ICU program cuts overtime, RN turnover

PS: It’s great for patients, too

Attention human resources professionals: Programs that are good for recruitment and retention don’t have to operate in a vacuum. Some of them even can be great for patient health and satisfaction and can have a great impact on the hospital bottom line. Case in point: the VHA Transformation of the ICU program.

Currently used in 25 intensive care units in 14 hospitals around the country, the program is designed to improve the ICU not through huge investments in technology, but through small changes in the way care is delivered. For instance, communication between caregivers and family is increased; visiting hours are extended; and best practices on issues such as ventilators and catheters are put in place in order to decrease the time spent by patients with these devices.

Among the results cited by the VHA, a national alliance of 2,200 hospitals:

  • Lower mortality rates and length of stay
  • Less time for patients on ventilators
  • Decreased patient pain reports
  • Less overtime for ICU nurses
  • Lower turnover rates
  • Improved patient satisfaction scores

Change isn’t always easy, though, particularly if the nurses in the ICU have been there for a long time. That was the case at Baptist Health in Little Rock, AR, a four-hospital system that includes the 600-bed Baptist Hospital. The average length of tenure in the four 18-bed critical care units is nine years. So when the system started looking into the Transformation of the ICU program about a year ago, there was some apprehension, says Sandra Ward, RN, director of critical care at Baptist. "We didn’t have bad numbers, so there was a feeling of why do this," she says. "But this program improves patient flow. They move on and out faster, and patient and family satisfaction goes up. And in the end, nurses are happier, too."

The first thing the units worked on was getting patients off the ventilator sooner. Using an evidence-based approach and practices others had found successful, they were able to cut ventilator time by two days and ICU length of stay by one day. What’s in it for administration? Less time for patients in the ICU means less need to hire new nurses for the unit or to use travelers.

This is the second ICU project that Lynchburg (VA) General Hospital has undertaken. It started in 2001 with the Institute for Healthcare Improvement’s Idealized Design of the ICU program and was followed in 2002 by the Transformation of the ICU (TICU) project. Since implementing the changes the two projects wrought, the medical ICU at the hospital has had a waiting list of nurses who want to work in it, says Patty Bumgarner, RN, BSN, CCRN, the unit’s manager.

The changes dealt a lot with increasing communication and options for communication between medical staff and patients and their families. "A lot of the nurses found it hard to think about letting visitors stay longer and giving patients direct lines to nurses on the unit," Bumgarner says. "We thought we had been doing a great job already in communicating with them. But now with these adaptations, we have seen improvements in family satisfaction and thus staff satisfaction."

Communication increased

Bumgarner says when she got back from the first TICU meeting with other hospitals engaged in the project, "I had a deer-in-the-headlights look. But about 30% of the staff was raring to go. They put it into place, and once they saw it worked, the rest jumped on board."

Part of the project involved keeping data on how much time was spent on certain tasks. The data were provided to the nurses so the units could see how they were doing clinically, as well as how the changes were affecting staffing.

Nurses now have to be present when physicians make the rounds, and families are encouraged to be there. "That has improved collegiality with physicians," says Bumgarner. "We are seeing the disciplines coming together to determine care, and the nurses feel a lot more respect from the physicians."

Nurses also are responsible for recording a message on each patient’s condition every 12 hours. Family members can call a special number and access that information whenever they want. "We are thinking more about the patients and their families," says Bumgarner. "For nurses who go into this profession because they want to care for people, this resonates. They are able to provide the kind of care they’d like their own family to receive."

This kind of program is an excellent way to improve your ICU by putting in place what has proved to be the best standard of care, Bumgarner says. "I think it has really helped our staff to be excited about coming to work."

As if a waiting list of nurses wanting to work on the unit wasn’t enough, there also has been a decrease in turnover from a high of about 8% to 2%. In addition, no agency nurses are ever used on the unit. "We live in an area where the nurse shortage is evident, but we don’t feel it in this unit."

Cutting turnover can lead to significant savings, says Lillee Gelinas, RN, chief nursing officer of VHA. "Each 1% turnover drop means an additional $1.2 million to the bottom line," she says.

Measuring for the future

As with all of the VHA work force programs, Gelinas says this one was undertaken with the understanding that "we don’t do anything without measuring. We focus on understanding the issues, diagnosing key components, and coming up with strategies to improve."

Often, when a nurse leaves a facility, he or she may say it is because of money. "But usually, it’s really about leadership," she says. "There is a correlation between retention and leadership. Understanding how sound the leadership is in the ICU can help. We measure worker satisfaction in the TICU program, and look at the differences in satisfaction between management and workers."

Second, they measure the ICU culture. One of the biggest issues in ICUs is the relationship between doctor and nurse, she says. "We have tools that can measure dysfunction in that relationship. Part of it is that it is a highly charged atmosphere that can create less sensitivity and less diplomacy."

The improved communication and the increased respect that nurses like those in Lynchburg are getting as a result of TICU can obviously help make the relationships more functional.

Third, TICU measures human resources processes. "Across the 25 ICUs in this program, when I stood up and asked them what the tenure equity of their staff was, they looked at me like I had two heads," says Gelinas. "There is a report card you should have for each staff member: when they were hired, how long their orientation was, how long they were with you, and how long they expect to stay with you. But most people don’t know the tenure equity and retention intent. Forget the exit interview. It’s too late then. Instead, ask staff how long they intend to stay."

You can get information from staff satisfaction surveys, but for the most part, people on the fringes of the bell curve complete them, says Gelinas. "The people in the middle aren’t always honest, and they worry about what happens if they are identified by their surveys." Instead, she recommends holding miniforums where structured questions are asked. For example, ask, "Would you recommend this as a workplace to others?"

Fourth is work design. One hospital in Kansas has no lifting for RNs and practice insurance premiums are down by more than $400,000. Employee satisfaction is higher because nurses aren’t getting hurt, and patients are happy because they aren’t waiting for moves. Instead of a nurse, there is a mechanical lift. "You don’t necessarily redesign what people do, but their work environment." Another example Gelinas cites is in Colorado, Exempla Healthcare of Denver has self-propelled beds in the ICU. A single nurse can move a bed and all its equipment

Last, organizations have to grow the next generation of nurses. Exempla has a program where board members shadow nurses so they can understand the stresses of the job and better recruit in the community. A similar program takes place in Frederickburg, VA’s MediCorp Health System.

"The way you measure that is by looking at how many new graduates you hire in a given year, or whether you have high-school shadowing programs," she says.

ICUs and hospitals in general — that want to go from good to great need to address all five of these issues. "No one has nailed all five of these," she says. "But when one does, it will be a facility with optimal performance in operations, cost, and the very best patient satisfaction."


• Sandra Ward, RN, Director, Critical Care, Baptist Health, 9601 Interstate 630, Exit 7, Little Rock, AR 72205-7299.

• Patty Bumgarner, RN, BSN, CCRN, Unit Manager, Lynchburg General Hospital, Medical ICU, 1901 Tate Springs Road, Lynchburg, VA 24501. Telephone: (434) 947-3024.

• Lillee Gelinas, RN, Chief Nursing Officer, VHA Inc., 220 E. Las Colinas Blvd., Irving, TX 75039. Telephone: (972) 830-0655.