Morale is a tricky issue as bed loads increase
Occupancy rates in ICUs at 90%
When managed care began changing the face of health care, few doubted its impact would soon be felt in the ICU. In areas of high managed care penetration such as Minnesota and California, the changes are well under way, and nurse managers are feeling the pressure.
"We are seeing a trend in the hospital with patients who have multisystem failures in the ICU,"says Joanne Disch, PhD, RN, FAAN, vice president patient/family services at Fairview University Medical Center in Minneapolis. "The nature of the ICU patient is more complicated, and this is contributing to the increase in ICU admissions." Disch says her hospital is experiencing an increase of five to six new patients a day out of a base of 35. That's a 20% increase to the ICU budget.
In Sacramento, CA, at least 95% of the population is covered by HMOs and as much as 40% is capitated. "We have already reduced our length of stay hospitalwide to 4.7 days, which is as low as I think we can go," says Carol Robinson, RN, MPA, director of nursing at University of California Davis Medical Center in Sacramento. "This is the average LOS that we and other hospitals are experiencing."
Robinson says the increases at her facility are due to patients who, although well-educated on managed care plans, may not seek prompt care, may have trouble getting an appointment with a primary care provider, or encounter difficulty obtaining authorization to see a specialist. Robinson says her hospital has seen a rise in census from 48,000 patient admissions one year to 58,000 the next. Moreover, one quarter of the medical center's beds are intensive care, which have a 90% occupancy.
More patients, sicker patients, plus more pressure to cut costs yet improve quality - it can all add up to an ICU being a less than ideal place to work. That's why nurse managers are struggling to reinvent their environments. Strategies being used in California, Minnesota, and elsewhere include:
· Several floating pools of nurses troubleshoot on units throughout the institution. "We have a per diem pool, a float pool, and a float-float pool," says Disch. Floating clusters of nurses are specially trained for the ICU.
· An incentive program was established to encourage nurses to take on extra shifts. If a nurse agrees to take six extra shifts per month, she is paid her salary for those shifts plus $60 per extra shift for a total of $360 in potential incentives.
· Nurses developed and implemented an on-call ICU nurse program. When the census goes down and the ICU is overstaffed, a nurse agrees to return home but remain on call for emergencies. This nurse gets paid an on-call rate while at home.
· The hospital implemented an aggressive recruitment program to increase staffing levels and eventually hired more than a dozen new nurses.
· The hospital works with staff to create a healthy working environment to increase retention. This makes nurses want to pitch in and help where they can.
· A new software program helps to take the drudgery out of paperwork. The nurses have expressed their delight with the program and says it helps them in their work.
The University of California Davis Medical Center has found success with implementing several of the following ideas:
· Expenses are paid for nurses who have abstracts accepted for presentation at conferences. The medical center sends at least six to eight people to these conferences per month which encourages nurses to stay active in their profession and advance practices.
· The ICU units focus on several projects, such as developing a protocol to wean patients off ventilators sooner, which produced a one day reduction in length of stay. Studies in pain management have provided ideas on alternative therapies, such as music or imaging therapies. One of the ICUs is working on a research project to study the agitation in patients to develop measurement techniques, drug treatments, and protocols.
· A recognition program shows nurses their contributions are valuable. Special recognition is given to teams or individuals, recommended by their peers, who have contributed significant ideas or research to help improve practices and save the medical center money. The financial bonuses range from $100 to $5000, depending on the impact of the idea.
Research is a winner
The medical center also has an active retention program, which is a training program for new graduates in critical care and offers flexible scheduling so nurses have more time to spend with their families. However, it is the research focus that has contributed to the waiting list of nurses who want to work for the organization. "We offer nurses in critical care and throughout the facility the opportunity to conduct research and publish and present it," says Robinson.
The medical center provides education and training on how to conduct research and has several projects under way simultaneously. Nurses are encouraged to seek out research that will improve their practice or advance the profession of nursing. "The research we do here focuses on nursing's impact on patient care," says Robinson. "These research projects foster self-esteem in our nurses and differentiate them from an hourly worker."
Robinson says further that nurses receive support for bedside care and any changes in practices or procedures have a base in research so they are validated process. "All our nurses are taught to ask why a procedure is done a particular way and if it can be improved," Robinson says "It is a sense of inquiry and investigation that gets nurses invested in their profession."
Many ICUs have seen their census increase, and in some parts of the country, are experiencing a shortage in critical care nurses. As a trend, experts agree that fluctuations in the ICU may be over. With sicker patients being admitted, the need for beds will continue to grow. Hospitals will need to address staffing levels and create unique and interesting methods of retaining nurses while maintaining quality care.
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