NJ hospital’s novel unit saves on patient transfers
A flex approach’ to patient care eases ICU load
A medical center in New Jersey has found a novel way to tailor the amount of critical care given to certain extremely ill patients while solving a stubborn, costly problem faced by many nurse managers and physicians.
Muhlenberg Regional Medical Center in Plainfield, NJ, is perfecting the use of what its clinicians describe as a "flex unit-approach" to handling certain patients who normally would be regarded as candidates for an ICU admission, but don’t quite fit that classification.
In 1994, the 420-bed hospital set up an intermediate critical care floor to serve patients whose diagnoses and conditions qualified for ICU care, but did not require the full, intensive nursing or monitoring traditionally delivered in the ICU.
The flex unit addresses many patient-care issues, but it also solves the burdensome problem of having to physically move a critically ill patient from a medical-surgical floor to an intensive care department, says Eva Besserman, DO, Muhlenberg Regional’s associate director of critical care.
Unit serves critical patients not right for ICU
"As any nurse knows the time and work involved in transferring a critically ill patient from one department to the ICU usually results in frustrating delays, system slowdown, and higher costs [in labor and time]," Besserman says. "Then there’s the discomfort to the patient and families."
By creating a dedicated unit to serve patients who are too sick to remain on most general medical floors, but not ready for full ICU services, clinicians have significantly reduced the number of patient transfers and admissions to the ICU.
The exact number is difficult to determine. The ICU continues to experience daily changes in patient status, discharges, and admissions even with the existence of the flex unit. But clinicians speculate that the flex unit has helped stabilize patient flow in the ICU.
In doing so, the system has enabled the ICU to better control patient management, daily census, and average length of stay by addressing the needs of patients who are likely to receive the full benefit of ICU care, Besserman notes. It also has reduced pressure on early discharges.
In fact, the flex approach to critical care has worked so well for the hospital that the ICU adopted a similar flex approach for its own patients, says Sheri Cleaves, RN MSN, CCRN, a clinical nurse specialist at Muhlenberg Regional.
At most hospitals, units of this type would be regarded as a step-down floor. But it doesn’t quite fit that profile, Cleaves observes. For one, step-downs usually take ICU patients who no longer need traditional intensive care.
In contrast, the flex unit is a self-contained floor that manages the amount and type of critical care given to patients by shifting the level of care up or down depending on the patients’ individual needs. It doesn’t admit patients whose conditions have improved, but quite the opposite, says Cleaves. At most hospitals, a large number of these patients would immediately go to the ICU.
Unit is selective about patient admissions
Criteria for admission to the unit include:
• cardiac patients with rapidly changing monitoring needs and levels of nursing care who may benefit from a flexible monitoring unit;
• patients who require continuous pulse oximetry with or without cardiac telemetry monitoring;
• medical-surgical patients who need frequent vital-signs monitoring and intensive nursing care with or without cardiac monitoring, e.g. gastrointestinal bleeding, asthma, sepsis, and hypertensive conditions.
• patients with uncomplicated bilevel airway pressure who don’t require one-on-one nursing or titration of sedative drips;
• cases in need of insulin drips with fingertip glucose every two hours, in addition to uncomplicated illnesses;
• newly intubated or tracheotomy ventilator patients who don’t require titratable drips or sedatives under long or short-term management;
• major post-surgery cases in need of close observation.
There are additional admissions parameters. But in general, the unit gives priority to patients with acute but reversible diseases over cases with a prognosis that is chronic, irreversible, or terminal, according to the admissions guidelines. It does not admit complicated ventilator patients, who require FiO2 or a PEEP (positive end expiration pressure) of more than 7.5 cm and who are hemodynamically unstable.
It also refuses cases with complicated intraoperative tracheotomies, those who require A-line Swan Ganz monitoring, CAVH (continuous arterial venous hemofiltration), CAVHD, (continuous arterial venous hemofiltration dialysis), or balloon pump cases. Patients who are post-code hemodynamically unstable or drip cases whose level of care is undefined are usually transferred directly to the ICU.
To appropriate care to the wide case mix that the unit does admit, nurses divide patients into color-coded nursing categories. The color-coded patient criteria with each patient’s name appear on a nursing assignment board kept in the unit. (See chart, above.)
Sorting out patient management criteria for nurses would seem difficult under such circumstances. But Cleaves says the system works well partly because the bedside nurses understand the color-coded assignment system, and the guidelines for patient care are clear. Furthermore, nurses have undergone considerable training in working specifically for the unit.
When the hospital opened the new floor in 1994, it was a converted obstetrics-gynecology floor that began admitting patients and assigning some nurses who had previously obtained their certification in critical care.
After some initial turnover (several ob/gyn-trained nurses left the unit), a pressing need arose to train the remaining RNs who weren’t certified in critical care as increases occurred in the unit’s patient population.
New nurses were put through an intensive 15-day training program that included hands-on and classroom work on subjects ranging from taking blood gas measures and interpreting arrhythmia readings, to legal and ethical issues in critical care.
In addition, some nurses were farmed out for training to the ICU to work under preceptors while others received similar preceptorship training on the flex floor, and others were still assigned only the less seriously ill cases. As a whole, the combination of classroom and floor training has given newer nurses the exposure they needed to work with this particular patient population, Cleaves says.
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