Where does critical care begin and end? The term has become a moving target over the last decade, as the hospitalized patient is now more acutely ill. Patients who were cared for on the nursing floors are now at home with home health nurses. Patients who were in the ICU are on the telemetry floors, and those who in the past didn't survive are now our ICU patients.
I look at the complexity of the medical-surgical patients and I'm impressed with the skills of the nurses on these units. Their ability to deliver critical care isn't limited by their knowledge, but by time. A nurse with five other patients can't monitor one patient every 15 minutes for a prolonged period of time. Such a level of intensity requires movement of the patient. How he or she is identified as a critical care patient in a medical-surgical unit varies from institution to institution.
A patient may be identified as requiring critical care by the rapid response team (RRT). Rapid response teams bring critical care to patients wherever they may be. The composition of the RRT typically includes critical care staff, whether it's a nurse, respiratory therapist, mid-level provider, or physician. An important goal is to reduce the delay in delivering critical care. Success may require that the team, in collaboration with the bedside nurse, provides critical care to a patient at his or her current location until a critical care bed becomes available. Whether or not this step translates into improved patient outcomes is still unclear, but intuitively, it makes sense.
It's important that critical care nurses partner with their colleagues throughout the hospital to identify critically ill patients. The Surviving Sepsis Campaign is an excellent example of such partnership. One of the reasons the diagnosis of severe sepsis may be delayed is because the patients are part of a heterogeneous population and can be located anywhere in an institution. Educating both our nursing and medical colleagues of the signs and symptoms of severe sepsis can change the outcomes for this patient population with the timely administration of early goal-directed therapy. The goal of early identification can link back to the RRT, if facilities provide the team with tools to screen and evaluate this patient population. Each call to the RRT is an opportunity to educate our colleagues outside of the ICU to identify patients that require a higher level of care.
Another indication that critical care has moved beyond the four walls of the ICU is the types of medications being administered outside of the ICU. Drips that were previously reserved for the ICU are now on the telemetry floors, requiring nurses to be knowledgeable about indications, titration, and side effects. Nevertheless, one important caveat is not to lose sight of the frequency or intensity of nursing assessment that's required to safely administer these medications. Critical care medications can be safely administered outside the ICU, provided that the appropriate level of monitoring is present. As the pressure for beds increases, it sometimes falls to the frontline staff to be this last line of safety and defense against the potential dangers of moving a critical care medication outside the ICU.
Nurses are the most qualified professionals to discuss the safety and reality of being able to provide an increased level of care for a patient without a subsequent change in nurse-to-patient ratio. Sharing our knowledge and expertise is paramount to keeping our patients safe and delivering the appropriate critical care wherever they may be.
Kate J. Morse, RN, CCRN, CRNP, MSN
Editor-in-Chief, Director of Nurse Practitioners Chester County Hospital West Chester, Pa.