was not the same woman that Jason Forche saw lying in the bed in room
52. One moment Sally R.* was alert and talking. She knew her name and
that she was in Emory University Hospital. A 39-year-old mother of two,
Sally was glad her husband was with her.
next moment—just 30 seconds later—Forche, the nurse responsible
for Sally’s care, knew something dramatic had happened. None of
the vividly colored monitors surrounding the bed had blinked, changed
their readouts, or uttered a peep. Everything seemed the same except Sally
had stopped talking to her husband.
To the untrained eye, that would mean little,
but in a neurointensive care unit that treats brain injuries, nurses are
keenly aware of any sign that suggests something is amiss.
Quickly, Forche called the nurse practitioner
in the unit, explained what he had checked and what he thought had happened,
and together they rushed Sally to the diagnostic CT machine down the hall.
The scan was negative. Forche then whisked her downstairs for an angiogram,
and as he feared, Sally was experiencing a cerebral vasospasm, a potentially
lethal constriction of a brain artery. It had clenched shut, depriving
parts of her brain of blood and oxygen. A quick infusion of strong drugs
reopened the vessel.
Sally was back.
* Her name has
been changed to protect her privacy
||"I love hands-on
nursing," says Kelda Kemp, a nurse for three years who
learns from experienced veterans like Angela Drummond, a neuro
ICU bedside nurse since 1999.
to 2D ICU, a unit unlike any others at Emory, or
like few in the United States. In both form and function, it is a place
where physicians, nurses, and staff are applying an emerging model of
Here families stay with patients 24/7, if
they like, and clinical care is led by neuro intensivists, a relatively
new breed of MDs who specialize in treating critically ill patients with
And it is on 2D ICU that nurses are migrating
from the monolithic central nursing station found on most modern hospital
floors back to patient rooms, to be as close to the bedside as possible—the
place where nursing care is traditionally valued.
Accompanying this transition, these nurses
also are assuming bigger responsibilities. They are providing input into
how patients should be managed as well as what should occur in a crisis.
They are drawing on the newest technology to provide smoother, coordinated
care. They are encouraged to move up the professional ladder and earn
additional certification—and many do. And in an even bigger way
than in the past, they are proving an indispensable resource not only
to patients and their families but also to the entire clinical team.
“Nurses are more than my eyes and
ears. They are my eyes, ears, mouth, hands, everything,” says Owen
Samuels, medical director of the neuroscience ICU program.
||It is on 2D ICU
that nurses are migrating from the monolithic central nursing
station found on most modern hospital floors back to patient
rooms, to be as close to the bedside as possible—the place
where nursing care is traditionally valued.
The building of 2D ICU represents a convergence of medical, cultural,
and market forces at play in health care, changes that help explain transformations
in hospital nursing.
Foremost among them is that some hospitals
are morphing into a collection of critical care units that treat the sickest
of the sick. Emory Hospital, because of its tertiary-care status and the
breadth of specialties operating here, has long been one of those facilities
with a burgeoning critical care census.
At the same time, because of new national
restrictions on the number of hours that residents and interns can work,
there are fewer residents on the units to treat patients than before.
The traditional resident-fellow-attending academic model has become strained,
and nursing shortages and a dearth of critical care specialists have plagued
hospitals not only in the Emory system but also across the country.
Simultaneously, health care consumers have
become savvier, more willing to choose a hospital based on rankings in
popular surveys, and on other criteria more akin to a shopping mall experience—the
look and feel of the place, the customer service.
Even as the Emory neuro ICU was dealing
with these changes, it was growing fast. From a single seven-bed unit
in 1998, Emory’s neurocritical care has expanded now to include
almost five times as many beds in three units. Occupancy now averages
more than 90%, says Ray Quintero, department director of 2D ICU.
One of the reasons for the rapid development
of the service is that patients are surviving catastrophic brain injuries
thanks to quicker, more advanced treatment. Another is that many patients
are referred here for procedures that are unavailable elsewhere.
For example, Emory is one of the few hospitals
in the Southeast to offer a less invasive treatment for aneurysms, or
life-threatening bulges in brain blood vessels. This technique involves
threading a catheter through the patient’s groin up into the brain,
and depositing a tiny coil in the bulge to block blood from entering.
