How Being an ICU Nurse Prepared Me to be NLM Director

In mid-May, at their 2022 National Teaching Institute & Critical Care Exposition in Houston, Texas, I received a great honor from the American Association of Critical Care Nurses (AACN): the AACN Pioneering Spirit Award. I was delighted to receive this prestigious award, which recognizes significant contributions that influence progressive and critical care nursing worldwide and relate to AACN’s values of integrity, inclusion, transformation, leadership, and relationships. I was humbled to receive this award for my work during my tenure as NLM Director, and it’s in large part due to the work that so many NLM employees do every day.

This acknowledgement from AACN is deeply meaningful to me because critical care nursing has been a part of my professional identity for almost 50 years! In 1974, while I was still in nursing school, I was assigned to work as a nursing assistant in the critical care medical unit at Lankenau Medical Center outside Philadelphia. After graduating in 1975, I became part of the nursing team in the surgical intensive care unit (ICU) at the very same hospital.

These early experiences have touched every part of my career, including my role at NLM—the epicenter for biomedical informatics and computational health data science research and the largest biomedical library in the world.

Then: Learning from My Teachers and Colleagues

I learned from Kathy McCauley, cardiac-care nurse extraordinaire, about the importance of the scientific basis of nursing. Nurses’ deep knowledge of physiology, pharmacology, and anatomy enables the bedside critical care nurse to almost instantaneously recognize vital changes in a patient’s medical status and determine just the right interventions to rebalance fluid or improve oxygenation. My colleague and ICU nurse, Nora Kelly, modeled respect for patient dignity that, to this day, shapes my work to support patient self-management using effective computer technologies. Nora showed me that even in the midst of an often hectic, fast-paced ICU environment, there was always time to provide a patient with comfort, help a person into a more comfortable position, or complete basic hygiene and grooming around tubes and monitor wires.

Now: Serving as Your NLM Director

What stands out the most to me now are the lessons about the importance of in-the-moment information processing; interdisciplinary teamwork supported by nurses, physicians, respiratory therapists, pharmacists, social workers, and others; and personal accountability that shape my everyday life as the director of NLM. Delivering high-quality care under extreme levels of uncertainty and risk is the hallmark of critical care. I learned early on that time was of the essence—there was rarely an opportunity to pause and read an article or two as one pondered how to intervene in a physiology cascade that could lead to sudden death.

The insights from these experiences taught me that for information to truly support in-the-moment care, NLM needed to make its resources open and available in machine-readable formats. It is our job to use machine-learning algorithms to make available NLM’s vast repository of biomedical and scientific literature that drives contemporary drug management or clinical guidelines interpretation. NLM invests in research that helps ICU professionals quickly interpret patient charts so they can predict the likelihood of pulmonary embolism diagnosis or track a patient’s probable health outcome trajectory using observations noted in their electronic health record.

NLM in the ICU

ICU patients in hospitals around the country are all supported by the best interprofessional teams that understand the unique aspects of patient care, whether that’s to advance the patient’s progress towards wellness or to provide alternative end-of-life care focused entirely on comfort. Because of the diversity of caregivers and professionals across hospital ICUs, we must acquire, organize, and disseminate the literature to all biomedical professional groups when they need it most.

It is in this spirit that each division in NLM—including our Library Operations team managing our NLM Collection, our MEDLINE Literature Selection Technical Review Committee to impanel experts across many specializations, and our PubMed and PubMed Central with the tools to index and catalog records—accelerates the dissemination of knowledge from many disciplines. Clinicians are required to have deep expertise and stay abreast of new research within their specialty and to recognize potentially valuable literature from other disciplines. In support of this requirement, we organize over 34 million citations by clinical problem and physiological underpinning. That way, no matter what your specialty, each search identifies literature from a wide range of perspectives and refines our “relevance-based results return” according to those patterns most valued by our patrons, as described by NLM’s Best Match algorithm.

Patients often find themselves in the ICU from somewhere else in the health care system and are frequently discharged not to their homes, but to other less-intensive clinical care units. To understand their conditions and efficiently guide their care in a vast, complex, and time-sensitive setting, health care interprofessional teams should understand all ICU clinical information and events so they can translate and transmit that information to the responsible post-discharge teams. This information flow relies on health data standards so that events that occur in one place are well understood in the next. NLM plays an important role by forecasting how health care settings like ICUs will use health data standards to promote interoperability and by shaping the public policies that protect patient records. NLM shares its expertise in data science, health information technologies, and computer science with our fellow federal agencies and with the private sector to make sure patient records are accessible while remaining private and secure.

