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Abstract |
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 Top Abstract BackgroundMethodsResultsDiscussionSummaryReferences |
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• Objective To test whether use of acuity-adaptable rooms helps solve problems with transfers of patients, satisfaction levels, and medical errors.
• Methods A pre-post method was used to compare the effects of environmental design on various clinical and financial measures. Twelve outcome-based questions were formulated as the basis for inquiry. Two years of baseline data were collected before the unit moved and were compared with 3 years of data collected after the move.
• Results Significant improvements in quality and operational cost occurred after the move, including a large reduction in clinician handoffs and transfers; reductions in medication error and patient fall indexes; improvements in predictive indicators of patients’ satisfaction; decrease in budgeted nursing hours per patient day and increased available nursing time for direct care without added cost; increase in patient days per bed, with a smaller bed base (number of beds per patient days). Some staff turnover occurred during the first year; turnover stabilized thereafter.
• Conclusions Data in 5 key areas (flow of patients and hospital capacity, patients’ dissatisfaction, sentinel events, mean length of stay, and allocation of nursing productivity) appear to be sufficient to test the business case for future investment in partial or complete replication of this model with appropriate populations of patients.
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To receive CE credit for this article, visit the American Association of Critical-Care Nurses’ (AACN) Web site at http://www.aacn.org, click on "Education" and select "Continuing Education," or call AACN’s Fax on Demand at (800) 222–6329 and request item No. 1173.
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These "bottlenecks" in the flow of patients have reached epidemic proportions and at times require tedious and even life-threatening diversions from hospitals and emergency departments because of the lack of beds or the inability to admit the next patient.3–6 These bottlenecks can delay appropriate assignments of patients to beds. Many times staff and administrators are torn between putting the next patient in the hallway of the emergency department—without appropriate nursing care and equipment—or diverting the patient to another hospital and delaying the patient’s care. If the new patient is admitted during times of full occupancy, the struggle for bed control to place the patient can continue for hours or days. This article focuses on flow of patients and models of care that offer significant opportunity for solving this problem.
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Background |
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TopAbstractBackgroundMethodsResultsDiscussionSummaryReferences |
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| Bottlenecks in patient flow delay assignment of patients to beds and adversely affect care.
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To receive the level of care that matches their variable patterns of acuity, patients often move 3 to 6 times during their short stay. The results of these moves include missed or delayed treatments, medication errors, patients falling, and individual contact with as many as 50 to 100 caregivers or allied health professionals. An increased workload index (tasks and physical movement) is inherent in current nursing care models, and it often adds no value to patients’ outcomes (A.L.H., unpublished data, 2003). Most tools for measuring acuity do not consider the effects of frequent moves of patients on caregivers or nursing units. Yet the calculation of weighted measures for patients’ acuity, converted to a workload index, is how most nursing departments budget and plan the number of nursing hours per patient day (NHPPD). Today’s typical nursing unit may transfer or discharge a staggering 40% to 70% of its patients every day. A reasonable workload index is a key predictor of retention of nurses; thus, it is a chief domain of opportunity as it relates to the flow of patients and the development of new care models.
During the past 10 years, the distinction between critical care and medical-surgical care units has blurred with an ever-increasing acuity of patients, resulting in the evolution of progressive care units. Patients are admitted to progressive care units if they require short-term mechanical ventilation, infusions of vasopressors, or physiological monitoring and if they have altered levels of consciousness, altered fluid status, hypertensive crises, gastrointestinal hemorrhages, or drug overdoses. These patients ("tweeners") are at an acuity level between the acuity levels for critical care units and medical-surgical care units. Progressive care units often present a staffing challenge when nurse staffing is at a 1:2 ratio, which mirrors the NHPPD for critical care units (19–20 NHPPD). This situation challenges the efficiency and productivity of small progressive care units (4–12 beds). The number of patients who require progressive care (also termed "low-risk monitored patients") has increased sharply in the past decade. Because this growth is consistent and measurable, it suggests the need for additional and flexible rooms for patients who require progressive care. A possible solution is acuity-adaptable rooms.
The problem of patient flow and hospital capacity is multifaceted and is externally driven by several key factors: an aging population; migration of short-stay (less acutely ill) patients from tertiary hospitals; new technologies; and compressed, higher acuity lengths of stay. Small, incremental improvements can be achieved from targeting bed placement, communication, and housecleaning efficiency. However, for long-term success and future delivery of care, the medical-surgical specialty part of patient flow must be examined.
| Nursing units transfer or discharge 40% to 70% of their patients every day.
