At Hoag Hospital in Newport Beach, California, our high census meant some critically ill patients had to be held in the emergency department (ED), postanesthesia care unit (PACU), or medical-surgical units. To ensure we delivered the same level of care to critically ill patients no matter where they were admitted, we created a critical-care (CC) resource nurse position. This position is staffed by a registered nurse from the neurocritical care and coronary care/cardiovascular intensive care units.
The priority of the CC resource nurse is to provide immediate interventions to patients who require the sepsis protocol or other acute critical-care management outside the critical-care unit (CCU)—anywhere except the neonatal intensive care unit.
How the role evolved
For the past 10 years, Hoag Hospital has attempted to implement and maintain a successful hospital-wide sepsis recognition and treatment protocol based on early goal-directed therapy. When we found we weren’t meeting our initial goals, we organized a multidisciplinary team to analyze the program. The team identified areas for improvement, designated key process owners to promote intervention bundle compliance, and tracked measurement and outcome data. Subsequently, our sepsis treatment improved and patient mortality decreased.
Approximately 95% of sepsis patients received in our units are admitted to the hospital through the ED. Thus, the initial focus of the CC resource nurse was to respond to the ED, begin goal-directed therapy, resuscitate the patient before organ failure began or progressed, and avoid the need for CCU admission. We believed this strategy would reduce the intensity of resources needed, lower overall costs, decrease lengths of stay (LOS), and reduce sepsis mortality.
Expanding the scope
Over time, we expanded the role beyond managing sepsis patients in the ED to caring for ED patients who are hemodynamically unstable and require pressure lines; have had a stroke and need tissue plasminogen activator; have been held in the ED for prolonged periods; or require electrocardiographic (ECG) monitoring, infusion and titration of critical-care drugs, ventilator management, hemodynamic line placement, hypothermia protocol, or transvenous pacemaker insertion.
We also expanded the scope of the CC resource nurse to all patient-care areas, whether inpatient or outpatient. If a patient isn’t doing well on a regular unit, the unit nurse first calls the rapid response team (RRT). The RRT nurse contacts the CC resource nurse for assistance if she believes the patient is septic, has respiratory distress, is hemorrhaging or hemodynamically unstable, requires induced therapeutic hypothermia, or is having an acute stroke. Along with other RRT members, the CC resource nurse manages the patient pending transfer to a higher care level.
After initial response and assessment, the resource nurse initiates evidence-based interventions, such as early goal-directed therapy, ECG monitoring, and chest X-rays. She also contacts the intensivist or other appropriate physician for orders to prevent further patient deterioration, such as central line insertion, rapid infusion of fluids or blood products, or intubation.
When the patient census is high and a CCU bed is needed, the CC resource nurse stays with the patient until a CCU bed is available. Then she accompanies the patient to the bed, completes handoff to the receiving nurse, and confirms that the team understands interventions and goals for the patient. She then continues hospital-wide rounds and follows up on patients as appropriate.
Tracking the at-risk population
The hospital uses preprinted order sets to track performance in treating at-risk patients (such as those with stroke, acute myocardial infarction, and post-arrest hypothermia). We also provide ED orientation to ensure that CC resource nurses know the location of all necessary equipment and supplies and understand patient flow throughout the ED. This enables them to work in tandem with ED nurses and ensures that diagnostics tests, I.V. fluids, and antibiotics begin as soon as possible.
A day in the life
At the start of the shift, the CC resource nurse signs in and retrieves a phone and a beeper, then begins rounds in the ED, PACU, and mother-baby unit. She continues to round on the other nursing units, speaking with each charge nurse to address patient concerns that require follow-up. This gives her a chance to learn about patients who need assessment or intervention. Also, she is responsible for inspecting the immediate ED area and sepsis supply cart to identify missing supplies and make sure anything missing is replenished and ready to use.
At the end of the shift, she returns the phone, beeper, and paperwork to the staffing office and updates the RRT nurse on all patients needing continued assessment and follow-up over the next 12 hours. She documents this information on a log sheet and identifies calls made on the previous shift, patients who required intervention during the last shift, and those who require follow-up on the next shift. Once the CC resource nurse signs out for the night, the RRT nurse responds to all RRT and sepsis calls until the CC resource nurse returns the next day. (See Responding to a call by clicking the PDF icon above.)
Required background
At Hoag, a CC resource nurse must be a critical-care nurse with at least 1 year of experience (preferably 2 years) and must be certified in both basic life support and advanced cardiac life support. She should have experience as an RRT and a “code blue” nurse, with the ability to manage patients who need extensive invasive interventions (central lines) and emergent respiratory support. Besides functioning independently and adapting well to diverse environments, the CC resource nurse must demonstrate excellent critical-thinking skills and problem-solving ability.
The payoff: Better outcomes
Outcome data for the first quarter of 2011 show that focused, dedicated early interventions provided by our CC resource nurses have decreased overall morbidity and mortality. “Code blue” incidents outside our CCUs have dropped 50%. Compliance with the lactate intervention bundle component has reached 100%. Antibiotic administration compliance has risen to 98.4%, and fluid-bolus bundle compliance is up to 67.3%.
In 2007, our critical-care cost per case was $28,053; for 2011, the year-to-date cost per case is $21,427. In 2007, critical care LOS was 4.64 days; for year-to-date 2011, LOS is 2.55 days. Overall LOS for all units decreased from 13.11 to 8.78 days. Mortality for all clinically identified cases that remained on protocol is now 8.9%. Overall hospital mortality is 15.45%, which includes patients with do-not-resuscitate orders. For 2011, our goal is to increase compliance with each measure by 10%, including fluid and antibiotic administration within the first hour of management.
Selected references
Boschert S. Is it septic shock? Check lactate level. ACEP: Clinical & Practice Management: ACEP News. 2007 Nov:1-3. http://www.acep.org/content.aspx?id=33984. Accessed September 30, 2011.
Institute for Healthcare Improvement. Implement the sepsis management bundle. http://www.ihi.org/knowledge/Pages/Changes/ImplementtheSepsisManagementBundle.aspx. Accessed September 30, 2011.
Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96.
Wang, HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med. 2007 Aug;35(8):1928-36.
Visit www.AmericanNurseToday.com for a complete list of references. Click the PDF icon above for a resource nurse tracking tool, and a resource nurse evaluation form.
When this article was written, Molly Hewett was an assistant vice president of nursing at Hoag Memorial Hospital in Newport Beach, California. Currently, Deborah Lepman is the department director for cardiac CCUs at Hoag, and Jodi Caggiano is a sepsis nurse coordinator at the same hospital.
