Medical/Surgical Intensive Care Unit
Emilee Snider
Historical Trends in Nursing

Critical Care Nursing

Critical care nursing can be traced back to the battlefield and recovery room of the earlier decades and has evolved into the modern intensive care units today. The early 1950s through the 1990s is an era in which unpredicted and radical changes occurred in the care of all patients with the development and growth of intensive/critical care units in hospitals. The reasons for initiating these units was multi-factorial and complex; the factors included the acute shortage of civilian registered nurses (RNs) during and following World War II, innovative surgical procedures developed in caring for wounded servicemen that later carried over to civilian hospitals, vastly overcrowded hospitals, and the unacceptably high mortality rate among postoperative patients. During this time nursing care wasn’t either standardized or organized. The nursing staff consisted of registered nurses, licensed practical nurses, and unlicensed nurse’s aides, each doing what seemed best for that patient at that given moment.
There have always been critically ill patients; critical care nursing itself is fairly new. Patient care is more complex as the technology and medicine have advanced. The first intensive care unit opened in the 1950s, allowing the patients to get the specialized care and continuous monitoring and treatment (A Community Of Exceptional Nurses, 2013). Dr. William McClenahan, in 1953, was the first to establish a separate a unit for the critically ill patient (Romaine-Davis, 1999). During the transition both the doctors and the nurses were not familiar with the newly developed cardiac monitors, resuscitation procedures (CPR), and the cluster care that is given to the critical ill (Romaine-Davis, 1999). Nurses and doctors worked hand in hand to help each other learn to operate the equipment, recognize cardiac dysrhythmias and to do CPR efficiently. A group of critical care nurses formed a national group, American Association of Critical Care Nurses (AACN), which developed standards of care, a national examination that certified knowledge and competency in critical care, and a core curriculum that educates nurses getting into critical care (Romaine-Davis, 1999). This group continues to aid in the education of nurses today.
Peter Safar is known as one of the great pioneers of critical care nursing. He was born on April 24, 1924 in Austria. The University of Vienna is where he received his medical degree; he then went on to Yale to complete his fellowship in surgical oncology [ (Bryan-Brown, 2004) ]. Safar continued his education studying anesthesiology which landed him a job in Lima, Peru. Safar remained a busy man; he was hired as an assistant professor at John Hopkins University while also serving as chief of anesthesiology at Baltimore City Hospital [ (Bryan-Brown, 2004) ]. Safar was appointed the first chairman of the Department of Anesthesiology/Critical Care Medicine at the University of Pittsburg; he retired from his chair many years later but remained an active member of the department [ (Bryan-Brown, 2004) ]. He opened the first physician staffed medical-surgical intensive care unit [ (Bryan-Brown, 2004) ]. Having strong beliefs in nursing education, he placed nurses on the faculty of all the national critical care programs that he was responsible for. The first multidisciplinary critical care medicine fellowship was also started by Safar. The editors of the CCRN examination chose him as one of the physicians to review the first test. Peter Safar believed, “that critical care is not bound by the walls of the intensive care unit, but rather it is a discipline that begins in the community when a patient becomes acutely ill” [ (Bryan-Brown, 2004) ].
Peter Safar is also the founder of modern cardiopulmonary resuscitation (CPR) and cardiopulmonary cerebral resuscitation [ (Bryan-Brown, 2004) ]. His interests didn’t stop at resuscitation. The United States Army hired him to be a consultant in disaster medicine. Rudolf Frey and Safar were founding members, to Club of Mainz, of one of the first significant groups in the field of international disaster medicine [ (Bryan-Brown, 2004) ]. His last article on the value of lowering body temperature to preserve cerebral function in patients after resuscitation from cardiac arrest was published a month before he died [ (Bryan-Brown, 2004) ] Max Harry Weil developed the crash cart, computerized vital-statistics monitors, and the “stat” laboratory diagnosis [ (Miller, 2011) ]. He was also one of the pioneers of the heart catheterization and the automated CPR machine [ (Miller, 2011) ]. He lobbied to put television cameras on the medical helicopters to assist with remote diagnosis. He taught CPR to nonmedical individuals and he put automatic defibrillators in public buildings. He trained thousands of nurses and doctors in critical care medicine. In the last article that he wrote on the evolution of critical care medicine he wrote, “The reality is the modern hospital is becoming one large Intensive Care Unit” [ (Miller, 2011) ].
Up to the 1950s, the iron lung, that used negative pressure, was being used to treat patients in respiratory distress and the treatment of polio. Bjorn Ibsen changed the management of ventilation by instituting intubation into the trachea which provided positive pressure ventilation. This also helped prevent aspiration of oral secretions. Positive pressure ventilation became popular after WWII. The intensive care units are still using positive pressure ventilation to treat patients with respiratory failure. To help prevent delirium in the intensive care unit the environment has been designed to become more humanistic. It is essential to provide comfort, temperature, noises, view, and light variances [ (Fontaine, Briggs, & Pope-Smith, 2001) ]. Pet and family visitation is essential with keeping the patient from developing delirium.
Critical care nursing is a specialty within nursing that deals specifically with patients that are exhibiting life threatening problems [ (A Community Of Exceptional Nurses, 2013) ]. According to a study that was done March 2004, critical care nurses account for thirty-seven percent of the total nurses in a hospital setting [ (A Community Of Exceptional Nurses, 2013) ]. Critical care nurses practice in settings where patients are higher acuity, have a complex presentation, require high intensity therapies, interventions, and need continuous nursing care [ (A Community Of Exceptional Nurses, 2013) ]. Critical care nurses are specialized in their area of nursing. They have an increased knowledge, skills, and experience to provide care to the patient and family. Intensive Care nurses need to be able to remain calm under pressure and to think and react quickly. Most importantly the critical care nurse is the patient advocate [ (A Community Of Exceptional Nurses, 2013) ]. The American Association of Critical Care Nurses define advocacy as respecting and supporting the basic values, rights, and beliefs of the critically ill patient [ (A Community Of Exceptional Nurses, 2013) ]. In this role, critical care nurses: * Respect and support the right of the patient or the patient's designated surrogate to autonomous informed decision making. * Intervene when the best interest of the patient is in question. * Help the patient obtain necessary care. * Respect the values, beliefs and rights of the patient. * Provide education and support to help the patient or the patients designated surrogate make decisions. * Represent the patient in accordance with the patient's choices. * Support the decisions of the patient or designated surrogate, or transfer care to an equally qualified critical care nurse. * Intercede for patients who cannot speak for themselves in situations that require immediate action. * Monitor and safeguard the quality of care the patient receives. * Act as a liaison between the patient, the patient's family and other healthcare professionals” (A Community Of Exceptional Nurses, 2013, p. 2).
.
Critical care has a huge history in dating back 150 or more years. The time line provided below traces the evolution of the specialty from focused nursing to intensive care [ (Advancing Critical Care, 2013) ].
Milestones in Critical Care Year | Event | 1850s | During the Crimean War, Florence Nightingale creates a dedicated care area for soldiers wounded in battle. She recommends establishing separate post surgical recovery areas in hospitals. | 1890s-1920 | As large hospital wards expand, critically ill patients are segregated in semiprivate areas watched over by special duty nurses. | 1927 | Dr Walter Dandy establishes a separate, defined site for postoperative patients—the first in the US—at the Johns Hopkins Hospital. | | | 1947-1948 | Intensive nursing care provided to patients suffering from respiratory paralysis during the polio epidemic in the US and Europe. | 1950s | In Europe and the US, respiratory intensive care units (ICUs) are established and equipped with mechanical ventilation devices for polio patients. | 1958 | Johns Hopkins Bayview becomes the first multidisciplinary ICU. | 1959 | The first modern critical care units were created at the University of California Los Angeles (under the leadership of Max Henry Weil, MD, PhD) and the University of Pittsburgh (Peter Safar, MD). | | | | | 1986 | The American Board of Medical Specialties approves critical care competency certification for specialties of anesthesia, internal medicine, pediatrics, and surgery. | | | Today | The US has an estimated 6,000 critical care facilities, subdivided based on specialty. | [ (Advancing Critical Care, 2013, p. 1) ]
In conclusion, critical care medicine is relatively new but an increasingly important medical specialty. Florence Nightingale initiated critical care guideline when she took care of patients during the Crimean War. Intensive care nursing has come a long way from the original units. Technology has advanced so much in such a short time from the use of the iron lung to the changeover to positive pressure and the invention of computerized vital sign machines and CPR. Critical care nurses today have to have a will to continue their education. They have to be up to date on all the equipment they have available to them. Nightingale started critical thinking in her era and we have expanded on it.