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Facilities are increasingly unable to meet the demand for beds in progressive care units. When the beds in the progressive care unit are full, a patient with mid-level acuity will be placed in a bed in a critical care unit. A significant number of beds in critical care units are often occupied by patients who are low risk but require monitoring according to the criteria of the Acute Physiology and Chronic Health Evaluation.7 The difference between the NHPPD of 19 to 20 in critical care units and the NHPPD of 5 to 6.5 in medical-surgical units is significant, and it is a primary factor in physicians’ decision making about placement of patients. Also, because it is a constant concern for nursing practice and patients’ safety when high-acuity patients are placed in general medical-surgical units, physicians and nurses will opt to place patients in the beds designated for patients with higher acuity. The resulting short stays and multiple transfers—or even discharges directly to home—contribute to increased workload index for critical care staff and poor utilization of scarce resources (human and fiscal). Moreover, the lack of availability of beds in a critical care unit can pose safety concerns: delays in placement of patients and referrals or transfers of high-acuity patients.
This phenomenon became the driving force behind our demonstration project, which we named Cardiac Comprehensive Critical Care (CCCC). A room with acuity-adaptable headwalls was developed to provide an improved care environment for patients who required progressive care.
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Methods |
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Two studies8,9 at British Columbia Women’s Hospital indicated that satisfaction of staff members and patients with the hospitalization experience was greater when patients remained in a single room throughout the entire stay (for low-risk obstetric admissions). An increase in satisfaction was indicated in the following areas: provision of information and support, physical environment, nursing care, education of patients, assistance with infants’ feedings, respect for privacy, preparation for discharge, and increased overall satisfaction with the work environment. Results of additional studies10–17 support these findings. Furthermore, Besserman et al10 tested use of an alternative flexible approach to traditional fixed intermediate and intensive care to minimize transfers of patients. Direct admissions to a flexible intermediate care unit increased, with no overall change in admissions to the intensive care unit. Fewer patients needed conventional mechanical ventilation, and more patients in both units (intermediate and critical care) could be treated with noninvasive ventilation. In addition, length of stay and mortality decreased, and some cost savings resulted from the decrease in the number of transfers. Further, allowance of flexible monitoring demonstrated a decrease in length of stay and saved one hospital more than $3 million in the first year of implementation.10
Planning for Evidence-Based Design
Discussion about the need for this type of unit began during the mid-1990s, when the Methodist campus of Clarian Health, Indianapolis, Ind, had an urgent need to plan for additional bed capacity, because of consolidation. Awareness of the problem of patient flow, which was occurring more often, was keen. Methodist Hospital had 2 floors of shell space for a nursing unit, a situation that presented a unique opportunity to combine current knowledge with a long-term, futuristic view of models for delivery of progressive and critical care.
The framework for team planning and the process used were interdisciplinary. A blend of continuous quality improvement principles and systems thinking was integrated with evidence from the literature. In order to proceed with the design process, the clinicians’ perspectives and results from 2 studies on work process and patient flow (A.L.H., unpublished data, 2003) were incorporated into the process. The first study was a 1000-hour video of time and motion on a medical-surgical unit that simultaneously detailed all activities in the patient’s room, the hallway, and the nursing station. The second study was a direct observational study of transport of patients. From these studies, it was clear that our weaknesses paralleled those outlined in the "Background" section of this article. The caregiver environment was addressed: workload index (including transfers of patients), ergonomics such as reach and distance to perform care tasks, and equipment location. An expert on designing environments that promote healing worked with staff on site to improve lighting, colors, air quality, warmth, and patients’ privacy.18 Focus groups of patients were used throughout the design process.
Discussions were held with the Joint Commission on Accreditation for Healthcare Organizations and the state department of health because some standards would be challenged by the new design. An unanticipated barrier was the definition of critical care in the HCFA guidelines. These guidelines define critical care and guide the billing standards that create limits about charging different amounts for the same bed according to the type of care provided. Variable rates generally cannot be used for beds designated for critical care. The language defining critical care created a barrier to the improvements. Ultimately, a HCFA appeal process was used to legitimize standard criteria for variable billing because patients would not be transferred from the acuity-adaptable rooms. Specific acuity criteria for variable rate billing and written physicians’ orders for discharging from one level of acuity to another were the final solution.
Our basis for choosing a population of patients included consolidation needs, characteristics of the bottleneck, and our need for a population with a fairly predictable clinical course. Consequently, the coronary critical care unit and its step-down medical unit were selected (Figure 1
). Once the population of patients was selected, the project team worked to solidify the overall design aims of the CCCC’s demonstration project:
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First, we needed to shift indirect time back to the nurses and patients’ care by reducing the steps necessary for nurses to obtain supplies, reduce transfers of patients, rework the care delivery model, minimize delays for placement of patients and waits in holding areas, eliminate equipment duplication, maximize technology for efficiency, and have information for patients and caregivers readily available at the point of care.19 Second, the development of a preeminent healing environment and experience for patients was a high priority.20–30 In order to provide rest and comfort for patients and their families and significant others and prevent clinical complications, additional space was planned for a family area.31,32 Finally, a high-tech, user-friendly approach to the education of patients and their families was developed to encourage prevention and self-care.
