Critical Care Plus: A La Carte Approach to Critical Care Works Well

Moving the monitor instead of the patient

Nine years ago, muhlenberg regional medical Center in Plainfield, NJ, opened Progressive Care, an intermediate critical care floor to serve patients with diagnoses and conditions that qualify them for ICU care but who don’t require the full, intensive nursing and monitoring that an ICU traditionally provides. The system has worked so well that the facility has added a second such flexible unit.

The idea for creating a flex-unit to relieve pressure on the center’s ICU first occurred to Eva Besserman, DO, Director of Critical Care during one especially busy triage. Besserman noticed that patient transfers to or from the ICU depended as much on which nursing environment could fill the patient’s needs as it did on the condition of the patient. That insight led to combining a medical-surgical and an intermediate care unit. "We decided to move the monitor instead of moving the patient from bed to bed," Besserman says.

Besserman says everyone at Muhlenberg bought into the flex unit approach during a time of gridlock when the facility had no place to put a chronic vent patient. "The patient had a transfer order but no med-surg beds were available," Besserman says. "We grabbed a monitor from another unit and the critical care nurses were able to treat this patient much more quickly than they could have if we’d had to transfer her to another unit. She was treated within moments, and that locked it in."

That patient had been hospitalized for about four months, and from that moment on she was never moved. The idea that began as a way to further a resource turned into a success story that created a facility-wide buy-in. "It wasn’t just me talking about how a flex-unit would be worthwhile," Besserman says. "Everyone saw it for themselves."

Better Outcomes

Muhlenberg’s flex-unit reduces demands on both the ICU and emergency rooms by taking patient overflow, thus creating an alternative model for patient care based solely on patient needs, says Sheri Cleaves, RN, MSN, CCRN, clinical nurse specialist at Muhlenberg. Cleaves says the flexible approach has raised nurses’ levels of job satisfaction and improved patient outcomes as well. "There’s a very big focus on performance improvement in these units," she says. "And in the last year, we’ve been able to stabilize the nursing staff on that unit, who now report a very high level of job satisfaction."

Improved outcomes were duly noted during Muhlenberg’s last Joint Commission survey. Figures showed the flex-unit had reduced its central line infection rate from around 6% to 1.9% and dropped the incidence of ventilator-related pneumonias from 12% to 5%.

Cleaves attributes much of the improved nursing morale to the fact that, under the flexible system, nurses are able to keep the same patients for the entire time that those patients are in the hospital. "It’s good because you’re not just taking care of a patient for a couple of days and transferring them off the floor before starting all over again with a new patient," Cleaves observes. "When a physician wants a patient who does not need full ICU level care to receive critical care monitoring, the patient gets that through our a la carte approach."

Admission Criteria the Same

Muhlenberg’s flex-unit is for patients who don’t need critical care but who do need a more intensive nursing than a regular floor patient. Cleaves notes that the criteria for admission haven’t changed since the unit’s inception. Patients with acute but reversible diseases receive priority over cases with prognoses of chronic, irreversible or terminal and leaves complicated ventilator patients and those who are hemodynamically unstable for the ICU. Neither does the flex-unit take cases with complicated intraoperative tracheotomies, patients who require A-line Swan Ganz monitoring, continuous arterial venous hemofiltration, continuous arterial venous hemofiltration dialysis or balloon pumps.

Other criteria 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.

Trained for Critical Care

Because all flex-unit nursing staff members are trained for critical care, Cleaves notes that there is great consistency of care throughout all shifts. "Through active recruitment, we’ve been able to get the right people there, people who are interested in investing themselves in that kind of unit," Cleaves says, adding that the unit now has assistant nurse managers on both the day and night shifts. "It’s one of our most stable units for staffing and outcomes. Staff work as a multidisciplinary team, with respiratory, dietary, social worker, and case manager giving our nurses support."

In 1999, Muhlenberg installed new monitoring systems. The same tech team now monitors patients in coronary care, intermediate care and med-surg, and can quickly notify appropriate personnel if there are problems.

One weekend while the facility’s IMCU was very busy while the CCU wasn’t busy at all, Besserman realized she could further enhance flexibility by removing the wall that divided the two units. When the facility’s coronary care unit was remodeled, the wall came down, creating one unit with the capacity to take care of patients on both sides.

Besserman says that some division of patients remains, but when an IMCU patient needs a higher level of care, nurses who already know the patient are there to give it. "Now we can use all the beds without restricting bed capacity for either unit," Besserman notes. "It’s really reduced the logjam we used to have in critical care."

The appropriate level of care for the wide case mix of patients admitted the Flex Unit is identified by color coding patients’ names on the unit’s nursing assignment board.

Level I: Red denotes extremely ill patients who need some ICU-level care such as:

  • Vital signs every four hours;
  • Cardiac monitoring as needed;
  • Charting or critical care flow sheet;
  • Ventilator support with telemetry;
  • High-risk status requiring frequent assessment.

Level II: Green denotes non-telemetry cases that require frequent nursing assessment

  • Vital signs every 4 hours;
  • Charting on critical care flow sheet;
  • Ventilator patient (non-telemetry) with vital signs;
  • Charting every 4 hours;
  • Telemetry discontinued by close observation.

Level III: Blue denotes nontelemetry cases that require medical-surgical care:

  • Vital signs every eight hours;
  • Charting on medical-surgical flow sheet.

(For more information contact Eva Besserman or Sheri Cleaves at [908] 668-2000.)


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