A Nurse responds to the SCCM article on Critical Care in Underserved Areas

May is National Critical Care Awareness Month in USA.

and the campaign is to “turn your ICU blue”

hey, read my second book

might as well include a link to my second book, The Sacrament of the Goddess, a novel about hospitals in Nepal ( among other things.)

Everyone needs to read this

It was only a couple of weeks ago that I came across the excellent article Defining the Need for Critical Care in Underserved Areas by David J. Dries, MD, MSE, MCCM.  It was published Feb 2014 in Critical Connections, the journal of The Society for Critical Care Medicine. I highly recommend this article to all my colleagues in Nepal, both in medicine and nursing.

Shift in focus is happening now, in real time

The article starts off by acknowledging the shift to more acute services in hospitals in Low Income Countries. Nepal might as well be a poster child for this phenomenon.  It seems everyone has just started an ICU, and nurses are getting hired to work specifically in critical care. This is taking place throughout Nepal, and there is great demand for critical care nurses.

Eventually these skills will be integrated into the curriculum of the nursing schools, but for now? the schools do not generally include these topics. The nurses who enroll in my courses, and the hospitals that support my training, are propelled to learn new skills because of the need. I have written about seventy blog entries on this. I’m sure to write more.

The main thing I like

the most important point of the CCM article is stated a bit obliquely.  A critical care unit is defined by the training of the nursing staff, not the qualifications of the doctor(s) who leads it, and not even by the presence or absence of items from an inventory of equipment.  (okay, you do need such things as oxygen and suction – but – beyond that? the list is more flexible than you may think)

Medicine and Nursing at the “organized” level

Another item worthy of note is the deference to nursing implied in this CCM article. In USA, the SCCM has a parallel organization for nurses – The American Association of Critical Care Nurses (AACN). the AACN publishes voluminous information on standards;  for training;  certification and procedures. The primary mission of AACN is to promote and advance critical car nursing in USA, and I do not think they have focused on Underserved areas.  Like most nursing organizations in USA, when AACN thinks about needs of nurses in Underserved Areas ( i.e., Low Income Countries) it is still stuck on the previous paradigm in place before this recent shift to more acute services. Very few nurses in AACN are informed by direct experience working at the bedside alongside their foreign colleagues. the few doctorally-prepared nurses who go abroad tend to interface with policymakers, or else focus in delivering primary care services.

In that sense, I think that there is still a gap even after the SCCM article. The SCCM does not focus on nurses. The author may be waiting for nurses to come up with a companion article that fills in the implied gaps. They are showing the professional courtesy to nurses by reserving direct commentary about nursing, for nurses to deliver. When I read the materials from AACN, I see that the Standards are not written in a “prescriptive” way.  I do not think this is as helpful as it could be. In Low Income Countries, we do need a more specific description as to what is needed. We need to find a dozen or so items and separate them from the thicket of standards.

A Nurse replies

here would be my list of practical,  boots-on-the-ground things that define whether the critical care area is functional. You can take this list and make a checklist out of it to assess the ability to function, the learning needs, etc. In my view, if you don’t have these, you don’t have an ICU.

1) at all times, there is a nurse available who can identify Ventricular fibrillation; initiate the team response; and use the defibrillator safely.

2) all staff are trained in CPR.

3) all staff can identify ecg rhythms‎ at least to the level of “the basic six rhythms”

4) there is a standing protocol for nurses to treat ecg rhythms while waiting for the doctor to arrive, or in the absence of the doctor.

5) nurses use vaso-active drips and assess for intended effect as well as side-effects. Nurses give all IV push drugs using procedures recommended by current pharmacological references. (duration, dilution, compatibility, etc)

6) nurses are trained to do fluid volume resuscitation, including transfusion.  Nurses can do a complex I & O. Nurses routinely listen to lung sounds and can identify what they hear.

7) nurses can maintain an airway, including endotracheal tube and using a bag-valve-mask.

8) nurses can identify proper “phasing in” during mechanical ventilation.

9) nurses use a “VAP Bundle”  including sterile suctioning technique.

10) nurses in all departments are aware of “failure to rescue” and there is a plan to identify at-risk patients prior to arrest.

11) ‎nurses know the chest pain protocol.

12) oxygen, suction and pulse oximetry are available at all times.

13) for all biomedical equipment in place, there is a maintenance and repair plan, and an adequate supply of nonreusable disposable parts ( such as stick-on pads for ecg monitoring in the case of ecg)

This list can serve as a jumping off point. If you are any kind of outsider who is being asked to assess the nurse’s knowledge, start by asking about these things.

Does Your ICU do this?

take this list and do a self-assessment. My own assessment has been that not all ICUs are at this stage.


If any reader can point me to a better list, or even just one point to add, please let me know.











About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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3 Responses to A Nurse responds to the SCCM article on Critical Care in Underserved Areas

  1. Pingback: Why not certify ICUs in Nepal? July 2015 | CCNEPal 2015

  2. Marie Michaud says:

    I would add to 6) Observe the patient’s respiratory status, use of accessory muscles, anterior and posterior auscultation, anxiety associated to breathing difficulties, and implement best positioning, and reassuring techniques, as well as oxygen needs, besides call for medications; this can delay or even prevent emergency intubation when done ahead of a crisis

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