The Final Design
The CCCC opened in the fall of 1999 as a preeminent care unit balanced with healing characteristics. The unit features 56 acuity-adaptable rooms (28 per floor), with an additional treatment room on each floor. The CCCC provides a warm atmosphere without sacrificing the nursing staff’s access to technological and medical needs. A national demonstration model within 3 years, the CCCC was recognized by the American Association of Critical-Care Nurses, the Society for Critical Care Medicine, and the American Institute of Architects as the critical care award winner. It has already established new standards for high-tech, holistic care.
Each room occupies 36 m2 (400 ft2) and consists of 3 main areas: the family zone, the patient zone, and the caregiver zone. The family zone offers many new features: a chair-bed for nighttime visits, a refrigerator, a computer hookup, voice mail, and a television/videocassette recorder. Each oversized room also includes 13.5 m2 (150 ft2) of family space. Waiting areas are designed to provide more soothing features, such as an indoor garden, an aquarium, a kitchenette, and small lockers. Additional features for patients and their families in the unit include customized educational kiosks and computer-based education. The content orients patients and their families to the unit and provides a source for education individualized to each patient.
| Acuity-adaptable rooms were designed so that progressive and critical care could be provided in the same setting.
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Technologically, the rooms are state of the art. All equipment and supplies required for the medical needs of critical care patients are easily accessible, including transforming (acuity-adaptable) headwalls and advanced computer technology located directly on the patient’s bed, so staff can record body weight and other vital data without disturbing the patients. Patients are admitted and discharged from the same room (Figure 2).
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and 4). Because most of the distance traveled by nurses in a typical unit consists of travel back and forth to the nursing station,3,14 we arranged for necessary supplies to be in each patient’s room. Nursing stations with computer access and servers for supplies are decentralized. Additional workspace for care-givers is located just outside each patient’s room. The design of the corridor allows emergency equipment such as defibrillators to be hidden behind doors.
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Data Collection
In order to assess the impact of this acuity-adaptable demonstration project, various clinical and financial measures were measured before and after the move. A list of 12 questions was formulated as the basis for inquiry; 7 are reported on here. Two years of baseline data were collected from the Transition System, Inc (Vanderbilt University Medical Center, Nashville, Tenn; International Classification of Diseases, Ninth Revision/diagnosis-related groups, demographics, admission/discharge/transfers, charge/cost, complication codes and case-mix index severity), QuadraMed (nursing acuity; QuadraMed Corp, Reston, Va), and the hospital’s data base of sentinel events before the move. The data obtained before implementation of the new design were to be compared with 3 years of data collected in the months after implementation. The 7 areas of inquiry were as follows:
Related variables such as case mix index and patient acuity, which could affect the analysis of outcome measures, were carefully compared to ensure that beneficial and adverse changes from the baseline could be detected.
Two sentinel events (ie, medication errors and patients’ falling) were tracked continuously because of their commonality and their potential adverse effect on quality of care and patients’ outcomes. In order to ensure that reliable measures were used in the comparison, a monthly index was used to track rates before and after the move. An index is sensitive to shifts in the number of days patients are in the unit, which could account for more or less opportunity for errors to occur. The annual medication error index, as measured by the hospital’s standard system for reporting adverse events, was used before and after the move.
Patients’ reactions were measured with the Patient Expectation Project standardized tool (Arbor Associates, Inc, Petoskey, Mich). Patients’ levels of satisfaction and dissatisfaction before and after the move were compared. This tool measures how closely patients’ experiences met their expectations as customers as well as key factors that predict patients’ overall willingness to choose the hospital again or to recommend it to family and friends. These factors are statistically weighted as to importance, and relative values are assigned.
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Results |
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).
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). The large reduction in hand-offs among clinicians, near-elimination of transfers of patients, and the simplification of the work milieu for caregivers are thought to be directly correlated with the reduction in the medication error index and are consistent with results reported in the literature on patients’ safety. Error reporting did not change during the study period; in fact, staff were encouraged and educated about the importance of error reporting in the new environment.
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| After implementation, transports of patients decreased by 90% and medication errors decreased by 70%.
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An additional finding was related to patients’ falling. Most patients fall while in their room, and the fall is usually related to elimination needs.33,34 The design of this unit incorporated decentralized nursing stations just outside each patient’s room, a feature that increases the time available for meeting patients’ needs and decreases the time and distance nurses must travel to help patients. As a result, the fall index for the cardiac population (a high-risk group) moved to a national benchmark level of 2 falls per 1000 patient days (Figure 7), a huge stride forward for patients’ safety.
