16(1):109.

5. Meyers, TA, Eichhorn, DJ, Guzzetta, CE. Do families want to be present during CPR? A retrospective survey. J Emerg Nurs. 1998; 24(5):400.

6. Boie, ET, Moore, GP, Brommett, C, et al. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med. 1999; 34(1):70.

7. Powers, KS, Rubenstein, JS. Family presence during invasive procedures in the pediatric intensive care unit: a prospective study. Arch Pediatr Adolesc Med. 1999; 153(9):955.

8. Meyers, TA, Eichhorn, DJ, Guzzetta, CE, et al. Family presence during invasive procedures and resuscitation: the experiences of family members, nurses, and physicians. Am J Nurs. 2000; 100(2):32.

9. Mangurten, J, Owens, J, Vinson, L, et al, Family presence during resuscitation interventions and invasive procedures in a pediatric emergency department: attitudes and experiences of healthcare providers and family members Unpublished data. Children’s Medical Center of Dallas, Dallas, 2004.

10. Mangurten, J, Scott, SH, Guzzetta, CE, et al. Effects of family presence during resuscitation and invasive procedures in a pediatric emergency department. J Emerg Nurs. 2006; 32(3):225.

11. Tinsley, C, Hill, JB, Shah, J, et al. Experience of families during cardiopulmonary resuscitation in a pediatric intensive care unit. Pediatrics. 2008; 122(4):e799.

12. NBC Dateline Poll. Should family members of patients be allowed in the emergency department during emergency procedures? Available at http://www.nbc.com. [Accessed August 17, 1999].

13. USA Today Poll. Would you want to be in the emergency department while doctors worked on a family member? USA Today. Available at http://www.usatoday.com. [Accessed March 7, 2000].

14. Mazer, MA, Cox, LA, Capon, A. The public’s attitude and perception concerning witnessed cardiopulmonary resuscitation. Crit Care Med. 2006; 34(12):2925.

15. Eckle N, Haley K, Baker P, eds. Emergency Nursing Pediatric Course: Provider Manual, 2nd ed, Park Ridge, IL: Emergency Nurses Association, 1998.

16. Jacobs BB, Hoyt KS, eds. Trauma Nursing Core Course: Provider Manual, 5th ed, Park Ridge, IL: Emergency Nurses Association, 2000.

17. Royal College of Nursing. Witnessed resuscitation: guidance for nursing staff. London: The College; 2002.

18. Guzzetta, GE. Critical Care Research: Weaving a Body-Mind-Spirit Tapestry. Am J Crit Care. 2004; 13(4):320.

19. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 2 Ethical Issues and Part 12 Pediatric Advanced Life Support. Circulation. 112(24 Suppl), 2005. [IV6 and IV167].

20. Clark, AP, Aldridge, MD, Guzzetta, CE, et al. Family presence during cardiopulmonary resuscitation. Crit Care Nurs Clin North Am. 2005; 17(1):23.

21. Davidson, JE, Powers, K, Hedayat, KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007; 35(2):605.

22. Henderson, DP, Knapp, JF. Report of the national consensus conference on family presence during pediatric cardiopulmonary resuscitation and procedures. J Emerg Nurs. 2006; 32(1):23.

23. Emergency Nurses Association, Presenting the Option for Family Presence, 3rd ed. Emergency Nurses Association, Des Plaines, IL, 2007. www.ena.org

24. Moons, P, Norekval, TM. European nursing organizations stand up for family presence during cardiopulmonary resuscitation: A joint position statement. Prog Cardiovasc Nurs. 2008; 23(3):136.

25. MacLean, SL, Guzzetta, CE, White, C, et al, Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses. Am J Crit Care. 2003; 12(3):246–257 and J Emerg Nurs 2003;29(3):32

26. Fallis, WM, McClement, S, Pereira, A. Family presence during resuscitation: a survey of Canadian critical care nurses practices and perceptions. Dynamics. 2008; 19(3):22.

27. Twibell, RS, Siela, D, Riwitis, C, et al. Nurses’ perceptions of their self-confidence and the benefits and risks of family presence during resuscitation. Am J Crit Care. 2008; 17(2):101.

28. Wolfram, RW, Turner, ED. Effects of parental presence during children’s venipuncture. Acad Emerg Med. 1996; 3(1):58.

29. Gonzalez, JC, Routh, DK, Saab, PG, et al. Effects of parent presence on children’s reactions to injections: behavioral, physiological, and subjective aspects. J Pediatr Psychol. 1989; 14(3):449.

30. Fiorentini, SE. Evaluation of a new program: Pediatric parental visitation in the postanesthesia care unit. J Post Anesth Nurs. 1993; 8(4):249.

31. Eichhorn, DJ, Meyers, TA, Guzzetta, CE, et al. Family presence during invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001; 101(5):26.

32. Robinson, SM, Mackenzie-Ross, S, Campbell-Hewson, GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998; 352(9128):614.

33. Doyle, CJ, Post, H, Burney, RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987; 16(6):673.

34. Hanson, C, Strawser, D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992; 18(2):104.

35. Timmermans, S. High touch in high tech: the presence of relatives and friends during resuscitation efforts. Sch Inq Nurs Pract. 1997; 11(2):153.

36. Powers, KS, Rubenstein, JS. Family presence during invasive procedures in the pediatric intensive care unit. Arch Pediatr Adolesc Med. 1999; 153(9):955.

37. Shapira, M, Tamir, A. Presence of family member during upper endoscopy. What do patients and escorts think? J Clin Gastroenterol. 1996; 22(4):272.

38. O’Connell, KJ, Farah, MM, Spandorfer, P, et al. Family presence during pediatric trauma team activation: an assessment of a structured program. Pediatrics. 2007; 120(3):e565.

39. Sachetti, A, Paston, C, Carraccio, C. Family members do not disrupt care when present during invasive procedures. Academic. Emergency Medicine. 2005; 12(5):463.

40. Maxton, FJ. Parental presence during resuscitation in the PICU: the parents’ experience. Sharing and surviving the resuscitation: a phenomenological study. J Clin Nurs. 2008; 17(23):3168.

41. Clark, AP, Calvin, AO, Meyers, TA, et al. Family presence during cardiopulmonary resuscitation and invasive procedures: a research-based intervention. Crit Care Nurs Clin North Am. 2001; 13(4):569.

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