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New ICU, care teams increase nursing strength
Last spring, officials at 379-bed Suburban Hospital in Bethesda, MD, opened a 24-bed ICU in hopes of enticing nursing talent to the community hospital. At a cost of $3.5 million, the unit was transformed from an aging, outmoded ICU to a new, state-of-the-art service. Recruiting talented nurses who were excited about working at Suburban was only part of the plan. For division director Lynne Bill, RN, MS, the effort played a big part.
"Our nursing complement remained unchanged. But we’ve focused on a truly multidisciplinary quality-approach to nursing," says Bill, an 18-year veteran of acute care nursing.
With a new facility, management hoped patient-care quality would climb, and getting skilled nurses to buy into the unit’s restructuring was extremely important.
Most institutions aren’t fortunate enough to rebuild their ICUs from the bottom up. In Suburban’s case, it didn’t hurt. The unit hasn’t solved its nurse shortage problems yet, but it’s confident it has taken the first steps. The effort represents a unique example of how one hospital went to extremes to restructure its ICU in the face of increasing patient demand and intense market competition.
What emerged wasn’t just a new physical plant, but according to hospital officials, a new way to treat patients.
"Hospitals everywhere boast about care management teams and interdisciplinary approaches. We actually did something about it," says Thomas Rainey, MD, Suburban’s director of critical care.
For the first time in the hospital’s more than 50-year history, Rainey and the nursing staff introduced board-certified physician intensivists 24 hours a day. They also formed a tightly knit corps of clinicians to be directly responsible for each patient’s progress while in the ICU.
The team consists of the intensivist, a bedside nurse, a respiratory technician, a patient-care technician, a pharmacologist, a nutritionist, and a member of the unit’s ethics committee. All but one conduct morning rounds. (The ethics committee member is available as needed.) The group also includes an advanced practice nurse and administrative support staff.
Much of the battle in nursing has focused on attracting and retaining good talent, observes Sharon M. Tanner, Suburban’s executive vice president and chief operating officer. "In terms of attracting good nurses, we’re having the same problems as any other hospital."
To maximize nurse effectiveness and blunt the effects of nurse shortages, designers of the new ICU built a step-down unit adjacent to the ICU. This was an added innovation, Rainey says.
The geographic closeness of the step-down allows nurses to work efficiently between both units and reduces the effects of staffing shortages.
It also offers patients a "truly seamless continuum of care," which has started to improve lengths of stay, observes Rainey, who also serves as president of CriticalMed, a Bethesda-based consulting firm that advises hospitals on repositioning their CCUs. In an era of nurse scarcity, it made sense to make the work easier for staff and patients, he adds.
The reorganization appears to be working. According to initial results, unofficial data show patient weaning days on mechanical ventilators dropped by about 30% since the spring, Rainey says.
Average length of stay in the ICU also is falling (Rainey is unsure about the exact amount) thanks in part to the "contiguous level of care" between the ICU and step-down unit.
Yes, the program is working despite expected difficulties, observes Bill. A nagging problem is still keeping nurse staffing at optimum levels on all shifts.
The current ratios haven’t changed, Bill says. It’s still one nurse to two patients in the ICU and 1:3 in the step-down. Management is working hard to keep those numbers in each category level.
Applicants for the unit are taken on a tour of the facility. The unit is spacious and sunlit, the floor space wide with large aisles. The private patient rooms have breakaway doors and new monitoring equipment at each bedside. A large family lounge resembles a hotel lobby. Everything is designed to make the nurse’s job easier.
Financially, the change hasn’t produced a windfall, but that wasn’t the goal, Tanner says. Revenue has risen slightly (as a result of going from 18 to 24 beds.)
The unit contributes about 4.6% of the hospital’s total patient revenue. Fifty percent of patients are on Medicare, and earnings haven’t risen either. Costs have eaten up potential net income from the additional beds.
"There’s been no bottom-line impact in doing this, but then we didn’t expect any. This has been a quality of care and customer service issue all along. Everyone is pleased with our progress so far," she concludes.