The Thinkers: Technology helps patients recover after intensive care

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When heart patients get out of intensive care in the hospital, many families assume the worst is over.

But about 25 percent of those patients will become unstable again in the next level of care, called a step-down unit, and that puts special pressure on the nurses there to keep them from deteriorating.

Marilyn Hravnak
  • Position: Professor, acute/tertiary care, University of Pittsburgh School of Nursing.
  • Age: 55
  • Residence: Chartiers
  • Education: Bachelor's in nursing, Indiana University of Pennsylvania, 1974; master's in pulmonary clinical nursing, Pitt, 1983; acute-care nurse practitioner certification, Pitt, 1993; Ph.D. in nursing, Pitt, 2000.
  • Previous positions: Acute care nurse practitioner, cardiothoracic ICU, UPMC, 1994-present; head nurse, surgical intensive care unit, Presbyterian-University Hospital, 1985-91.
  • Professional honors: Dean's distinguished teaching award, Pitt School of Nursing, 2006; chancellor's distinguished teaching award, Pitt, 2007; Norma J. Shoemaker Critical Care Nursing Excellence Award, Society of Critical Care Medicine, 2008.
  • Publications: Thirty-seven papers and book chapters in professional publications and refereed journals.

That's why Marilyn Hravnak, an acute-care nursing professor at the University of Pittsburgh, is excited about a new technology that may tell nurses which patients are vulnerable to reversals much earlier than in the past.

The system, made by OBS Medical of Carmel, Ind., automatically monitors vital signs and issues an alert when a patient's heart rate or breathing starts to get out of control. And that could make a big difference in step-down units, where each nurse has more patients to keep track of.

In intensive care, a nurse will have one or two beds to cover, and patients also will be watched closely by specialists, other health care professionals and a panoply of high-tech equipment.

"But when patients are on stepdown units," Dr. Hravnak said, "the nurse-to-patient ratio is 1 to 4 or 1 to 6, and a nurse's attention is diffused across a larger number of patients."

The new system, she said, "helps to call your attention really very early on when the patient starts to develop instability, sometimes when there isn't even what we would consider to be a significant change in vital signs that would have set off the traditional alarms."

The OBS Visensia technology is just one of the advances in acute-care nursing that is promising to make hospital treatment quicker and better as America's aging population keeps increasing the demand for intensive-care beds, with no end in sight, Dr. Hravnak said.

Another is using a sensor-packed mannequin known as SimMan for specialized training.

In a computerized lab, acute-care nurses can use the mannequins to practice everything from taking vital signs to putting in a breathing tube to shocking the heart back into a regular rhythm, Dr. Hravnak said.

The mannequins also can "talk," she said, so in many cases, a nursing faculty member will go into the control room and pretend to be the patient while the nurse asks questions. The faculty member also can control the mannequin's vital signs, so that what nurses hear and see will test their responses to different problems.

In one situation, she said, the "patient" may say he is feeling dizzy and shaky, and the blood pressure readings may show a mild drop. In another case, she said, the patient will start talking about how his pet dog is in the room -- a clear sign of confusion -- and the blood pressure readings will be much lower.

Depending on what the nurse does, the mannequins' blood pressure readings may climb back toward normal, or the crisis may deepen.

The advantage of the SimMan training, Dr. Hravnak said, is that "it gives you the ability to present [nurses] with a large variety of cases that we can't always be certain they will come across in a clinical setting.

"The other value is that we can allow them to make mistakes and learn from those mistakes, which of course, in the interest of patient safety, we would never be able to do in the clinical setting."

Dr. Hravnak grew up in Canonsburg. Her father was an airplane mechanic and her mother a homemaker.

She went to nursing school at Indiana University of Pennsylvania, and when she was rotating through different hospital units as a student, "from the moment I walked into the ICU the first time I felt intrigued -- I was scared, but it was also very challenging to me because I knew that the decisions I made for those patients would make a significant difference."

She has stayed in that field ever since and today is a professor in the department of acute and tertiary care at Pitt's nursing school. This month, she received the Norma J. Shoemaker Award for Critical Care Nursing Excellence from the Society of Critical Care Medicine.

From her parents she got "that typical Western Pennsylvania work ethic," she said, plus a lot of loving support. When she received a chancellor's award for distinguished teaching at Pitt last year and her husband couldn't go, she invited her father.

"My mom called me early that day and said, 'You're not going to believe it; your father's already getting ready for this; you'd think he was going to the prom!' "

One project close to her heart is UPMC's Acute Care Nurse Practitioner program, which has trained about 180 nurses for this higher-level role since it began in 1995.

Demand for the program's graduates has stayed high, Dr. Hravnak said, and because medical interns rotate through the intensive care units every few months, the nurse practitioners provide vital continuity of care for those patients.

If there is one thing that has changed most for hospital nurses over the past two decades, Dr. Hravnak said, it has been the explosion of new technology, not just for monitoring and treating patients, but for charting them.

Just 15 years ago, she said, she oversaw the first experiment in automating the recording of patients' vital signs at their bedsides, using much more primitive computers than today's.

"Sometimes I'd walk past," she recalled, "and a nurse would be crying, because many had never learned to type and didn't have computers at home.

"Today when I walk down a unit, those nurses' fingers are just flying over the keyboard."

Mark Roth can be reached at or at 412-263-1130 First Published March 3, 2008 5:00 AM


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