Nursing practice at its best on a busy intensive care unit
It’s just before 7 in the morning, and here on the coronary care unit on Nelson 5, nurses are huddled in pairs around computer monitors, intently reviewing how patients fared during the last 12 hours. It’s morning report, a time when nurses on the nightshift transfer their patients to their daytime counterparts.
“We had to intubate one lady in Room 24,” nurse Andrea Redman is telling daytime nurse Morgan Etheridge, clicking through pages of lab stats, vitals, med lists, assessments and protocols. “She was anxious, depressed and uncomfortable.
“In Room 18, Mrs. B.—she’s 93—had syncope,” Redman continues, using a medical term for blackout. “She’s supposed to get a pacemaker today. She’s DNR [do not resuscitate], but the doctor said if we can bring her around quickly, we should. But her vitals are stable, she’s breathing room air, she’s alert and oriented.”
Just then, Redman’s stat pager emits three distinct beeps. The patient in Room 24 is in trouble. Redman rushes to the bedside—a preview, Etheridge thinks, of what the day might bring.
* * *You never know what will happen on the CCU, where some of the hospital’s sickest patients suffer with serious heart ailments. There are 10 patients, many sedated and on ventilators, attached to monitors with a tangle of wires. There are 10 rooms, five on one side and five on the other with the nurses’ station in between. Outside each room, signs caution: No Right Arm Procedure! Special Precautions. NPO (an abbreviation for the Latin phrase non per os, “nothing by mouth”). Bleeding Precautions. *
Some patients have been admitted from the Emergency Department, having just had heart attacks. Some need transplants; others, devices to help their hearts pump. Most will be discharged to a step-down unit. Some will not fare as well. They might code (require resuscitation) or gradually deteriorate. Some will die.
Patients give high marks to their nursing care, and in recent months, satisfaction scores have been higher here than on any other Department of Medicine unit. So, in the spirit of National Nurses Week, we spent a morning tracking nurse Etheridge and getting a taste of what it takes to deliver superior nursing care on a busy, high-performing unit like the CCU.
Things are not looking good for the patient we’ll call “Mrs. J.” Sedated and on a vent, her face is contorted in a perpetual frown. She has heart failure and an irregular heartbeat. She has a pacemaker. She has type 2 diabetes. She’s obese.
Etheridge checks her lines. The monitors they’re attached to are resisting, emitting a cacophony of beeps. “I need to make sure the lines are connected and untangled,” Etheridge says over the din. “If an emergency happens, I’ll know just what’s going where.”
Etheridge has her eye on one number, the one that measures the level of oxygen in the blood. It reads 79. “She’s not doing well,” Etheridge says, taking a bag of oxygen, or “ambu bag,” and pumping the gas directly into the patient’s airway. The number rises to 96 but soon resumes its steady descent, dropping into the low 80s.e.
From New Grad to Skilled RN
Dressed in red scrubs, Etheridge is a veritable walking supply closet. In her pockets are a few tools of her trade: small scissors, wipes, meds. Around her neck, her stethoscope. Clipped to her scrubs, about half a dozen laminated cards—cards with quick references on drips and IV meds; cards with key pager and phone numbers; cards with names of all the interns and residents on the cardiology service. Her picture ID is her lifeline, for so much on the CCU is accessed via card-swipe. On her waistband, her stat pager. Connected to her patients’ cardiac monitors, it can relay changes in heart rhythms and blood pressure as well as text messages.
With an open face and ready smile, Etheridge, just 26, radiates a sort of Midwestern unpretentiousness. She’s from Oklahoma and never expected to come East but says that when her husband, a fellow student at Oklahoma University, was accepted at the School of Medicine, “we couldn’t turn it down. After all, Hopkins is the No. 2 medical school in the country.”
Arriving in Baltimore in the summer of 2004, Etheridge applied to several area hospitals. The only one that gave her an interview was Hopkins. “The others,” Etheridge surmises, “just didn’t want to train new grads.”
She started on the coronary progressive unit, the 15-bed, step-down unit. Last November, she moved to the adjacent CCU where for two months she was carefully supervised by veteran nurses.
“There is so much nurturing, support and camaraderie on the unit. The nurses work as a team. Each nurse has only one or two patients, depending on acuity. We have lots of acute MIs,” says veteran CCU nurse Darlene Giles, using the abbreviation for myocardial infarction, or heart attack. “When a patient codes or we get a new patient emergently, all of the nurses come together to help.”
“It’s awesome,” Etheridge says. “You can ask anyone for help any time. If nothing’s going on with your patients, there’s usually a busy nurse with a really sick patient, so you can always help out.”
She is weak, her speech incomprehensible, but elderly Mrs. B. insists on moving from bed to chair all by herself. First, Etheridge checks her vitals—temperature, heart sounds, eyes, pulses in the wrist and feet—and enters her assessment on a computer mounted on the wall.
A physician from the cardiovascular interventional lab (CVIL) arrives. He is one among the parade of specialists—doctors, pharmacists, therapists, social workers and more—who regularly descend on the unit to help treat patients. The nurses interact with them all.
The doctor explains to Mrs. B. that she passed out because of a slow heart rate. “We’d like to put a pacemaker in, and we need you to sign papers.” Mrs. B. knows she needs a pacemaker. Her son told her so. She can barely hold a pen but manages to make a mark in the appropriate space.
It’s not easy to transport someone from the CCU around the hospital, even to CVIL, which is just down the hall. It takes Etheridge nearly a half-hour just to prepare Mrs. B. for the excursion. She hooks the patient’s lines to a portable monitor. She gets out what looks to be a big, red toolbox. It’s full of drugs in case anything goes awry.
It’s just before 9 as Etheridge grabs a seat in the nurses’ station and begins filling out her “rounds template,” listing her patients’ vital signs, drips and labs for yesterday and today. She’ll present the information to doctors on walk rounds.
The nurses’ station is quickly filling up with white coats. Attending physician David Theimann will lead rounds. The group includes the cardiology fellow, two cardiology residents and interns, a medical student on rotation, a pharmacist, residents from pulmonary and emergency medicine, and the senior nurse clinician—about 10 in all.
On this day, it takes about three hours to round on just 10 patients. Each one, therefore, has the benefit of carefully considered decisions made by some of the brightest young minds in medicine. Mrs. J., in Room 24, is last of all. The group spends about 20 minutes debating what ails her. Bacterial pneumonia? Viral pneumonia? Influenza? The group listens intently as Etheridge presents the latest information. Mrs. J.’s oxygen levels are up and holding, she reports.
The pulmonary resident advocates getting a diagnosis with a lung biopsy in the OR. Etheridge prepares mentally for another patient transport. Considering Mrs. J.’s numerous monitors and lines, not to mention her precarious condition, this one would be far more challenging.
That afternoon, Mrs. B. returned to the CCU, pacemaker in place. Etheridge transferred her to the step-down unit. Soon after, another patient, a “priority 1” from Bayview, arrived to take Mrs. B’s bed. Just then, Mrs. J’s blood pressure began fluctuating wildly. Etheridge struggled to keep it in check as several other CCU nurses helped with her new patient, who was having constant chest pain and would have bypass surgery that evening. By 6:30 p.m., Etheridge had prepared both patients to be transported to the OR. At 7, she gave her report to the nightshift nurse. By 7:30, she was on her way home.