ICU/CCU Only

Competencies

Read Johns Hopkins MHA Keystone ICU

Project module
Complete Hemodynamic Monitoring and ICP
Monitoring self learning modules before
attending agency nurse orientation class
Verbalization/Demonstration of arterial
line/Swan Ganz and ICP set-up with
verbalization of normal values during
agency nurse orientation class
General ICU exam covering all systems,
including medication calculations
Attendance at 4-hour Pain Management Class
for GCH epidural certification must register
for class
Review Post Cardiac Arrest Therapeutic
Hypothermia module

Johns Hopkins
MHA
ICU Keystone
Project
Compiled by:
Professional Nursing Development

SK/VA 03, Revised 1/10 FC

Overview
In November 2003, Garden City Hospital became a participant in a two-three year
Johns Hopkins/ Michigan Hospital Association ICU Keystone Project along with 58
other Michigan hospitals, which is an ongoing culture change of practice in medicine and
nursing. The project is being conducted to improve patient safety and communication
among caregivers in association with the US Department of Health and Human Services
Agency for Healthcare Research and Quality, Johns Hopkins University, and the Institute
of Healthcare Improvement (IHI).
The objective of the project is to implement evidence-based medicine and nursing and
reduce the risk of medical errors:

Implementing the use of specialists who coordinate ICU care with a checklist
approach to daily rounds that encourages communication among multiple
caregivers.
Multidisciplinary rounds/patient goal setting form (see attached) is done
daily and left at the bedside.
Attempting to eliminate bloodstream infections.
Improving care of ventilator patients to reduce dependence on the breathing
apparatus, which is a key factor in reducing length of stay and infections.
Accomplished through interventions called vent bundling.
~ bundling refers to the interventions specified ~
Developing skills to sustain care of patients with severe infections
Early recognition: Emergency Department, Medical/Surgical units,
Obstetrics, etc
Sepsis: Early goal directed therapy
Communication & Symptom Management
Family Centered Care
Developing a comprehensive patient safety program that includes a web-based
error reporting system (ICU only) Completed in 2005.

Please visit the web sites:

http://www.MHA.org
http://www.josieking.org/memories.html
http://www.mharchives.org/ICU/projectoverview.asp

Johns Hopkins MHA ICU Keystone Project Interventions

Intervention 1: Cultural Unit Based Safety Program (CUSP):
Patient Safety Initiative
Advocates safety for healthcare providers and patients by participating in:

Cultural safety survey to identify staffs safety concerns

Daily walking rounds with all healthcare providers.

Briefing process

Report session at change of shift with Resident/Charge Nurses

Reporting errors and follow-up on quality reports

Investigate defect: Staff identify defects in frontline caregivers

Implementation of improvements

Disseminating results of the survey and reports

Medical rounds assigned

Executive walking rounds

CEO executive summary (ICU, Progressive and Acute Care)

Intervention 2: Daily Goals and Rounding

(Goal: To be a permanent part of the chart)
Evaluates the effect of interventions & to improve communication by utilizing the Daily
Goals Sheet (see attached sheet) during multidisciplinary team rounding to determine:
Safety risks

Discharge needs

Scheduled labs/tests

Progression of interventions as set

Forth by JHH/MHA

Family/social issues

Pain management and sedation

Cardiac status

Consultations

Implemented on 1 East (oncology/medical) & 2C/N (acute/progressive care)

Intervention 3: Ventilator Bundle

(ICU, Progressive and Acute Care)
For mechanically vented patients (refer to standing order sheet for adult mechanical
ventilated patients):

HOB >30 degrees to reduce the frequency and risk for nosocomial pneumonia

Oral care protocol every 2 hours and PRN.

Thromboprophylaxis to prevent deep vein thrombosis (DVT)

Peptic ulcer disease prophylaxis to reduce the risk of UGI bleeding

Daily interruption of sedative drug infusions to decrease the duration of

mechanical ventilation and length of stay

Intensive insulin therapy: Goal is to maintain blood glucose 100-139mg/dL to

reduce morbidity and mortality among critically ill patients.
Tight glycemic control protocol (see attached copy) may be instituted if
criteria are met:
Patient must be on a ventilator
Two consecutive blood glucose results of >139 mg/dL or one blood
glucose >200 mg/dL, would initiate an order for an insulin drip
Intensivist/ICU Resident order

Daily screening of respiratory function followed by trials of spontaneous breathing to

reduce the duration of mechanical ventilation, decrease complications and cost of care

Intervention 4: Eliminate Catheter-Related Blood Stream Infections

(CR-BSI) Hospital wide intervention
Compliance with the following interventions will decrease the risk for CR-BSIs:

Appropriate hand washing: Proper hand washing is required before and after
palpating catheter insertion sites, as well as before and after inserting,
replacing, accessing, repairing, or dressing an intravascular catheter

Mandatory use of protective covering for all healthcare providers: Sterile

gown, sterile gloves, face shield with mask. Stop procedure if indicated
until sterility observed.

Use of full-barrier precautions for patient: Full body drape head to foot.

Use of chlorhexidine for skin preparation: Located in all sterile dressing kits
and central line kits

Apply sterile dressing to site with all dressing changes

Subclavian vein placement is the preferred site: Attempt to avoid the femoral
site

Removing unnecessary central venous catheters

Intervention 5: Improvement in Sepsis Care:

Intervention ensures patients receive optimal care by improving sepsis care
(Refer to attached Severe Sepsis journal article & Standing order sheet for Severe Sepsis)

Prevention: hospital acquired infections such as catheter related blood stream

infections, ventilator-associated pneumonia, surgical site infections, and
urinary tract infections.
Early goal directed therapy (EGDT): proactive approach in patients with a
known or suspected infection.
Appropriate intervention: antibiotics, steroids, activated protein c

Continuum of sepsis:

Systemic inflammatory response syndrome (SIRS)

Sepsis (known or suspected infection)
Severe Sepsis (Sepsis and one or more organ system dysfunction)
Septic shock (Severe sepsis plus hypotension)

What is Early Goal Directed Therapy (EGDT)?