More typical treatment for an aneurysm involves use of a titanium clip
to bind the bulge, which first requires a craniotomy to remove part of
While placement of the coil is less invasive,
it requires a huge amount of technology in the care of these patients.
And because complications may arise one or two weeks after coiling or
clipping, such treatments require one of the longest hospital stays of
any disorders, Quintero says.
||To create an environment
where nurses feel invested, 2D ICU Director Ray Quintero, turns
to the nurses themselves. "It's not my unit. It's your
unit," he says.
Long before 2D ICU was built, Samuels saw how these long stays combined
with resident shortages could damage the quality of care delivered in
the ICU. He turned to mid-level caregivers, what are known as physician
extenders, to fill the “care gap.” These physician extenders
include physician assistants, surgical assistants, nurse anesthetists,
and nurse practitioners (NPs).
NPs are registered nurses who have completed
advanced education and rigorous training in the diagnosis and management
of illnesses. As such, they are able to provide a broad range of health
On the neuro ICU, “they do all sorts
of complex, high-risk procedures, which would have been unheard of years
before,” Samuels says. Among them are placement of invasive centralized
arterial lines and pulmonary artery catheters as well as lumbar punctures
Since NPs stay in the units during day shifts
(with plans to expand coverage to 24/7), they work hand in glove with
physicians, the care team, and, of course, bedside nurses. The partnership
between NPs and bedside nurses is important, says NP Michelle Ossmann.
“Bedside nursing is key,” she says. “The nurses determine
everything, including when we take action. I can’t function without
As NPs increasingly were given authority
in neurocritical care and as the number of beds and the services grew,
responsibilities also grew for experienced bedside nurses. With patient
safety as the top priority, they have the power to stop care if they feel
uncertain about a process.
“We are more empowered to make a change,”
says Angela Drummond, who has worked in the unit since 1999. “I
question, I ask, I reason.”
Yet through all this increased responsibility
and empowerment, the element that can’t be diminished happens at
the bedside. It is the human touch.
||The lessons learned
in 2D ICU will help shape the renovation and design of future
intensive care units at Emory, including those in a proposed
new hospital complex on Clifton Road.
The tragedy that unfolds daily in the neuro ICU underscores the fact that
anyone can suffer a sudden and devastating neurologic event. The disorders
treated here are not the exclusive province of the elderly.
“A man can say goodbye to his family
in the morning and unexpectedly be in our unit in the evening,”
says John Scala, who has worked in neurocritical care for seven years.
“Families are often in shock and grief because of the abruptness
of this illness.”
His point was made when, as the night nurse
in charge, he rounded on patients in 2D ICU. On this typical evening,
the patient mix included a woman in her 30s with a cranial bleed caused
by taking ten tablets of ephedra a day to lose weight; a 31-year-old man
in a coma from a steroid-induced stroke; and seven patients, aged 39 to
72, recovering from aneurysm treatment.
In older models for delivering intensive
care, families in shock huddled together outside the intensive care unit
and were asked to refrain from intruding when the medical team held rounds
to discuss patient care and prognosis. The scenario was less than ideal,
“Medicine and nursing have become
so complex and so demanding that it has taken both nurses and doctors
farther and farther from the patient’s bedside, both physically
and metaphorically,” says Samuels. “There is less hand-holding,
less hands-on touching, healing, and bonding with patients.”
When Emory administrators decided in 2005
to expand the busy neuro ICU, Samuels put together a team of nurses, neurologists,
pharmacists, social workers, design experts, and family members of former
patients to figure out how to move caregivers back to the bedside.
“I think it’s a mistake to view
families as yet another sort of checklist for the doctors and the nurses
to take care of,” Samuels says. “Medicine in general has neglected
the powerful and important role that families and patients can play in
the healing process.”
So the team set about to design a unit “where
the family and the patient are not objects of treatment but are full participants
in the whole healing process,” he says. And that meant that nurses
and families, too, returned to the bedside.
||"We are far
beyond Florence Nightengale's day, for sure, but we have gone
miles beyond what nursing was even five years ago," says
mother, like daughter
In June Sharkey’s experience, the nursing profession is “completely
different now” from when she first stood by a patient’s
bed in a small Mississippi hospital in 1979. “If a doctor came
into the room and you were sitting down, you got up and gave him the
chair,” she says. “Nurses were no more than handmaidens
to the doctors.”
