Nursing the chronically critically ill patient.

The provision of care to the CCI patient is complex, challenging, and unique. The advanced practice nursing model at Mount Sinai Hospital is one successful care delivery model that fills the needs of both CCI patients and the nurses who work with them. The following transferable aspects of the RCU add to the unit's successful outcomes: (1) an interdisciplinary approach assures that all aspects of care are included in the clinical plan; (2) clinical care pathways, algorithms, and standard protocols based on physician, NP, and clinical nurse collaboration are successful management strategies; (3) formal discharge planning meetings with participation of patients, families, NPs, and social workers provide a forum for discharge planning and an avenue to address ethical issues such as advance directives, resuscitation status, and patient self-determination decisions; (4) full participation by nurses in all aspects of the unit's activities is a cost-effective strategy for maximizing positive outcomes for patients and their families. RCU patients and their families are in great need of emotional support. Patients have survived catastrophic illnesses, and are facing the arduous task of pulmonary rehabilitation as the desired outcome. Those patients unable to wean need to plan for a life dependent on ventilatory support. Presently in New York, there are not enough facilities to care for ventilator-dependent patients or patients who are weaned but in need of further pulmonary care and rehabilitation. The RCU LOS reflects this situation. Although a cost-benefit analysis is an effective way to evaluate the RCU program, the human element must not be forgotten. This is the daily challenge for the RCU staff and other health professionals engaged in the care of the CCI patient. Although the aim of this paper is to share the experience of patients and health care providers in the RCU, the reader should be aware that the RCU operates in the context of health care delivery at an academic health center in New York City. Our goal is to increase understanding of the challenges and opportunities present in the care of CCI patients and their families from the nursing perspective. Aspects of this model are adaptable to other health systems, and can be modified as appropriate. For example, in environments without NPs, trained RNs can collaborate with dedicated physicians to coordinate patients' care [1-3,8]. Other successful models use respiratory therapists to coordinate weaning protocols [9-12]. As we reflect on our experience, we hope to heighten the reader's awareness of CCI patients as thinking, feeling, and unique human beings. As Benner [31] suggested, we hope this paper will facilitate seeing the person beyond the disease. As limited financial resources increasingly affect health care, providing high-quality, cost-effective care to the CCI patient remains one of the greatest challenges for nurses and physicians in the United States.