How-To Ski: Nursing on the NCCU NCCU Nurse Manager Ski Lower: "I love to open units." In the midst of a nationwide nursing shortage, openings on Hopkins' neuroscience critical care unit fill almost the moment they appear. Under the direction of Nurse Manager Judith "Ski" Lower since its inception 21 years ago, the NCCU has always been a place where nurses thrive. "Ski grows her people," says Filissa Caserta, who signed on with Lower in 1989, left to manage another unit, then returned three years ago "because it's so incredible. The education here is what helps with retaining nurses. When we do daily rounds, it's the nurse who presents the patient to all the residents and the attendings." To bring her nurses to that level, in a unit that cares for some of the hospital's sickest patients, Lower has honed the art of customized training. "I don't ever expect to get ready-made, specialized critical care nurses," she says. "I look for RNs who care. They can learn the high- tech." All new hires attend eight days of classes in basic critical care plus neuroscience anatomy and physiology; a 10-week orientation helps those with no ICU experience get up to speed. Additional classes during the first year act as a support group to address coping skills, "imposter syndrome" and other fears. At one year, training is available to those interested in becoming preceptors and charge nurses. Every year thereafter, semiannual classes maintain and build knowledge. Even so, Lower constantly looks for new ways to educate, like having her nurses observe various neurosurgeries. "If a family member asks, Why does he have these pinpoint holes in the front of his head when his surgery was back here, we can tell them it's because of how he was positioned on the operating table," she says. "Seeing how a procedure is performed sharpens our assessment and care postoperatively." "Because there are so many physicians around, it would be easy for the nurses to defer to them," says NCCU director Marek Mirski. "But we want the nurses to think. You can't have the best care unless they do-it's 20 percent physician, 80 percent nursing. For example, they can do subtle neurological assessments, like detecting small changes in language or strength that signal when an awake patient may be developing a hemorrhage in the head. By picking up these deficits early, we can intervene before the patient goes into a frank coma." If there's a secret to all this, says Lower, it's understanding what keeps her staff motivated. "People like an environment where they feel valued and where they continue to learn," she says. "To learn how to return a person who's had a catastrophic stroke to a fairly functional state is unbelievably rewarding."

Among John Griffin's sharpest memories of his rookie year in neurology are four patients on Brady 2, one with porphyria, the others paralyzed from Guillain-Barré syndrome. All were on respirators and needed round-the-clock attention. But in 1970, Hopkins' Department of Neurology was just four years old, and dedicated intensive care units were in their infancy. "We took care of these patients," says Griffin, now director of neurology, "by having house staff sleep in a chair in the rooms."

Times have changed.

This spring, the largest neuroscience critical care unit in the country made its debut on Hopkins Hospital's Meyer 7. "There is no other comparable department," says Griffin. "The science of neurocritical care has grown up, and it makes an enormous difference in outcomes. Lives are saved, and hospital stays are shortened. This new unit provides a setting where the most advanced treatments can be brought to bear."

Not that the neuro ICU it replaced hadn't already moved light years beyond that first set-up in Brady. In 1982, a newly hired nurse named Judith "Ski" Lower helped then-neurosurgery chairman Donlin Long organize a real four-bed unit on Halsted 6. Three years later, the tiny NCCU expanded to eight beds on Meyer 7, where it's been playing an integral role in the advances in neurology and neurosurgery ever since.

By the end of the 1990s, though, even with 14 beds, the NCCU was struggling. Decade-of-the-Brain breakthroughs-clot-busting drugs that stem the effects of strokes, stents that expand narrowed blood vessels-began to overwhelm the unit's capacity to handle the demand for its highly specialized services. Caring for patients who've suffered gunshot wounds, traumatic brain injury and serious seizures, as well as those who've had massive brain or back surgeries, the NCCU was so consistently full that scheduled surgeries and neurological admissions were being canceled. The solution, not surprisingly, was a relatively easy sell. From proposal to drawing board to ribbon-cutting, the NCCU went from a warren of outdated rooms to the future look of neuro critical care in less than two years.

Now occupying all of Meyer 7, the unit has 22 all-private rooms, each with a ceiling-mounted arm that corrals oxygen, suction, electrical hook-ups and other technology near the bed, then swings aside when patients need to be moved. Room doors swivel out to accommodate bulky equipment, and motorized beds-the first in the hospital-simplify the inevitable travel off the floor for CT scans, MRIs and other procedures. Soundproofing and electronic "people finders" have reduced noise. Visitors have a waiting area inside the unit instead of being stuck 500 feet down the hall, and a room has been set aside for families facing catastrophic news. Physicians and nurses have education rooms, clerical associates have their own space and phones, even the pantry and clean utility are now separate.

Furthermore, the reconfiguration supports other innovations. All patients get full critical care nursing coverage, but are split into two distinct groups. On one end of the floor are 10 beds for very unstable patients who need frequent physician attention. At the other end, in the 12-bed neurovascular ICU, are patients no less ill but whose care is more amenable to critical pathways-if X, then Y-which the nurses handle.

The set-up means that despite the eight new beds, the unit hasn't needed more residents-a feat that NCCU director and neuroanesthesia chief Marek Mirski attributes in large part to the skill levels of the staff. Faculty are all neurointensive-care fellowship trained with specialties in neurology, anesthesiology or both; nurses are neuroscience critical care certified.

"What I'm proud of is not just the new unit," says Mirksi, who trained at Hopkins under the hospital's first NCCU director, Daniel Hanley, founding father of the concept of neuro critical care as a distinct subspecialty. "It's the interdisciplinary program. We're fortunate here that the departments of neurology, neurosurgery and anesthesiology maintain very good relationships, so it wasn't hard to bring them even closer together. We now have a regular Tuesday staff meeting where everybody-doctors, nurses, stroke specialists, people from neurology and neurointerventional radiology-can get together and talk. It's an acute neuroscience world here, an incredibly collegial environment, and I think we've only improved upon it. If everyone's talking to each other, isn't that the best?"

-Mary Ann Ayd