It wasn’t much better at Emory
when she came in 1980 to work on a seven-bed special care unit for
neurology patients and a few overflow heart patients. Nurses had little
say in how the unit was operated or patients were managed. “It
was more like a dictatorship than a democracy,” says Sharkey
(above, right). “The staff nurses did what the ranks above them
told them to do.”
Yet in 2006 when June’s 22-year-old
daughter, April Sharkey (above, left), joined Emory
as a nurse in the same unit as her mother, she entered a dramatically
different environment. The younger Sharkey’s experience of nursing
is as “the patient’s advocate,” she says.
The change in scenario began to unfold
about 10 years ago for nurses in the neuro ICU when they first were
invited to attend leadership meetings. There, nurses have come into
their own in a way that is still atypical in other hospitals, both
Sharkeys say. For example, June Sharkey now can do such things as
manage drug titration if a patient’s status changes. “Our
autonomy has increased,” she says. “The majority of doctors
here are open to my input.”
In this new climate, nurses also are
pushed to do more, she says. “The patients are sicker, and there
is more technology to help us monitor them. We have many more responsibilities
in addition to the typical bedside duties.”
April Sharkey, who received her nursing
degree from Emory less than two months before she started working
in 2D ICU, finds neurology to be a challenging area for nursing. “You
have to keep up with the research,” she says. “I can’t
believe how much I learn every day, and after a 12-hour shift, I feel
I have made a difference in someone’s life.”
There is no other critical care unit like 2D ICU in Atlanta, and few in
the country. Its form has helped further define the function of the patient
Patient-centered care is not new in Emory
Hospitals. The hospital care teams have followed the philosophy for years,
but they have been hampered by the design of the physical plant. By contrast,
2D ICU, which opened in February, features a new design tailored for 21st-century
health care. Among its features are a large waiting area for family members,
with a kitchenette and a children’s play area on one side. Like
a hotel concierge, two assistants take turns staffing a welcome desk,
offering solace along with towels for the shower room or soap for the
washer and dryer. Within each patient room is a separate studio area for
family members, with chairs that open into beds. Soon, the suites will
have laptop computers.
When not at the bedside or in treatment
areas, nurses work from alcoves situated between patient rooms. They have
only to glance in to see and hear the patients and to monitor IV fluids
and a myriad of machines. Often, a probe is embedded into the brain to
measure temperature, oxygen, and intracranial pressure, and transcranial
Doppler ultrasound is available to look at the velocity of blood flow.
A CT scanner is just steps away.
Families come and go and are welcome to
talk with physicians and nurses during rounds. Their presence has put
nurses front and center to answer questions and provide information. Quintero
sees this change as positive, emphasizing the needs of the patient before
those of the medical team.
To create an environment where nurses become
invested and can contribute the most, Quintero has turned to the nurses
themselves. “I tell them, it’s not my unit. It’s your
unit.” Creation of 2D ICU involved shared decision-making, a process
that sent a team of nurses across the country to search for the perfect
equipment boom for the patient rooms, among other tasks.
“I was amazed that I was asked to
go,” says June Sharkey, who has worked as a nurse for 27 years.
“They listened to what I had to say about one of the most costly
decisions to be made in the unit.”
“I know what nurses need because I
am a clinical nurse too,” says Quintero, who has 25 years of hands-on
nursing experience, including 20 years as military nurse in Texas at the
Air Force’s largest hospital.
However, changes in the environment may
have unknown consequences for nurses, says John Scala. “Until you
build it and live in it, you don’t know how it works,” he
says. “We work at a high stress level anyway, but now we have to
explain everything we are doing to everyone and act as both educator and
psychologist. The thing that makes it okay is that we all know it is the
right thing to do.”
The adjustment can take some time. “It
was difficult at first,” says Angel Sostre, a nurse and the day
shift clinical manager. Recently Sostre came from a trauma ICU in Miami,
where he learned to work fast and on his own. “Having family around
when I want to do procedures took an adjustment on my part. I felt I was
crowding them,” he says. “But once they build a trust in me,
the family will let me do my job. It works as long as we understand the
roles each of us plays.”
Everyone in 2D ICU is adjusting, figuring
out what works and what doesn’t, and where the limit exists for
just how much nurses can do, says Samuels.