Early goal directed therapy to restore a balance between oxygen delivery and oxygen
demand are provided during the first 6 hours of suspected or known infection. Patients
may be given intravenous fluids (colloid or crystalloid), vasoactive agents, and blood
transfusions to increase oxygen delivery. Early identification of severe sepsis is critical
to provide EGDT and improve patient outcomes.

Who is at risk for Severe Sepsis?

All critically ill patients
Severe community acquired pneumonia
Urinary tract infection
Chronic Diseases
o Diabetes
o Heart failure
o Chronic renal failure
o Chronic obstructive pulmonary disease
Intra-abdominal surgery
Meningitis
Compromised immune status
o HIV/AIDS
o Use of cytotoxic and immunosuppressive agents
o Malignant neoplasms
o Alcoholism
Cellulitis

Criteria for Early Goal Directed Therapy (EGDT) for

Severe Sepsis and Septic Shock
1. Two or more signs of inflammation:
Temperature >100.4 F (38.0 C) or < 96.8 F (36 C)
Heart Rate >90 beats per minute
Respiratory Rate >20 breaths per minute or PaCO2 <32 mmHg
WBC >12,000 cells/mm3, <4000 cells/mm3, or >10% bands
2. Suspected or confirmed infection.
Positive cultures (blood, sputum, urine, etc.)
Antibiotic, antifungal, or other anti-infective therapy
Documentation of pneumonia (x-ray, ultrasound, etc.)
Have WBCs been found in normally sterile fluid
Perforated organ (bowel)
3. Systolic blood pressure <90mm Hg after fluid bolus (Septic shock)
Lactate > 4 mmol/L
Evidence of > 1 organ dysfunction (Severe sepsis)

References
Ely, E.W. & Bernard, G.R. 2005. Contemporary Diagnosis and Management of Sepsis
Ahrens, T. & Tuggle, D. 2004. Surviving Severe Sepsis: Early Recognition and Treatment. Critical Care
Nurse Supplement October 2004.
Severe sepsis overview. http://www.xigris.com/overview/at

Diagnostic Criteria for Sepsis

Infection, documented or suspected, and some of the following:
General variables
Fever (core temperature >38.3 C)
Hypothermia (core temperature < 36 C)
**Heart rate >90 min 1 or >2 SD above the normal value for age
Tachypnea
Altered mental status
Significant edema or positive fluid balance (> 20mL/kg over 24 hours)
Hyperglycemia (plasma glucose > 120 mg/dL) in the absence of diabetes
Inflammatory variables
Leukocytosis (WBC > 12,000 uL)
Leukopenia (WBC < 4000 uL)
Normal WBC count with > 10% immature forms
**Plasma C-reactive protein > 2 SD above the normal value
**Plasma procalcitonin > 2 SD above the normal value
Hemodynamic variables
Arterial hypotension (SBP< 90 mm Hg, mean ABP < 70, or a SBP decrease > 40 mm Hg)
Mixed venous oxygen saturation > 70%
Cardiac index > 3.5 L/min
Organ dysfunction variables
Arterial hypoxemia (PaO2/FIO2 <300)
Acute oliguria (urine output <0.5 mL/kg/hr or 45 mmol/L for at least 2 hrs
Creatinine increase >0.5 mg/dl
Coagulation abnormalities(international normalized ratio >1.5 or activated partial thromboplasm time>60)
Ileus
Thrombocytopenia (plt count < 100,000 uL)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 mmol/L)
Tissue perfusion variables
Hyperlactatemia (>1 mmol/L)
Decreased capillary refill or mottling
** SD: Standard Deviation: A parameter that indicates the way in which a probability function or a probability density function is centered
around its mean and that is equal to the square root of the moment in which the deviation from the mean is squared. (Standard Deviation (SD) is not
reported on the lab report. To obtain SD lab personnel may be contacted)

Intervention 6: Communication & Symptom Management

Intervention that encourages promoting a family-centered environment.
Provide family with information, reassurance/support, and opportunity to be near
the patient.
Obtain clarification about how to meet the needs of the family by asking the
family members.
Integrate family-centered values in the units standards and policies
Provide family with ICU patient brochure
Be consistent with patients families
o Visiting hours
o Pain management
o Treatments
Make family-centered care a multidisciplinary group endeavor
o Physicians
o Nurses
o Respiratory Therapist
o Case Managers
o Dietary
Discuss challenging cases/concerns at staff meetings and committees.

Documentation Reminders
Completion of daily rounds sheet
Daily interruption of sedative drug infusions (wake-up call)
& assessments
Pain assessment/management q2h
Oral care q2h
Communication & Symptom Management

References
http://www.MHA.org
http://www.josieking.org/memories.html
http://www.mhaarchives.org/ICUgrant/projectoverview.asp
Michigan Health & Hospital Association Members Join Johns Hopkins to Enhance ICU
Safety. Michigan Health & Hospital Association Newsletter. October 22, 2003
Pronovost, P., and Berenholtz, S. Inproving Sepsis Care in the Intensive Care Unit: An
Evidence-Based Approach. VHA Research Series 2004