References
A Community Of Exceptional Nurses. (2013). Retrieved April 1, 2013, from American Association of Critical - Care Nurses: Pg.2. http://www.aacn.org/wd/pressroom/content/aboutcriticalcarenursing.pcms?menu=
Advancing Critical Care. (2013). Retrieved April 1, 2013, from IKARIA: pg.1 http://www.ikaria.com/critical-care/milestones.html
Bryan-Brown, C. a. (2004, January 1). Pioneer of critical care medicine: Peter Safar (1924-2003). American Journal of Critical Care, 13(1), 87. Retrieved March 30, 2013, from American Journal of Critical Care: http:// ajcc,aacnjournals.org/contest/13/1/87.short
Fontaine, D. K., Briggs, L. P., & Pope-Smith, B. R. (2001, November). Designing Humanistic Critical Care Environments. Critical Care Nursing Quarterly, 24(3), 21-34. Retrieved April 1, 2013, from http://journals.lww.com/ccnq/Abstract/2001/11000/Designing_Humanistic_Critical_Care_Environments.3.aspx
Miller, S. (2011, August 4). He Led Critical Care into the Modern Age. Retrieved April 1, 2013, from The Wall Street Journal: http://online.wsj.com/article/SB10001424053111903885604576486570730092788.html
Romaine-Davis, A. (1999). Critical Care Nursing: A Histoy. In J. F. Lynaugh, Bulletin of the History of Medicine (Vol. 73, pp. 350-351). John Hopkins University Press. Retrieved April 1, 2013, from http://muse.jhu.edu/login?auth=0&type=summary&url=/journals/bulletin_of_the_history_of_medicine/v073/73.2br_fairman.html