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). The new unit experienced a 3% decline in overall dissatisfaction in the 3 years after the move (Figure 9).
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This finding suggests that the acuity-adaptable room design may be able to help reverse the rising shortage of nurses by ensuring that available nursing hours are directed toward patients rather than waste and inefficiencies in the environment (Figures 10 and 11). The increase in patient days per bed, with a smaller bed base (number of beds/patient days) is significant (Figure 12) and confirms that acuity-adaptable rooms allow care for more patient days in fewer beds. This result has implications for long-range building plans, suggesting smaller area requirements for physical plant space—if acuity-adaptable beds are used—as a real possibility. In the short-term, without adding additional beds, facilities may be able to stretch additional capacity out of the same number of beds by simply introducing some acuity-adaptable rooms within each service area or specialty.
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| Blending the critical care and medical nurse cultures was challenging but ultimately successful.
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Some turnover of additional staff occurred in the first year (Figure 13). However, this turnover stabilized in years 2 and 3, confirming that the benefits for patients and the system are well worth the risk of cultural change. In the beginning, critical care nurses expressed concerns over isolationism because of decentralized work areas and a sense of loss over the traditional critical care environment (limited visitation, controlled access of patients’ family members, and a "pure" critical care staff mode). The culture of the critical care nurse merging with the medical nurse was a barrier that took time and energy to refocus. Team-building exercises, clinical sessions, validation of clinical competency, and luncheons were used to prepare staff members for the change. In the future, efforts to build a cohesive work team might be expedited by using an employee profiling tool for hiring selection and more extensive team-building exercises. Ultimately, it may simply be the human reaction to this level of change that will prevent 100% of the individuals from adapting.
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Discussion |
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Such patients have similar needs and create workload intensity when added to the areas for the general population of inpatients.
Another finding was that the newness of the technology contributed to the staff ’s underuse of some equipment. For example, nursing call lights had infrared scanning to enable caregivers to locate each other anywhere on the unit from within a patient’s room, yet nurses were still seen walking to find each other. Technology can meet the expectations of improved performance only when the users are familiar and comfortable with it. Constant reminders on how to use the technology and the benefits of its use for caregivers and patients can assist staff members in accepting technology as a tool rather than perceiving it as an obstacle.
The characteristics of the healing environment caused anxiety for some staff members. The size of the unit and decentralized nursing stations both contributed to the sense of isolationism and promoted more autonomous decision making. Some critical care nurses were uncomfortable not having another critical care nurse visible. Although ongoing education of the medical nurses was crucial as they learned additional skills, they adapted to the change in environment most easily. They also voiced personal satisfaction as a result of new clinical skills and professional expectations. Eventually, review classes for the critical care nurses and frequent staff meetings helped diminish these effects. Physicians remained skeptical and cautious during the first 2 years as nursing skills were validated.
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Summary |
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Hundreds of new hospitals are being built without short-term answers related to the supply and demand for healthcare labor. Adding new hospital beds to match demographic growth may be a straightforward decision. However, adding hospital beds without reflecting on the root problem of hospital bottlenecks or considering community-based prevention and disease management programs to lessen the healthcare burden may only worsen the shortage of caregivers. Future delivery of care will be strategic if disease management and community-based models are combined with new, more efficient hospital designs to add beds when needed yet conserve nursing and healthcare labor resources. A significant opportunity exists for organizational innovation and change for the good of patients, caregivers, and an ailing healthcare delivery system.
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ACKNOWLEDGMENT |
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REFERENCES |
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This article has been cited by other articles:
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  M. E. Detsky and E. Etchells Single-Patient Rooms for Safe Patient-Centered Hospitals JAMA, August 27, 2008; 300(8): 954 - 956. [Full Text] [PDF]
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 D. Pati, T. Harvey, and C. Cason Inpatient Unit Flexibility: Design Characteristics of a Successful Flexible Unit Environment and Behavior, March 1, 2008; 40(2): 205 - 232. [Abstract] [PDF]
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 S. B. Hassmiller and M. Cozine Addressing The Nurse Shortage To Improve The Quality Of Patient Care Health Aff., January 1, 2006; 25(1): 268 - 274. [Abstract] [Full Text] [PDF]
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 J. Matukaitis, P. Stillman, E. Wykpisz, and E. Ewen Appropriate Admissions to the Appropriate Unit: A Decision Tree Approach American Journal of Medical Quality, March 1, 2005; 20(2): 90 - 97. [Abstract] [PDF]
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