Garden City Hospital

Critical Care Services
Tight Glycemic Control Protocol
PURPOSE: The goal is to maintain a blood glucose range between 100-1
39mg/dL Regular Human Insulin Concentration =l00units/l00mL 0.9%
NaC1
SUPPORTIVE DATA: Hyperglycemia associated and insulin resistances are
common in both diabetic and non-diabetic critically ill patients. Studies
have reported substantially reduced morbidity and mortality in patients
admitted to the intensive care unit for mechanical ventilation who had
tight glycemic control (some literature presents 80-1 l0mg/dL).
Significantly fewer deaths due to multiple organ failure with sepsis
occurred with intensive insulin therapy and the length of stay for patients
requiring more than five days of intensive care was substantially reduced.
Bloodstream infections, critical illness, polyneuropathy and duration of
mechanical ventilation were all significantly lower in patients who had
tight glycemic control. Recent studies supporting these findings have
further defined these benefits by demonstrating a definite relationship
between increasing morbidity and mortality and increasing blood sugar
levels.
AOA 29.00.01 Special care Units (SCU): Special care Units exist to provide the
focused use of intensive staff and technologic resources for
patients.
AOA 16.03.00 Standards of Practice and Care: Nursing care is based upon
written
standards of practice and standards of care.
DOCUMENTATION: Document blood glucose levels and rate changes on
Nursing Insulin Flow Sheet. Documentation should include the amount of
the rate change as well as the new drip rate.
SCOPE: RN ICU-CCU
PATIENT POPULATIONS:
1. ICU patients with anticipated ICU stays of greater than 24-48 hours.
2. The protocol does not apply automatically to patients with diabetic
ketoacidosis hyperosmolar-nonketoacidosis, but may be used for such
patients at attending physicians discretion.
3. Adult patient receiving mechanical ventilation in a critical care bed.

4. Diabetic and non-diabetic patients are eligible.

5. Discontinue all previous insulin orders including insulin in total parenteral
nutrition.
6. Discontinue all antidiabetic medications.
EXCLUSION:
1. Hematocrit <20% or >55% (lab draw is required in these patients due to
limitations of bedside glucose meter).
INITIAL ASSESSMENT:
1. On admission to the ICU and at a minimum once daily, all patients will have
baseline blood sugar ordered. If over 1 39mg!dL, repeat xl after two hours.
2.Assess for:
History of DM
Obesity
How much glucose patient is getting from diet, 1Vs, IVPB, etc.
Medications (steroids, anti-diabetic medications)
Nutrition Support
CRITERIA FOR INITIATION OF PROTOCOL
REQUIRES PHYSICIAN ORDER and one of the following:
1. Two blood glucose values greater than 139 mg/dL or;
2. One blood glucose value greater than 210 mgIdL
3. Unstable blood glucose values on sliding scale
TRIGGERS FOR DISCONTINUATION OF PROTOCOL/CONVERSION TO
LONG OR INTERMEDIATE ACTING INSULIN PLUS SLIDING SCALE
(REQUIRES PHYSICIAN ORDER).
1. Patients ability to eat and is eating, has received their 1 dose of subcutaneous
insulin or when patient is normoglycemic while receiving < 2 units per hour.
2. Glucose less than 8Omg/dL x 3 consecutive measurements.
3. Glucose less than 140 mg/dL on stable insulin dose for more than 12 - 24
hours.
4. Notify physician of any or all of the above. Ask physician to consider
discontinuation of insulin infusion and initiation of longer acting insulin and
sliding scale coverage when infusion rate and blood glucose is stable for 12 24 hours.
ADMINISTRATION
1. Standard insulin drip = 100 units regular human insulin in l00ml 0.9% NaCL.
2. Administer insulin via an infusion pump.
3. Insulin drip must be changed at least every 24 hours.
INITIAL DOSE
1. Bolus and infusion rate=Blood Glucose divided by 100.

2. Round to nearest 0.5 unit (nearest half of a unit). For example: If a patient has
a blood glucose = 258, Initial bolus = 2.5 units
Initial infusion rate = 2.5 units per hour
Initial Blood Glucose (mg/dL)
Initial Bolus
Initial Infusion Rate (100 units regular insulin/100 mL NaC1)

Initial Blood Glucose (mg/dL)

Initial Bolus

140 - 175
176 - 225
226 - 275
276 325
326 375
> 376

1.5 units
2 units
2.5 units
3 units
3.5 units
4 units

Initial Infusion Rate (100

units regular insulin / 100
mL NaCl)
1.5mL / hour
2 mL / hour
2.5 mL / hour
3 mL / hour
3.5 mL / hour
4 mL / hour

KEY POINTS:
1. If blood glucose falls 50 mg/dL between 2 consecutive readings and current
blood glucose is 200mg/dL: decrease insulin drip by 50% (round up to the
nearest 0.5 units).
2. If blood glucose falls> 50 mg/dL between 2 consecutive readings and current
blood glucose is > 200 mg/dL: continue insulin drip at the current rate.
3. Notify ICU Resident/Intensivist if Blood Glucose> 400 mg/dL or if there is a
change >100 mg/dL in one hour.
FREQUENCY OF TESTING:
While insulin is infusing, either finger sticks (bedside glucose testing) or serum
glucose measurements should be taken every hour X 4. Then glucose checks
can be reduced to every 2 hours until 4 consecutive values remain in the desired
range with no change in infusion rate, then glucose checks can be reduced to
every 4 hours. Every 2-hour testing should be continued or resumed if any of the
following occur: changes in clinical condition, changes in nutrition, and changes
in steroid or pressor therapy. STAT blood glucose should be checked if patient
shows sign of hypoglycemia.
NUTRITION PROTOCOL:
If tube feedings, TPN, or other forms of nutrition are held for >1 hour, hold insulin
infusion; check blood glucose every 6 hours. When nutrition is restarted, resume
insulin drip at the previous rate and resume blood glucose checks as listed in
section entitled, Frequency of Testing.

