American Journal of Critical Care. 2004;13: 406-409
Cardiovascular Single-Unit Stay: A Case Study in Change
By
Elizabeth I. Clark, RN, MS, CCRN, CCNS,
Constance L. Roberts, RN, MS, CCRN and
Karen C. Traylor, RN, MBA, CCRN.
From
North Memorial Medical Center, Robbinsdale, Minn.
 |
Abstract
|
|---|
A cardiovascular single-unit-stay program began at North Memorial Medical Center, Robbinsdale, Minn, in January 2000. Before then, cardiac surgery patients had been admitted to the intensive care unit directly from the operating room and then transferred to the postcoronary care unit on postoperative day 1 or 2. The traditional care delivery model created multiple transfers and delays in care, which often led to dissatisfaction among patients, increased costs, and greater potential for errors. The cardiovascular single-unit-stay program allows patients to stay in the same room with a consistent care team throughout the patients’ postoperative course. Decreased lengths of stay, decreased morbidity and mortality, increased satisfaction among patients and their families, and improved collaboration between members of the multidisciplinary team are just a few of the positive trends since the program’s inception.
In January 2000, the cardiovascular single-unit-stay program began at North Memorial Medical Center, a 518-bed community-based hospital in Robbinsdale, Minn. Before that time, cardiac surgery patients had been admitted to the intensive care unit directly from the operating room and then transferred to the postcoronary care unit on postoperative day 1 or 2. This traditional care delivery model had created multiple transfers and delays in care, which often led to dissatisfaction among patients, increased costs, and greater potential for errors. The cardiovascular single-unit-stay program allows patients to stay in the same room and have a consistent care team throughout the patients’ postoperative course. In this article, we describe the process of establishing a single-unit-stay program for cardiac surgical patients.
|
Historical Perspective
|
|---|
In 1995, nursing administration and the cardiovascular surgeons at North Memorial Medical Center identified key areas for improvement in the open heart surgery program. The areas targeted for improvement included mortality rate, sternal wound infection rate, and length of stay. The desire to make improvements led to the formation of a team to participate in the Breakthrough Series of the Institute for Healthcare Improvement (Boston, Mass, 1996–1998): "Reducing Costs and Improving Outcomes in Adult Cardiac Surgery." The Breakthrough Series involved a collaborative effort of 44 organizations representing more than 47 adult cardiac surgery centers working together from November 1996 to November 1997. An interdisciplinary team was created to participate in the Breakthrough Series and consisted of representatives from administration, anesthesia, cardiac surgery, and nursing. This team was charged with the task of designing a new care delivery model that enhanced patients’ outcomes and reduced costs. The team visited multiple sites throughout the United States, forming ideas on strategies for improving open heart surgery. As a result of the Breakthrough Series, a unique care delivery model known as The Cardiovascular Single-Unit Stay was developed. This program was modeled after the heart surgery program at Loma Linda Medical Center, Loma Linda, Calif, and was the first of its kind in the Midwest. The elements of the Loma Linda model we chose to emulate included minimal transfers of patients, rapid extubation, early ambulation of patients, enhanced communication, continuity of care, telephone calls to patients after discharge, and early referrals to other medical and nursing specialists.
The components that had to be developed before we opened the cardiovascular single-unit-stay program included converting the existing coronary care unit (where medical patients were cared for) to a cardiovascular intensive care unit (where medical and cardiothoracic surgical patients are cared for), recruiting and developing staff, and creating the multidisciplinary development team.
|
Redesign
|
|---|
The preexisting unit was built in the mid 1980s and consisted of 10 private and 6 semiprivate critical care bedsides with power columns, toilets, and sliding glass doors. The cost of renovating the existing 16-bed critical care unit was minimal. Renovations consisted of adding a community shower for infection control purposes and wound care education. Other costs included in the startup were related to the purchase of remote telemetry monitors and recliners for patients. Expensive renovations, though aesthetically pleasing, are not necessary for successful outcomes (Table 1
).
|
Staff Recruitment
|
|---|
The staff recruitment effort began with an invitation to all critical care nurses interested in the new care delivery model to participate in a panel interview. This self-elimination process gave the nurses an opportunity to ask questions and obtain information about the single-unit-stay program so they could make an informed decision about practicing within the new care delivery model. A 1-year commitment to the program was required. The new team was made up of critical care nurses; all of the nurses had solid critical care experience in the coronary care unit. Only 2 of the nurses who elected to practice on the unit were experienced in cardiothoracic surgical nursing.
Staff development was a major financial investment. An extensive educational process was developed to educate the staff. The cardiac surgery educational program consisted of 2 days of didactic education, 1 day of operating room observation, and 3 to 10 supervised training shifts caring for patients immediately after cardiothoracic surgery (Table 2).
|
Evolution of the Multidisciplinary Development Team
|
|---|
The evolution of the multidisciplinary team was a key component of the program’s development. The team consisted of the nursing staff, a cardiovascular clinical nurse specialist, a nurse manager, nurse clinicians, surgeons, and representatives from the respiratory care, social services, home care, utilization management, pastoral care, nutrition, education, cardiac rehabilitation, anesthesia, and pharmacy departments. This group was charged with developing the guidelines for care, which included the development of a critical pathway, revisions in policies and procedures, information for patients’ education, standing orders, discharge planning processes, and staffing patterns.
