NURSING COLUMN
Neurocritical Care at Harborview Medical
Center Exemplifies Interdisciplinary
Collaboration: From the Delivery of Care to
the Design of Care
By Patricia A. Blissitt Ph.D., ARNP-CNS, CCRN, CNRN, SCRN, CCNS, CCM, ACNS-BC
Harborview Medical Center (HMC) in
Seattle, Washington, is an exceptional place
to practice neurocritical care nursing. The 413
bed academic medical center is one of four
University of Washington Hospitals. Critically
ill neuroscience patients from Seattle and
beyond receive neurocritical care in the 30
bed neuro ICU or the medical cardiac, trauma
surgical or burn pediatric ICU depending on
their primary needs. HMC is the only Level I trauma center for
a four state area — Washington, Alaska, Montana and Idaho —
and the only Joint Commission Certified Comprehensive Stroke
Center in Washington State.
Nurses that provide care to the patients at HMC have an active
voice in the care of the patient, from presentation of the patient
during interdisciplinary rounds to the development of the plan of
the day for each patient. Nurses may independently request ethics
consults and also have access to palliative care service as needed.
The two neurocritical care teams consists of physicians and nurse
practitioners from neurocritical care, neurology and neurosurgery,
a respiratory therapist, registered dietician, rehabilitation
therapists, a physiatrist, a social worker, and the direct care nurse
and charge nurse. Neurohospitalists and acute care neuroscience
nurse practitioners also round with the neurocritical care teams
to ensure a smooth transition to acute care. The neuroscience
clinical nurse specialist is available as needed for nursing or
interdisciplinary consults.
The neurocritical care nurses actively participate in a number of
continuous quality improvement activities and scientific studies,
some nurse-led and others directed by other team members. The
neuro ICU nurses recently participated in an international nurseled
study to validate a behaviorally based observational tool to
assess pain in critically ill cognitively impaired neuroscience
patients. More recently, they provided input for the development
of a “smart,” non-gravity-based, external ventricular drainage
system and will be trialing the device to evaluate its performance
and safety.
Several physician-led investigations to improve the outcome of
critically ill stroke patients involve the HMC neurocritical care
nurse. One of those studies looks at the efficacy and safety of
intraventricular administration of a biodegradable polymer-based
sustained-release microparticle containing nimodipine versus
standard administration of Intraventricular administration may
lessen the hypotension associated with enteral nimodipine. The
nurse is key to the early recognition of deterioration related to
delayed cerebral ischemia as it may or may not occur in this study.
Another study involves the neurocritical care nurse in the
intravenous administration of deferoxamine mesylate (DFO).
Deferoxamine is thought to facilitate the removal of the iron
accumulation in the brain from intracerebral hemorrhage and
improve outcomes. A multicenter randomized controlled trial,
involves the intravenous administration of natalizumab, a
monoclonal antibody that is currently used in the management of
multiple sclerosis and Crohn’s disease but has been postulated to
reduce infarct size in acute ischemic stroke.
The neuro ICU nurses at HMC have led the way in a quality
improvement initiative regarding early mobility. The nurses were
awarded a grant from the American Association of Critical Care
Nurses Clinical Scene Investigator initiative to design and trial an
early mobility program with patients in the neuro ICU.
Physician partners, physical and occupational therapists, patients
and families were involved in the development of the mobility
program. The daily shift report sheet was modified to include the
patient’s mobility status. A daily huddle between the neuro ICU
charge nurse and the lead rehabilitation therapist was initiated.
This information is presented to the interdisciplinary team during
daily rounds to facilitate early mobility. Benefit versus risk is
carefully considered in patients with actual or potentially unstable
intracranial dynamics.
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