SPECIAL CIRCUMSTANCES:
Stop insulin infusion if the patient is off the unit for more than 1 hour and blood
glucose monitoring cannot be continued. When nutrition is restarted, resume
insulin drip at the previous rate and resume blood glucose checks at
the previous rate and resume BG checks as listed in section entitled, Frequency
of Testing.
HYPOGLYCEMIA PROTOCOL
In this protocol hypoglycemia is defined as blood glucose < 70mg/dL
If blood glucose <50 mg/dL
Hold insulin infusion
For Patient who is responsive and able to swallow:
1. Give 15gms. carbohydrate po:
1 cup skim milk or cup orange or apple juice. Do not use OJ for renally
impaired patients. Do not add sugar.
2. For patients with blood glucose <50mg/dL., obtain lab draw to confirm
glucose
results, but do not delay treatment.
3. Recheck blood glucose Q 15 minutes X 2.
4. Feed small snacks with protein and carbohydrate ( ie. cheese and
crackers )
5. Investigate cause and call physician.
6. Repeat treatment in 15-30 minutes if glucose remains under 70 mg/dL.
7. Establish IV access if not already available.
For patient who is unresponsive, OR symptomatic, OR on an insulin drip,
OR
unable to swallow.
1. Dextrose 50% - 50ml. ( 25gm ) IV.
2. For patients with blood glucose <50mg/dL., obtain lab. draw to confirm
glucose
results, but do not delay treatment.
3. Recheck blood glucose in 15 minutes X 2, if <70mg/dL, repeat step 1 and
recheck.
4. a. If patient is receiving a long acting product ( e.g. Lantus (glargine ) or
70/30,
run D5W at 100mL/hr X 4 hours.
b. If a patient on a Tight Glycemic Protocol, check blood glucose Q 15
minutes When >100mg/d., wait 1 hour then restart insulin infusion at 50%
of original rate.
5. Investigate cause and call physician.

REFERENCES:
Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin
therapy in critically ill patients. N EnglJMed200l; 345:1359-67.
Evidence Based Rating Scale : Level V
Finney SJ, Zekveld C, Elia A, et al. Glucose control and mortality in
critically ill patients. JAMA. 2003;290:204l-2047.
Evidence Based Rating Scale : Level V
MHA Website
ADA Website, 2008
ADA Nutrition Recommendation and Interventions for Diabetes
Position Statement, Diabetes Care, Volume 31, Supplement I
January, 2008.
Policy and Procedure collaboratively developed and approved by the Critical
Care and Pharmacy and Therapeutics Committees. May 2005
APPROVAL: Critical Care Committee
Pharmacy Department
DISTRIBUTION: Critical Care Unit Based Clinical Policy and Procedure Manual
REVIEW : 8/06, 10/08
REVISION: 1/09

Arterial Line and Swan Ganz Set-up

Competency for Agency Nurse Staff
Name: ________________________________

Date: ________________________

Behavioral Objective:
Demonstrate proper set-up of equipment for arterial lines and Swan Ganz.
Verbalize pressure of each chamber: RAP (CVP), PAP, PCWP.

Competency

Arterial Lines
I.
Verbalize and gather equipment.
II.
Demonstrate set-up pressure line
III.
Verbalize zeroing line after demonstration
of leveling phlebostatic axis
IV.
Verbalize maintaining pressure bag at ___
at all times and flush q ___ hour and PRN
V.
Verbalize method for obtaining blood
specimen from arterial line
VI.
Demonstration calculation of MAP
VII. Verbalize normal arterial SBP and DBP
VIII. Verbalize nursing responsibilities and
troubleshooting
Swan Ganz
I.
Verbalize and gather equipment
II.
Demonstrate set-up pressure line
III.
Verbalize preparation of room and patient
IV.
Verbalize assisting physician and remaining
at the bedside throughout the procedure
V.
Verbalize recording waveforms and
documenting strips in the chart
VI.
Demonstrate interpreting waveforms
VII. Verbalize pressure of each chamber:
RAP (CVP):
PAP:
PCWP:
VIII. Verbalize and demonstrate identifying
placement of catheter
IX.
Verbalize procedure for removal of PA line
after physician order obtained.
X.
Verbalize Nursing Responsibilities and
troubleshooting

Method of
Verification

Verbalize and
Demonstrate

Verbalize and
Demonstrate

Reviewer
Title,
Initial
and Date

XI.

XII.

Verbalize use of catheter ports:

Distal Lumen - Yellow:
Proximal Port - Blue:
Distal Port - White:
Red:
Temperature probe
Verbalize procedure for performing Cardiac
Output:
*Preparation
*Procedure

Verifying Signature: _________________________________

Date: ____________

Comments:

SK/07, revised FC/10

GARDEN CITY HOSPITAL

CRITICAL CARE SERVICES PROTOCOL
CARE OF PATIENT WITH INTRACRANIAL PRESSURE MONITOR
PURPOSE: To direct the caregiver in the care and management of the patient
with Intracranial Pressure (ICP) Monitor.
SUPPORTIVE DATA: Continuous measurement of intracranial pressure (ICP
provides useful information in patients with intracranial
hypertension and in patients at risk for developing intracranial
hypertension ICP recording is achieved by operative (burr-hole)
placement of an epidural pressure transducer or alternatively by
insertion of an intraventricular catheter.
AOA 16.03.04 Standards of Care; Standards of care describes the application
nursing technique / intervention to specific patient problems,
needs, and nursing diagnoses.
AOA 29.00.01 Special Care Units (SCU); Special Care Units (SCU) exist to
provide the focused use of intensive staff and technologic
resources for patients.
CONTENT STEPS:
1. Position patient to prevent flexion of the neck or hips. Neck, head
and extreme head flexion increase ICP. Head rotation of 90
degrees to either side may also result in increased ICP. Head of
bed should be elevated 30-45 degrees (unless otherwise ordered)
to improve venous drainage from the head. Normal levels ICP 415mm hg.
2. Initially record ICP, MAP, CPP every 15 minutes to establish a
trend.
A. MAP mean arterial pressure by A-line or by non-invasive
blood pressure monitoring with the following formula:
MAP = diastolic BP x 2 + systolic BP 3
B. CPP cerebral perfusion pressure may be altered by
hypertension or hypotension. It may also be affected by
increased ICP. Normal range CPP= 60-90 mmHg. In
patients being monitored with ICP, CPP is not allowed to
fall below 50mmHg. CPP is calculated with the following
formula:
CPP = MAP ICP mmHg

