Send in SWAT

Vol. 6 •Issue 6 • Page 16
Send in SWAT

Designated critical care nurses lend their expertise in a variety of acute situations at Yale-New Haven Hospital

When nurses at Yale-New Haven Hospital in New Haven, CT, experience a sudden deterioration in a patient’s condition or an overwhelming increase in nursing workload, they know the SWAT team is only a phone call away.

An acronym coined by the Los Angeles Police Department, SWAT stands for the Special Weapons And Tactics team, a group of seasoned and specially trained officers ready to respond to situations that demand extraordinary expertise.

When the floating critical care nurse role was implemented 5 years ago at Yale-New Haven Hospital, the designated nurses decided to call themselves the SWAT team.

“We originally started out with a nurse who was doing conscious sedation for MRI patients,” said Judy Grant, BSN, RN, patient service manager of the resource support unit that includes the SWAT team. “We didn’t have enough work to support that role on every shift, so we expanded the role to include other areas of the hospital. Today, we have SWAT nurses available 24/7, drawn from the 100 or so nurses in our resource support unit.”

Just a Phone Call Away

On a typical shift, the designated SWAT nurse makes rounds throughout the hospital, carrying a beeper until someone calls for assistance.

“We triage and put out fires wherever we’re needed,” said SWAT nurse Angelique Garay, BSN, BA, RN. “We’ll be called to administer conscious sedation for procedures, to do 1:1 care on a med/surg unit to stabilize a patient before transfer to ICU, or to help in the ED to transport a critically ill patient to an MRI.”

SWAT nurses often are paged when a patient’s clinical status begins to deteriorate. “A nurse on the floor may call us to say, ‘Things don’t look quite right with this patient,’ and we’ll come right away,” Garay said. “Sometimes what the nurse sees are very subtle changes in neurological or hemodynamic status. We’ll complete a nursing assessment and facilitate the conversation with the physician, putting the pieces together in a way that makes sense clinically.”

Garay explained SWAT nurses are not there to replace the patient’s primary nurse. “Just bringing our critical care perspective and experience to the scene can help determine what’s going on with the patient,” she said. “Sometimes we can intervene and other times we just need to reassure the nurse that nothing more needs to be done for this patient.”

Training, Teaching & More

SWAT nurses cover most areas of the hospital, providing intensive nursing care to manage medical emergencies in specialty units. “We may go into labor and delivery to provide the critical care nursing for women with obstetrical emergencies such as DIC [disseminated intravascular coagulation] while the maternity nurse deals with the care of the mother and the birth of the baby,” Garay said.

In other situations, SWAT nurses provide teaching and coaching to nurses who are developing their own expertise with particular nursing skills.

“For example, we may be called to the PICU as back-up to teach and coach a PICU nurse who’s learning to float a Swan-Ganz line,” Garay said. “Or we may walk a nurse through the steps to start an insulin drip on the weekend, and that nurse will then be able to begin the drip the next time.”

SWAT nurses also have the expertise to pitch in when a nursing unit has a sudden increase in workload. “Sometimes we provide the acute monitoring and attention that one patient needs, alleviating the pressure so the nurse can take care of the rest of her workload,” said SWAT team assistant manager Twila Balint, RN. “We can help keep patients flowing from ED, PACU or the cardiac cath lab to the nursing units.”

An Extra Set of Hands

Early intervention by SWAT nurses can be instrumental in avoiding critical care admissions.

“Most of the time, we can put out the fire, coordinating with the physician to control an arrhythmia so the patient doesn’t need a critical care bed, or stabilize a patient in renal failure until that individual can go for dialysis,” Garay said.

When patients do need critical care, the SWAT nurses can make a big difference in the clinical outcomes. Called to assess a male patient on the orthopedic unit, a SWAT nurse determined he was showing signs of deterioration in his respiratory status. She coordinated the intubation and stabilization on the floor before the patient was transferred to SICU.

When one of the critical care units needs an extra pair of hands, the SWAT team is on the scene.

“SICU recently had two full trauma cases that ended up coming from the ED almost simultaneously,” Garay said. “Staff members were doing procedures on both of them, including volume resuscitation, massive transfusions, multiple line insertions and med titration. The SWAT nurse was there to handle the extra workload.”

An Unqualified Success

Grant consistently hears about SWAT team successes from clinicians throughout the facility.

“We’re in the process of setting up a better feedback loop because most of the information I receive now is by word-of-mouth,” she said. “The SWAT nurses make a huge difference in patient outcomes, and this is great stuff.”

Physician response to the SWAT team has been quite good, Garay said. “When we get paged somewhere, we’ll often hear, ‘The doctor wanted me to call you for this patient,’ and that’s rewarding.”

While most of the calls to the SWAT team are very appropriate, occasionally the team identifies an educational need on a nursing unit.

“While we do try to help everyone who needs our assistance, sometimes we may need to educate the staff on how to handle a particular situation themselves,” Balint said. “For example, we recently noticed a number of calls to one nursing unit when the staff needed to access ports. We shared that information with the nurse manager as an educational need.”

Becoming a SWAT Nurse

All RNs on the SWAT team are ACLS-certified and have extensive critical care experience; most are CCRN-certified.

“SWAT nurses need very good clinical skills, and they need to be extremely flexible, self-motivated clinicians who aren’t going to get lost in the system,” Grant said. “We’ve learned that not just anyone can fill the role. We pull from nurses in the resource support unit who have a broad range of clinical experience, those who are used to working in MICU, SICU, CCU and ED.”

In order to become a SWAT nurse, members of the resource support pool must demonstrate leadership within the hospital’s clinical ladder system. “Right now, nurses have to be at least a CN-II, and we may be changing that to a CN-III because most of our current SWAT nurses have already reached that level,” Grant said.

Balint described SWAT nurses as very dedicated professionals. “They’re the nurses who jump in whenever there’s an emergency situation, always ready and able to help. They have excellent customer relation skills, which are recognized by their peers as well as patients, families and physicians,” she said.

Because the SWAT team members are the first responders in diverse clinical situations, it’s important that they keep up with the latest nursing practices.

“I rotate the SWAT nurses back into clinical settings regularly, so they maintain their clinical skills,” Grant said. “Each of the SWAT nurses has to work shifts wherever the need is, whether that’s MICU, CCU, SICU or ED, to make sure they stay at the top of their game.”

Grant described the SWAT team as an internal emergency resource. “Our SWAT nurses are like our very own flight nurses,” she said. “The SWAT nurse is the one person you can put anywhere — even in the most difficult crisis — and he or she just fits.”

Sandy Keefe is a regular contributor to ADVANCE.