“In trying to establish a new standard
for providing care for these critically ill patients and their families,
we are all pushing the envelope,” Samuels says. “Creating
this new culture doesn’t have a beginning and an end: it’s
a process, and it’s an extremely challenging one at that.”
||Bedside nurses like
Leanne Breshears and John Scala are the eyes and ears of the
care team. Says Angela Drummond, "I question, I ask, I
it to the next level
In a sense, 2D ICU is a demonstration unit that is transforming the culture
of patient care, says Susan Grant, chief nursing officer for Emory Healthcare.
The lessons learned here will help shape the form that future intensive
care units in the proposed new Emory Hospital complex will take.
“Having family members in a unit 24/7
changes clinical practices, challenging the old way of doing things,”
says Grant. “It is not a small thing.”
But just as family-centered health care,
along with new technology and better designed physical space, improves
outcomes, so does the evolution of nursing practice.
Grant herself began her professional career
as a bedside nurse at Emory. In the 20 years since, as a nurse and nursing
administrator serving in educational institutions across the United States,
she has witnessed firsthand the changing profession. “We are far
beyond Florence Nightingale’s day, for sure, but we have gone miles
beyond what nursing was even five years ago,” she says. The professional
practice of nursing now is responding to and being proactive around technology,
research, medical advancement, reimbursements, regulations, risk aversion,
and disease management, Grant says. Nursing as a discipline needs especially
to be more central to the health care administrative process.
For all those reasons, Grant is taking nurses
throughout Emory Healthcare on the kind of progressive journey that neurocritical
care has navigated. She is seeking to have the entire Emory Healthcare
system awarded “magnet” recognition, bestowed by the American
Nurses Credentialing Center. Magnet status is exceedingly hard to come
by. Only 11 health care systems have been so designated since the program
began more than 20 years ago. Only 4% of U.S. hospitals—238 out
of 5,764—have earned these credentials, which may take up to seven
The magnet program is designed to provide
consumers with the ultimate benchmark by which to measure the quality
of care offered by nurses, and by extension, their institution. “This
is not window dressing. High nursing standards really improve patient
care,” says Grant, who in a previous position led the University
of Washington Medical Center through two renewals of credentialing for
the magnet program.
“In many ways, issues of patient safety
have really forced this movement,” Grant says. “To address
them, health care is learning a lot from aviation and other high-risk
industries. To ensure safe flight, everyone on the flight team—not
just the pilot—has to be able to say something is not right when
it deviates from the routine standard of care.”
Emory Healthcare has already instituted
a “shared decision making” structure across its system to
include input from workers at all levels as well as from families. And
on the floors, nurses are engaged in “unit practice councils”
that identify practices that could be improved and then determine how
to make that happen.
Angela Drummond leads the effort in the
neuro ICU. The 13-member council has identified bloodstream infections
ventilator-associated pneumonia as two areas of concern. Nurses have researched
the existing rates, matched these to national averages—“too
high,” Drummond says—and are now seeking ways to lower the
incidence. In the space of just two meetings, they have found that two
very low-cost yet high impact solutions will help: proper hand-washing
on the part of all clinical staff and mouth care for patients every four
“This encourages nurses to practice
evidence-based nursing, and we are all excited about it,” Drummond
says. “We are working hard to get the number of those infections
down, which will improve outcomes.”
Magnet designation also comes when nurses
develop professionally, and on that score, Emory has a good leg to stand
on, says Grant, who also serves as the first assistant dean for clinical
leadership at the Nell Hodgson Woodruff School of Nursing.
“As far as nursing education goes,
you can do anything at Emory Healthcare,” Drummond says.
The neurocritical care nurses seem to take
that slogan to heart. Of the 87 registered nurses working in the three
ICUs, nine are taking graduate courses, and six are studying to be nurse
Ironically, a commitment to staff advancement
also has the potential to create rapid turnover in nurses and even shortages—the
very thing professional development is supposed to bring to an end, says
Sharkey, who spends a lot of her time training new nurses.
Part of the challenge on this frontier of
transforming health and healing, then, is to balance new empowerment and
knowledge for nurses with the traditional hands-on care they deliver at
the bedside. That will create the strongest kind of magnet for patients
and nurses alike.
“This is a more humanized kind of
health care,” Drummond says. “The feeling now is that we are
all in this together.”
about the neuro ICU
Renee Twombly is a freelancer
who writes frequently on health care topics.