3. Subsequently record ICP, MAP, CPP every 1 hour.

4. Inform physician if:
MAP < 60
ICP > 20
CPP < 50
5. Utilize neurological assessment sheet to record level of
consciousness, GCS, MAP, ICP, CPP.
6. Concentrate nursing care activities into schedule blocks of time
to avoid over stimulation of the patient.
7. Avoid frequent inducement of cough reflex. Hyperventilate
prior to suctioning patient.
8. Monitor for HA, nausea, vomiting, seizure activity, changes in
ventilator patterns, hyperthermia, posturing, decerebrate or
decorticate, increased diuresis, papilledema and Cushings
triad (irregular respiratory pattern, widening pulse pressure and
bradycardia.
9. Avoid hypothermia and hyperthermia.
10. Avoid excessive fluid intake.
11. Avoid stimulating valsalva movements.
12. The site must be kept clean and dry and should be covered
with an occlusive dressings at all times.
CROSS REFERENCE: Intracranial Pressure Monitoring
Camino, Becker, Goeltec
REFERENCE: AACN Procedure manual for critical care 4th edition LynnMcHale, Carlson; WB Saunders Zool, 2001 pp 561-569
Nursing Assessment and Management of Patients with Head
Injuries, LeJeune, Gerard M., Howard-Fain, Tamara. Dimensions
of Critical Care Nursing, Nov 2002 Vol 21.
Caring for patient swith increased intracrancial pressure. Le
Jeune, M.RN, Howard-Fain, Tamara, RN, Nursing 2002
Evidence Based Rating Scale: Level II
Nursing Procedures and Protocols
Lippincott, Williams, and Wilkins 2003 pp 393-398
Evidence Based Rating Scale: Level II
Critical Care Nursing Reference, Fourth Edition, Mosby, 2006
Pp 463-468
Evidence Based Rating Scale: Level II

APPROVAL: Critical Care Committee

Neurology Department
DISTRIBUTION: Critical Care Unit Based Clinical Policy and Procedure Manual
REVIEW: 6/99, 5/2000, 7/03, 1/05, 11/06, 10/08
REVISION: 6/99, 1/05

GARDEN CITY HOSPITAL

CRITICAL CARE SERVICES PROCEDURE
BECKER INTRACRANIAL PRESSURE MONITORING SYSTEM INSERTION
PROCEDURE

PURPOSE: To direct the caregiver in preparing the patient and the equipment for
the
insertion of the Becker Intracranial Pressure Monitoring System.
SUPPORTIVE DATA:
A physician order is required. Intracranial pressure monitoring is
utilized to monitor intracranial pressure and evaluate for trends in
pressures and therapeutic interventions. Danger signals of
increased intracranial pressure (ICP)
1. Level of consciousness (LOC) changes
2. Increased blood pressure
3. Decreased apical rate
4. Onset hemiparesis
5. Pupillary changes
6. Sudden headache or worsening headache
7. Vomiting
AOA 16.03.04 Standards of Care: Standards of care describe the application of
nursing technique / intervention o specific patient problems,
needs, and
nursing diagnoses.
AOA 29.00.01 Special Care Units (SCU): Special Care Units exist to provide
the focused use of intensive staff and technologic resources for patients.
SCOPE:

RN CCU/ICU

EQUIPMENT LIST:
1. Becker External Drainage and Monitoring System
2. Mounting bracket
3. IV pole
4. Transducer pressure monitoring system (no flush system:
Baxter Tru-Wave Disposable Pressure Transducer with
Stopcock.)
5. Preservative free 0.9% NS Solution 250 ml
6. Surgical mask, gown, sterile gloves, towels
7. Standard Monitoring set
8. Cranial Access (separate package) in Pyxis

CONTENT STEPS:
Refer to figure 1.0 1.3 for the following content steps
A. Equipment Set-Up
1. Obtain all equipment
2. Remove Becker system wearing a surgical face mask and
sterile gloves.
3. Check to ensure that all components are assembled and all
connections are tight and leak free.
4. Remove air from saline bag by inserting a 23 gauge 1-inch
needle into additive port and squeezing bag.
5. Connect standard monitoring set to main stopcock, flush
tubing from main stopcock through patient line, then from main
stopcock through Becker tubing system.
6. Discard standard monitoring tubing and IV bag and attach the
non- flush tru-wave valve to the main stopcock. Keep clamp
open to drainage bag while flushing (this is done by removing
red dead end plug and tightening transducer to stopcock.
7.

Attach Becker system to pole clamp. The zero reference mark;

main pole clamp and main system stopcock will all line up at
the Foramen of Monroe (zero mark). Do not change zero
reference.

8.

Check system for any residual air bubbles. Air can be

removed by combined injection of saline and aspiration of air
via 25 gauge needle at injection sites on patient line stopcock
or patient line.

9.

Ensure no fluid comes through filter at top of collection

chamber. (If filter becomes wet a new system must be
obtained).

B. Equipment Connection to Patient To be completed by

Physician.
1. Before attaching system to patient; zero, drainage/monitoring
system to Foramen of Monroe.
2. Connect catheter to pre-filled system; *Remember to turn patient
line stopcock to off position. Remove patient line dead end cap
and connect.
3. Care should be taken to ensure that the catheter and complete
system is devoid of any air bubbles.