|
Current Practice
|
|---|
Patients are now admitted directly from the operating room to the cardiovascular intensive care unit, where postanesthesia recovery occurs. The rapid recovery phase begins with early extubation within 2 to 6 hours after surgery. This phase is followed by aggressive pulmonary toileting. In addition, each patient is assisted out of bed to a chair within 2 hours of extubation. Once the patient is extubated, is weaned off inotropic drugs, and has a stable hemodynamic status, he or she is transferred to intermediate status. The transfer is a change of status only and requires no physical transfer to another area of the hospital. The staffing ratios change as patients move from critical to intermediate status (Table 3). Removing the barrier of physical transfer allows early ambulation and initiation of the rehabilitation process. This nurse-initiated change in status usually occurs 12 to 18 hours postoperatively and consists of removing the pulmonary artery, arterial, and Foley catheters. Continuous electrocardiographic and oxygen saturation monitoring is discontinued, and remote telemetry monitoring is started. Specific criteria for the nurse-initiated transition were developed through a collaborative process involving nursing, cardiac surgery, anesthesia, and respiratory care departments. These criteria are incorporated into the standing orders (Table 4). Other protocol-driven nursing practices include treatment of atrial fibrillation, extubation, weaning from and discontinuation of oxygen therapy, and management of diabetes.
Other processes that have helped to increase the efficiency and continuity of care have been supported by the care management team. This support consists of rapid rehabilitation (Table 5), education of patients and their families, and discharge planning. The care team includes the staff nurse caring for the patient, the charge nurse, the nurse manager, the clinical nurse specialist, the patient/family educator, the cardiac rehabilitation specialist, the dietitian, the utilization management nurse, the respiratory care practitioner, the social worker, the home care liaison, the chaplain, and the nurse clinician from the surgeons’ group. This team meets 3 times a week to review the progress of each cardiac surgical patient. The team coordinates the care of each patient, reviews the plan for discharge and follow-up care, and expedites referral to appropriate healthcare members. These collaborative efforts often result in decreased delays in discharge, and patients and their families are able to progress rapidly through the system.
The staff nurses in the cardiovascular intensive care unit continue to provide support to patients and the patients’ families after early discharge by conducting 2 follow-up telephone calls on the first and seventh day after discharge. During the telephone calls, nurses have an opportunity to answer questions related to patients’ recovery at home, reinforce discharge teaching, and obtain feedback from patients about the patients’ stay in the unit.
|
Outcomes
|
|---|
The composite result of these practices has been enhanced continuity of care. In addition, patients and their families enjoy a greater sense of security knowing that they are always in the care of the vigilant critical care staff. In more tangible ways, the success of the cardiovascular single-unit-stay program is evidenced by decreases in mortality rate, earlier extubation times, fewer deep sternal wound infections, and shorter lengths of stay. The mortality rate for patients having first-time elective surgery declined from 4.2% to 0% during the past 6 years. Postoperative median extubation times were reduced from 9.9 to 5.5 hours. Deep sternal wound infection rates were reduced from 4.2% in 1994 to 0.9% in 2002, thanks to standardization of preoperative skin preparation practices, intraoperative administration of antibiotics, maintenance of blood glucose levels at less than 11.1 mmol/L (200 mg/dL), and postoperative wound care practices. Before implementation of the single-unit-stay model in 2000, the length of stay for patients who had undergone open heart surgery was 7.5 days. During the first quarter of implementation of the new delivery model, the length of stay for patients who had elective surgery for the first time decreased to 5.3 days. With continual emphasis on quality improvement, the length of stay for the second quarter of 2003 was 4.0 days. Recent reports from the National Research Corporation on satisfaction of patients and their families revealed that 100% of those polled would recommend the cardiac surgery program. Improved satisfaction among staff members is evidenced by increased staff retention rates. Staff turnover has decreased from 28.3% to 1.7% since the single-unit-stay model was implemented.
A significant cost savings was achieved by changing the culture and modus operandi of the traditional critical care units. Delays in care while patients wait to be transferred from the intensive care unit to a telemetry unit are eliminated. Ambulation, cardiac rehabilitation, and education begin as soon as each patient is ready, leading to an earlier discharge.
The primary cost advantage of the single-unit-stay concept is the decrease in length of stay. During the first year, length of stay decreased from 7.5 days to 5.3 days for all patients at our institution. The financial savings in today’s dollars equates to approximately $4567 per admission. Moving to a single-unit-stay program resulted in an estimated potential cost savings of approximately $1.95 million. This cost savings is based on charges for beds in the intensive care and intermediate/stepdown units.
|
Summary
|
|---|
The success of the single-unit-stay program can be attributed to the daily enthusiasm, dedication, and professionalism of each member of the multidisciplinary team as the team continues to provide expert care to patients and patients’ families. Decreased length of stay, decreased morbidity and mortality, increased satisfaction among patients and their families, and improved collaboration between members of the multidisciplinary team are goals reflected in this innovative model for delivery of patients’ care.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
This article has been cited by other articles:
|
|
|
|
 
N. Noiseux, D. Bracco, I. Prieto, and T. M. Hemmerling
Do patients after off-pump coronary artery bypass grafting need the intensive care unit? A prospective audit of 85 patients
Interactive CardioVascular and Thoracic Surgery,
February 1, 2008;
7(1):
32 - 36.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Historical Perspective
