CRDAMC Intensive Care Unit team raises the bar on critical care efforts

By Mikaela CadeMay 21, 2020

FORT HOOD, Texas – As the world considers post COVID-19 life, some things will never be the same, and Carl R. Darnall Army Medical Center's Intensive Care Unit is one of them.

The team's recent innovations in the practice of critical care medicine position them to take care of sicker, more complicated patients, a benefit to the Fort Hood community that will remain long after the pandemic passes.

"The changes here are the gold standard, and will lead to improved patient outcomes. In fact, we've already seen amazing things like people successfully coming off a mechanical ventilator after prolonged intubation," said Maj. Amaya De La Garza, chief of pulmonary and respiratory services.

De La Garza believes the ICU transformation will positively impact patient outcomes, facilitate readiness training and enhance the graduate medical education program for Army Medicine's next generation of leaders.

"In the last eight weeks, we've taken care of more complex, critically ill patients than we have since I've been here," De La Garza, said proudly. "We used to send them to other hospitals, but now we can keep them here and provide excellent medical care. Seeing patients improve and return to health is why I got into medicine."

One of the most significant critical care advances, De La Garza noted was the ability to provide prone positioning therapy. Patients suffering from severe acute respiratory distress syndrome (ARDS) often require mechanical ventilation to help with breathing and lie on their back. With proning, the patient lies in a face-down position to improve oxygen flow.

"We proned the first-ever CRDAMC patient just a few weeks ago," she said. "It took a lot of training and practice, but our team is committed. Everyone was willing to do whatever it took to raise the bar in the care for our patients."

She attributes successes to a combination of the willingness of critical care teams to come together selflessly. The team had to get the right equipment and undertake a massive training effort to ensure the highest levels of proficiency among staff.

"We did not just make changes because of COVID-19. The situation just made it easier for us to make the changes we knew we were ready for," she said. “Planning was underway, but forecasting what success would look like in the fight against COVID-19 helped things move along at a faster pace.”

Although the changes occurred during COVID-19, the procedures are not limited to COVID-19 patients.

"We're taking care of all types of critically ill patients, not just those with COVID-19," she said, adding that the team has also managed patients with sepsis, pancreatitis and acute respiratory distress.”

Collaboration is a critical component of success when caring for seriously ill patients and CRDAMC and Madigan Army Medical Center in Washington are collaborating to provide Continuous Renal Replacement Therapy (CRRT) for critically ill patients soon.

"Another pretty amazing thing is the multidisciplinary team approach to managing patients,” De La Garza explained. "Everyone from anesthesia to primary care to physical therapy to nutrition care come together daily to discuss every detail of the patient's situation and develop a comprehensive care plan."

Multidisciplinary rounding has become the standard for managing critical care patients at top academic hospitals, according to De La Garza. Improved patient outcomes are just one of the benefits of multidisciplinary rounding.

Jennifer Jerdon, a critical care nurse, is impressed with the transformation and believes it could not have been successful without the staff's willingness to move beyond the status quo to improve patient care.

"The most amazing thing was the coming together," Jerdon said. "Everyone was so willing to do whatever was needed. The selflessness of our teammates was incredible.”

Jerdon said they trained nurses from other areas of the medical center and even outlying clinics in critical care nursing skills to increase ICU staff.

"We did a lot of training from the 66G, OB/GYN nursing students to community-based medical home nurses to nurse administrators," Jerdon said, adding that all the nurses are licensed, but for those not currently involved in patient care standard practice requires them to receive refreshers in patient care and safety and equipment usage.

Tasha Parker, CNOIC pulmonary intensive care and respiratory services also believes CRDAMC has a very cohesive and tight-knit group of people who are beyond good at their jobs.

"We can sometimes get comfortable just doing our jobs, but this experience of expanding our critical care capability in the middle of a pandemic reminds us that we must do things for the person in the bed—the patient. And, when we do that, we've done our jobs,” she said.

Skyler Brown, family medicine resident, believes his recent critical care experience has made him more confident and prepared for future success.

"I've been here for three years, and before the pandemic, we took care of routine things, but now we're running codes in one room and setting up vents in another," Brown said. "It's good, and we're getting excellent training."

Brown, who graduates from Darnall's Family Medicine Residency program in June, also completed a training rotation at Baylor, Scott & White. Working with critical care providers as they manage a new disease was an invaluable learning experience for him.

“In medicine, we learn about disease processes and understand patterns, but COVID-19 is a new process. We're learning more every day, so watching more senior physicians critically think through what they're seeing and planning the appropriate care is great,” said Brown.

The ICU staff learned valuable lessons from the other hospitals. And from those lessons, they moved quickly to ensure they were ready to implement new procedures and safety measures by the time the first COVID-19 patient arrived.

“Before the COVID-19 pandemic, we were increasing the acuity of the hospital and improving our processes," said Col. Karin Nicholson, pulmonary, critical care and sleep physician. “We are now well-positioned to continue more complex patient care. We are looking forward to the opportunity to continue to take care of our patients in the medical center, and keep our staff skilled and ready to deploy."

CRDAMC's prone positioning therapy bed
Col. Karin Nicholson, CRDAMC chief medical officer, is enclosed in a new rotating bed during a recent ICU staff training. The bed is used in prone-positioning therapy for patients with acute respiratory distress syndrome (ARDS). Prone positioning is just one of the recent innovations at CRDAMC that allow the critical care team to take care of patients with complex respiratory conditions like COVID-19. (Photo Credit: courtesy photo) VIEW ORIGINAL