C. System Calibration
1. Level transducer with Foramen of Monroe. (Between top of ear
and end of eyebrow).
2. Turn stopcock off to patient and open to air
3. Drop flow chamber to zero; monitor will read zero (0), when zero
on monitor pressed. Then raise chamber to 20-22 mmHg to
verify accuracy monitor should read 22+ or one.

4. Use cm H20 and set scale (verify physician order for

measurement units)
5. If catheter changed, system is changed.
D. Sampling needed:
1. Open sample port stopcock.
2. Use a syringe with barrel pulled back 1cc before needle placed in
port.
a. Place needle in port and let drain; then pull cut needle
and send specimen.
b. DO NOT pull on barrel of syringe.
c. Document color of specimen and amount taken.
E.Trouble Shooting for system malfunction
1. Turn stopcock near patient off to patient.
2. Mount on IV pull set up.
3. Flush collection chamber if not done. See step 1 of original setup
4. Take needle and syringe and pull back for fluid fill and air bubble
removal or flush forward to where stopcock is. Can use 20cc
syringe with normal syringe and flush up to chamber with bag
open at bottom.
5. All injection sites should be cleaned with alcohol and then
alcohol allowed to dry before a needle is inserted into them.
6. Sterile technique should be observed in setting up the system.
7. The main stopcock must be correctly aligned with the patient for
accurate pressure monitoring.
8. Mounting panel must be securely mounted. If the panel is
allowed to drop, reduction in system pressure will result and overdrainage of CSF may occur.
9. Always ensure stopcocks are in the proper position for the
maneuver being carried out.
10. Be aware waveform if it dampens, check entire system.

F. To Replace Drain Bag

1. Close flow chamber slide clamp.
2. Remove the bag from the system mounting panel using sterile
technique.
3. Disconnect the drainage bag connection line. Discard the bag.
DOCUMENTATION:
1. Document date and time of initial insertion and set up of the
Becker ICP system.
2. Tag the line for start date and change date.
3. Document in nurses notes initial readings and readings at least 2
hours or at intervals as ordered. Document any procedures
performed that may increase or decrease ICP.
SEE ATTACHMENTS.
REFERENCES: Becker EDMSII Booklet
AACN Procedure Manual for Critical Care 4th edition.
Lynn-McHale, Carlson; WB Saunders Zool, pp 561-569.
Evidence Base: Level II
Sole, Klein, Moseley, Introduction to Critical Care Nursing,
5th Edition; Chapter 13, Nervous System Alterations, p. 393
Evidence Based Rating Scale: Level II
APPROVAL: Critical Care Committee
DISTRIBUTION: Critical Care Unit Based Clinical Policy and Procedure Manual
REVIEW: 3/91, 1/05, 11/06, 10/08
REVISION: 11/95, 1/97, 1/98, 8/00, 7/03, 1/05, 8/06

Tranducer Hook Up

Name: ________________________ Date: ____________

Intracranial Pressure Monitoring Post-Test
1. Name two functions of a Becker ICP monitor/drainage system:
_____________________________________________
_____________________________________________
2. List the three components within the skull that determine ICP:
_____________________________________________
3. Calculate the CPP based on the values below: ___________
MAP=82 ICP=12
4. When would you expect an increase in P1 amplitude?
a. Development of a mass
b. Increased CSF volume
c. Hypertension
d. Increased Venous Volume
5. An elevation in which wave would indicate poor compliance within the
skull?
a. P1
b. P2
c. P3
6. List three symptoms associated with increased ICP:
_______________________________________________
7. What three components make up Cushings Triad? (circle all that apply)
a. Irregular respiratory pattern
b. Narrowing pulse pressure
c. Widening pulse pressure
d. Bradycardia
e. Tachycardia
8. True or False: Maintenance of any ICP monitor should be done
sterilely.
FC/10

Becker ICP Set Up

Competency for Agency Nurse Staff
Name: ________________________________

Date: ________________________

Behavioral Objective:
Demonstrate proper set-up of equipment for Becker ICP.
Verbalize normal values ICP and CPP.
Competency

Becker ICP
VI.
Verbalize and gather equipment.
VII. Demonstrate set-up pressure line
VIII. Verbalize zeroing after demonstration of
leveling at Foramen of Monro
IX.
Verbalize maintaining pressure bag at ___
at all times
X.
Verbalize method for obtaining CSF
specimen
VI. Demonstration calculation of CPP
IX.
Verbalize normal ICP
X.
Verbalize nursing responsibilities and
Troubleshooting
XI.
Verbalize signs and symptoms of increased
ICP

Method of
Verification

Reviewer
Title, Initial
and Date

Verbalize and
Demonstrate

Verifying Signature: _________________________________

Date: ____________

Comments:

FC/10

Post Cardiac Arrest

Therapeutic
Hypothermia
Self Learning Module
For ICU RNs

Why Use Therapeutic Hypothermia?