Connecting the Dots

I remember the enormous intimacy involved in my ICU nursing experience, often including myself and a patient, at times the patient’s family, and certainly every time the rest of the care team. But teamwork only works when each member holds sacred their responsibility to the patient and the care that they require. Personal accountability does not occur in a vacuum; rather, it is molded and shaped through conversations with colleagues, collaborative care-planning rounds, candid postmortem reviews, and quiet heart-to-hearts in the staff lounge. Even these efforts are touched by NLM, from providing literature and guidelines that lay out the various roles of professionals to furnishing our citations repository with the contact information of those authors whose work guides clinical thinking. In this way, NLM becomes a partner for personal accountability.

If only that fledgling ICU nurse from 50 years ago knew that her entire cultural and practical experience was preparing her to direct the most important health science library in the world! Because of who she was as that nurse and who we are as NLM, critical care remains a cornerstone of health care information and systems in best support of all patients. If you have ideas for how NLM can better support the critical care of YOUR patients, please let us know!

The Next Normal: Supporting Biomedical Discovery, Clinical Practice, and Self-Care

As we start year three of the COVID-19 pandemic, it’s time for NLM to take stock of the parts of our past that will support the next normal and what we might need to change as we continue to fulfill our mission to acquire, collect, preserve, and disseminate biomedical literature to the world.

Today, I invite you to join me in considering the assumptions and presumptions we made about how scientists, clinicians, librarians and patients are using critical NLM resources and how we might need to update those assumptions to meet future needs. I will give you a hint… it’s not all bad—in fact, I find it quite exciting!

Let’s highlight some of our assumptions about how people are using our services, at least from my perspective. We anticipated the need for access to medical literature across the Network of the National Library of Medicine and created DOCLINE, an interlibrary loan request routing system that quickly and efficiently links participating libraries’ journal holdings. We also anticipated that we were preparing the literature and our genomic databases for humans to read and peruse. Now we’re finding that more than half of the accesses to NLM resources are generated and driven by computers through application programming interfaces. Even our MedlinePlus resource for patients now connects tailored electronic responses through MedlinePlus Connect to computer-generated queries originating in electronic health records.

Perhaps, and most importantly, we realize that while sometimes the information we present is actually read by a living person, other times the information we provide—for example, about clinical trials (ClinicalTrials.gov) or genotype and phenotype data (dbGaP)—is actually processed by computers! Increasingly, we provide direct access to the raw, machine-readable versions of our resources so those versions can be entered into specialized analysis programs, which allow natural-language processing programs to find studies with similar findings or machine-learning models to determine the similarities between two gene sequences. For example, NLM makes it possible for advocacy groups to download study information from all ClinicalTrials.gov records so anyone can use their own programs to point out trials that may be of interest to their constituents or to compare summaries of research results for related studies.

Machine learning and artificial intelligence have progressed to the point that they perform reasonably well in connecting similar articles—to this end, our LitCovid open-resource literature hub has served as an electronic companion to the human curation of coronavirus literature. NLM’s LitCovid is more efficient and has a sophisticated search function to create pathways that are more relevant and are more likely to curate articles that fulfill the needs of our users. Most importantly, innovations such as LitCovid help our users manage the vast and ever-growing collection of biomedical literature, now numbering more than 34 million citations in NLM’s PubMed, the most heavily used biomedical literature citation database.

Partnerships are a critical asset to bring biomedical knowledge into the hands (and eyes) of those who need it. Over the last decade, NLM moved toward a new model for managing citation data in PubMed. We released the PubMed Data Management system that allows publishers to quickly update or correct nearly all elements of their citations and that accelerates the delivery of correct and complete citation data to PubMed users.

As part of the MEDLINE 2022 Initiative, NLM transitioned to automated Medical Subject Headings (MeSH) indexing of MEDLINE citations in PubMed. Automated MeSH indexing significantly decreases the time for indexed citations to appear in PubMed without sacrificing the quality MEDLINE is known to provide. Our human indexers can focus their expertise on curation efforts to validate assigned MeSH terms, thereby continuously improving the automated indexing algorithm and enhancing discoverability of gene and chemical information in the future.

We’re already preparing for the next normal—what do you think it will be like?

I envision making our vast resources increasingly available to those who need them and forging stronger partnerships that improve users’ ability to acquire and understand knowledge. Imagine a service, designed and run by patients, that could pull and synthesize the latest information about a disease, recommendations for managing a clinical issue, or help a young investigator better pinpoint areas ripe for new interrogation! The next normal will make the best use of human judgment and creativity by selecting and organizing relevant data to create a story that forms the foundation of new inquiry or the basis of new clinical care. Come along and help us co-create the next normal!

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