Unit improves care for short-stay cardiac patients

Team focused on meeting needs quickly

Creating a special unit just for short-stay cardiac patients at Sioux Valley Hospital USD Medical Center has resulted in shorter lengths of stay and a tremendous increase in satisfaction among patients who are ready to be discharged within 24 hours from the Sioux Falls, SD, tertiary care hospital.

A multidisciplinary team developed the initiative as a way to provide more timely care for patients who are in the hospital for a very short time, says Joyce Monrad, RN, BA, CPHQ, utilization management/APC coordinator.

"This population can get lost when they are on the same unit as a cardiac population with more intense needs who are going to be in the hospital for days, rather than hours. The treatment team is so focused on the more severely ill patients that the immediate needs of the short-stay patients don’t always get priority," she says.

The program was developed as an "incubator unit," a conceptual model of developing (or incubating) new ideas, according to Doreen Miller, APRN, BC, MS, CNS, director of geriatric services and case management."The intent is to refine the new process in a defined area and then to replicate applicable concepts in other areas or patient populations," she adds.

The initiative targeted short-stay patients who have a procedure, such as coronary angioplasty and stents, installation of a pacemaker or internal defibrillator, or who are under observation to rule out a myocardial infarction and whose length of stay is measured in hours, rather than in days.

"Many organizations say these are such simple patients from the standpoint of medical complexity that they don’t require the services of the case manager. These people were transitioned through so quickly that they feel like they were lost in the system, that we weren’t meeting their educational and other needs," says Diana Berkland, RN, MS, CNS, vice president and chief nurse executive.

The interdisciplinary team that developed the initiative included representatives from cardiology, admissions, case management, utilization management, pharmacy, and the hospital’s center for learning and innovation.

"For this project, a core nursing staff was established by the unit director. Case management hours were redirected to this patient population by dedicating a cardiology case manager to the unit," Monrad says.

The core nursing team, which included clinical care coordinators, registered nurses, and the nurse case manager, drove the work flow redesign with the interdisciplinary team.

The team looked at what was happening from a patient’s standpoint as it examined the care for the short-stay cardiology patients from admission through discharge. Members looked for glitches in patient throughput, then participated in problem-solving sessions and brainstormed new ideas and work flow changes to develop ways to improve the process.

"We wanted to incorporate efficiencies of time and space to make sure the patients receive what they need quickly, to target their educational needs and complete the educational process in a timely fashion," Monrad says.

Their solution was to create a special unit on one wing of the cardiology unit with a case manager dedicated to the short-stay patients.

"We redesigned how care is delivered from the moment the patient returns from the procedure until discharge," Monrad says.

For instance, staff were waiting until the patients came back from a cardiac procedure to order food, resulting in delays before the patients, who had been fasting before the procedure, could eat. Sometimes the meal planned for the day by the dietitian was difficult to eat for a patient who had to lie on his or her back after a procedure.

Now, instead of ordering food from the kitchen and waiting for it to arrive, the staff can provide easy-to-eat food and get it quickly to the patients.

"It’s little things like that that meet our customers’ expectation and result in better satisfaction," Monrad says.

Nursing staff were spending a lot of time gathering equipment and supplies after the short-stay patient arrived back on the unit.

As part of the work redesign, the case manager who works exclusively in that wing of the cardiac unit collaborated with the unit director and staff to determine the equipment and resources required for the patient population. Now equipment is available in the right place at the right time.

The case manager makes sure each patient receives an educational packet tailored to his or her individual needs. The team streamlined the documentation process by developing a short-stay form that meets the requirements for an outpatient. If the patient is admitted, there is an additional sheet that meets the documentation requirements for an admission, eliminating the duplication in charging for the nurse and the repeated questions for the patient.

At Sioux Valley Hospital, case managers typically saw cardiac patients late in the day of admission or early the next day, often too late to take care of the needs of the short-stay patient in a timely manner.

The new process called for a shift in the timeframe in which the case manager screens the short-stay cardiac patients. The case manager sees the patients immediately after they come onto the unit, determines their education and discharge needs, and makes sure that everything is in place so the patient can be discharged that day or the next morning.

"The case manager coordinates with the nursing staff on what the patient needs in the next hour, the next two hours, the next three hours, and so on. The team on the unit works together closely to move these patients forward," Monrad says.

The team studied the appropriateness of admission status for short-stay patients, particularly those who were admitted under observation status. They set up a process so the utilization manager and case manager collaborate with the rest of the team to ensure that the patients are admitted in the appropriate status.

"We work closely with the physicians relating to orders for observation vs. inpatient status and what is appropriate based on the patient’s needs. We work together to make sure that patient is placed in the correct status while they’re here," Monrad explains.

The team isolated patient satisfaction survey results from the short-stay patients compared to other patients on the same unit. "This population was not as satisfied with their care as other patients on the unit. They were in and out so quickly that some expectations were not getting met," she says.

After the program was begun, satisfaction scores increased for the short-stay patients.

"The patients felt things were very organized, that the nurses were highly skilled, and that they received a good explanation of what was going on. They saw the team work together and gave the team high marks for it," Monrad says.

Based on the success of the short-stay cardiology patient initiative, the team intends to make similar changes on other units, Berkland says.

"The whole incubator concept is about coming up with innovations and ideas and growing them in one area, then diffusing it throughout the organization. The innovation has given us the opportunity to look at different ways of providing nursing care and working through processes and work flow," she adds.