Brain temperature during the first 24 hours after resuscitation from cardiac
arrest may have a significant effect on survival and neurological recovery.
Cooling to 32-34 degrees Celsius for 24 hours may decrease chance of death
and increase the chance of neurological recovery. Hypothermia activates the
sympathetic nervous system causing vasoconstriction and shivering. Shivering
increases oxygen (O2) consumption by 40-100%. Sedatives, opiates, and
neuromuscular blockers can counteract these responses and enhance the
effectiveness of active cooling.
How Does Therapeutic Hypothermia Work?
Hypothermia shifts the oxyhemoglobin curve to the left and may result in
decreased O2 delivery. However, the metabolic rate is also lowered, decreasing
O2 consumption/carbon dioxide (CO2) production. Ventilator settings may
need to be adjusted due to decreased CO2 production, using temperature
corrected blood gases. Hypothermia initially causes sinus tachycardia, then
bradycardia. It is extremely important to keep the patients temperature >30
degrees Celsius as temperatures <30 degrees Celsius place the patient at an
increased risk for arrhythmias and core temperatures <28 degrees Celsius
place the patient at an increased risk for ventricular fibrillation.
Severely hypothermic myocardium (<30 degrees Celsius) is less responsive to
defibrillation and medications, decreases cardiac output and increases
systemic vascular resistance (SVR). Hypothermia can induce coagulopathy
(which can be treated with platelets and fresh frozen plasma). Hypothermiainduced diuresis is to be expected and should be treated aggressively with
fluid and electrolyte replacement. Magnesium, phosphorous and potassium
should be monitored closely and maintained within a normal range.
Decreased insulin secretion and sensitivity can lead to hyperglycemia, which
should be treated aggressively.
Re-warming must proceed slowly over 6-8 hours to prevent profuse
vasodilation, leading to hypotension, rapid fluid and electrolyte shifting.

Who Is Eligible For Therapeutic Hypothermia at Garden City Hospital?

Adults over the age of 18 (Women must have a negative UCG)
Witnessed cardiac arrest with a ROSC (return of spontaneous
circulation) to a systolic blood pressure >90, with or without the use of
vasoactive medications
Unresponsive at enrollment with a GCS (Glasgow coma scale) < 8 after
ROSC
No primary intracranial event or comatose due to other causes (CVA,
head trauma, status epilepticus, drug overdose)
Less than 6 hours have elapsed since ROSC
Does not have an order for Do Not Resuscitate (DNR) or Do Not
Intubate (DNI), patient must be a full code
Must be intubated and mechanically ventilated
Pulseless <60 minutes
Pre-arrest cognitive status is not severely impaired (i.e. can perform
ADLs independently)
Who Is NOT Eligible For Therapeutic Hypothermia at Garden City
Hospital?

Pulseless >60 minutes

> 12 hours since ROSC
Glasgow Coma Scale >8
Minimal pre-morbid cognitive status
Other reason for coma (i.e. drug overdose as etiology for arrest) and/or
intracranial pathology (i.e. intracranial hemorrhage, ischemic stroke),
subarachnoid hemorrhage (SAH), sedation
Sepsis as etiology for arrest
Uncontrollable bleeding/Pre-existing coagulopathy or bleeding if
known: INR > 3.0, Platelets < 30,000
Significant trauma, especially intra-abdominal such as splenic or liver
laceration (due to increased risk of bleeding)
What Supplies Do I Need To Prepare?
Two one liter bags of 4 degrees Celsius 0.9% NS (stored in the
ED/ICU refrigerators)

 Arterial line kits (both femoral and radial)

Central Venous Catheter
Gaymar External Cooling System with two complete sets of hoses, one
torso wrap and two leg wraps
Foley catheter with temperature probe
Preparation For Cooling
Ensure the central venous catheter is inserted BEFORE initiating cooling.
Once the patient is cooled venous access is difficult to obtain. Insertion of a
triple lumen catheter is ideal, though any central venous catheter is
acceptable. An arterial catheter should be placed concurrently if possible.
Obtain baseline labs:
Urine HCG on all women of child bearing age
ABG with ionized calcium and magnesium
CBC, platelets, PT/PTT/INR, fibrinogen
Comprehensive metabolic panel
Amylase, Lipase
Lactate, CK, Troponin
Cortisol level
Pan Culture
Toxicology screen if appropriate
Then, place the temperature probe indwelling foley catheter. Complete and
document a thorough skin assessment before applying cooling system wraps.
Insert an oral gastric tube and initiate low intermittent suction.
Cooling
Infuse 4 degrees Celsius 0.9 Normal Saline (30ml/kg) over 30 minutes. DO
NOT INFUSE FLUIDS VIA JUGULAR OR SUBCLAVIANLINE. Infuse
maintenance IV 0.9 Normal Saline at 100 ml/hr. Titrate to keep CVP
between 8 and 12. Apply Gaymar cooling device wraps, first the chest and
then the leg wraps connecting the appropriate hoses. Connect the
temperature monitoring indwelling foley catheter to temperature monitoring
port on Gaymar machine. Turn machine on, ensure that the cool fluid fills
the body wraps. Check fluid volume in machine once wraps are full, you will
need to add more fluid to the machine at this time. Keep 4 additional liters of
fluid with the machine at all times. If the Gaymar machine is not available

pack the patient in ice (groin, sides of chest, axilla and neck). DO NOT
STOP COOLING DURING TRANSPORT OF PATIENT.
Gaymar Cooling Device Settings
Initially set the machine to rapid cooling automatic mode with target
temperature of 34 degrees Celsius. Once the patient reaches 34 degrees
Celsius, set gradual cooling automatic mode to 33 degrees Celsius. Assess the
cooling blanket settings and patients temperature in degrees Celsius. Cooling
is maintained for 24 hours from the time the target temperature, between 3234 degrees Celsius is reached. KEEP THE GAYMAR UNIT PLUGGED IN
AT ALL TIMES.
Monitoring The Patient
Temperature
Our goal is to maintain the patients core temperature between 32-34 degrees
Celsius for 24 hours. Maintain the patient blanket temperature at 33 degrees
Celsius in gradual automatic mode, assess and document the patient temp
hourly. If ice packs are being used, add or remove ice packs to maintain the
core temperature of 32-34 degrees Celsius. If the patients temperature drops
to < 31 degrees Celsius, consider infusing 250 ml boluses of warm 40 degree
Celsius 0.9 Normal Saline or LR until temperature >32 degrees Celsius.
Monitor closely for arrhythmias if patient temperature < 32 degrees Celsius.
Skin assessments should be completed and documented every 6 hours.
Hemodynamics
Vital signs are to be documented every 15 minutes for the first hour, then
hourly. Maintain a MAP 65-120 mmHg with IV fluids, vasopressors or
nitrates if needed. Levophed is included in the standing orders to start at
1mcg/min, titrate to keep MAP 80-100mmHg (Max dose 30mcg/min, RN to
call pharmacy when needed).
Laboratory
Request temperature correction when blood gas values are being calculated.
Patients may require intensive glucose control. If the blood glucose is
>150mg/dl X 1, initiate the Tight Glycemic Control Protocol. Urine output
should be documented at least every two hours. Hypothermia induced
diuresis is common, aggressive fluid replacement may be required. If an acute
decreased in urine output is detected, confirm bladder contents with bladder

scanner. The patient will have serial labs drawn throughout the procedure
contact physician if:
Potassium < 3.4
Magnesium < 2
Calcium < 8
Uncontrolled shivering
Heart rate < 50 or > 110 beats per minute
Systolic blood pressure < 80mmHg or > 180 mmHg
Any change in Troponin value
Shivering
Shivering is a bodily response to early hypothermia. When the core body
temperature drops, the shivering reflex is triggered. Muscle groups around the
vital organs begin to shake in small movements in an attempt to create
warmth by expending energy. The approach towards shiver control involves
the combined us of pharmacological and non-pharmacological interventions.
The goal of these therapies is to achieve a Bedside Shivering Assessment Scale
score of 0.
BSAS Score
Treatment
0 = none
None reassess in 30 minutes
1 = Mild (localized to neck
and/or thorax only
2 = Moderate (gross movement
of the upper extremities)
3 = Severe (gross movement of
the trunk & upper & lower
extremities

Meperidine (Demerol) 25mg IVP,

may repeat q15 minutes prn x 3
doses, if ineffective, in any 6 hour
period (Maximum 75mg). PLUS
Buspirone 30mg down OGT
(synergistic with Meperidine) Q 12
hours PRN X 24 hours.
If Meperidine ineffective,
administer: Roccuronium
(Zemuron) 50 mg every 30 mins
PRN and reassess in 30 minutes
(RN to call pharmacy when
needed).
Magnesium Sulfate 1-3
grams/hour gtt for persistent
shivering (RN to call pharmacy
when needed).

Medications For Sedation/Analgesia

Administer sedatives using the Richmond Agitation Sedation Scale (RASS).
Our goal is (-4) deep sedation, these scores should be documented hourly.
Begin sedation with Propofol at 5mcg/kg/min, increase every 5 minutes by
5mcg/kg/min, with a maximum dose of 50mcg/kg/min. Add Fentanyl drip
in addition when Propofol is maximized. Begin Fentanyl at 1mcg/kg slow IVP
then start drip at 50mcg/hr. Increase infusion by 25mcg/hr every 30 minutes,
if needed, with a maximum dose of 150mcg/hr (RN to call pharmacy when
needed). Add Lorazepam in addition to Propofol and Fentanyl when they are
maximized. Give Lorazepam 2mg IVP every 30 minutes until sedation goal
achieved then start drip at 1mg/hr. Increase infusion by 1mg/hr every 30
minutes, if needed with a maximum dose of 10mg/hr (RN to call pharmacy
when needed).
RASS Scale

Re-Warming
Begin re-warming 24 hours after target temperature reached. Re-warm
gradually in a controlled manner to avoid vasodilatation and hypotension.
Our goal is to re-warm the patient over 6-8 hours. Re-warming too rapidly can
cause vasodilatation, hypotension, and rapid electrolyte shifts. Our goal is to
maintain a MAP of 80-100mmHg. Anticipate a reduction in cardiac output
and BP (decreased CVP) as the cooler blood shifts from the core to the

extremities. Follow the CVP closely; aggressive IV fluids may be necessary to

maintain adequate volume status during re-warming.
Gaymar: Increase the blanket temperature setting by 0.5 degrees
Celsius every 1-2 hours.
Passive Re-warming: Remove all cooling devices and cover patient
with a sheet.
Assess and document vital signs with CVP every 1 hour until temperature
reaches 36 degrees Celsius. Monitor K+ every 4 hours and prn. Monitor
serum glucose levels every 1 hour until temperature reaches 36 degrees
Celsius. As insulin resistance resolves, the patient is at risk for hyperglycemia.
Follow ABGs as needed with temperature corrected values. Adjust ventilator
settings according to the physician orders. Maintain paralysis until patient
temperature > 36 degrees Celsius, then discontinue. Titrate sedation to
comfort and ventilator synchrony as per physician orders.

Celsius
30.0
30.5
31.0
31.5
32.0
32.5
33.0
33.5
34.0
34.5
35.0
35.5
36.0
36.5
37.0
37.5
38.0

Fahrenheit
86.0
86.9
87.8
88.7
89.6
90.5
91.4
92.3
93.2
94.1
95.0
95.9
96.8
97.7
98.6
99.5
100.4

Reference: Hypothermia after Cardiac Arrest Study Group. (2002). Mild

Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac
Arrest. New England Journal of Medicine, 346(8):549-556.

Bernard SA, Gray TW, Buist MD, et al. (2002). Treatment of Comatose
Survivors of Out-of-Hospital Cardiac Arrest With Induced Hypothermia. New
England Journal of Medicine, 346(8): 557-563.
Zeiner A, Holzer M, Sterz F, et al. (2001). Hyperthermia After Cardiac Arrest
is Associated with an Unfavorable Neurologic Outcome. Arch Intern Med,
161(16): 2007-2012.