Critical Care Plus: Empowering Nurses Dramatically Lowers Hospital’s Staff Vacancy Rate

Luther Middlefort Applies Multiple Strategies to Improve Patient Flow

A policy that empowers frontline nurses to temporarily halt admissions when their units don’t have enough nursing staff to care for more patients has significantly slashed the nursing vacancy rate at a Wisconsin hospital. Roger Resar, MD, Physician Change Agent at 300-bed Luther Middlefort Hospital/Eau Claire, reports that the two-year-old policy also increases throughput and improves patient care. "We believe the people who know best how many patients a unit can safely care for are the people who actually taking care of those patients," Resar says.

When the current nursing shortage hit, Resar’s hospital began experiencing overall vacancy rates for nurses between 10-12%. In February 2000, Luther instituted its "capping trust" policy, building an Intranet-accessible population board that allows hospital staff to monitor patient census in real-time. Within six months the nursing vacancy rate dropped to 2%.

Resar acknowledges that during the same period Luther Middlefort also raised nursing pay, started nurse internship programs, improved orientation procedures and paid recruitment bonuses to nurses. But, he points out, virtually every other hospital in the country did those exact same things without attaining nearly the degree of staffing success that Luther enjoys. "Our nurses will tell you that capping trust has had a major impact on recruitment and retention," Resar says. "We see a direct relationship between our ability to hire staff in a time of shortage and the fact that we empower our nurses by trusting them to make the right choices."

Multiple Strategies Bring Multiple Successes

Staffing to peak patient demand leaves staff working below potential when patient flow is average-a luxury hospitals can no longer afford-and staffing to the average demand when flow is at peak creates safety risks for patients and staff alike. Resar smoothed operating room flow and reduced the number of patients awaiting post-surgical beds by using variability control methodology shown to improve patient throughput by Eugene Litvak, PhD, professor of health care and operations management at Boston University School of Management.

Litvak’s work at two Boston hospitals revealed that although 50% of surgical patients arrive through the emergency room, the 30-35% of patients who arrive for scheduled surgeries exerts far greater influence on the number of available beds. Despite the fact that they receive blocks of time throughout the week in which they can use operating rooms, many surgeons perform most of their scheduled surgeries on Mondays and Fridays in order to free the mid-week for seeing patients in office. When operating room time isn’t used, hospital rooms held open for post-op surgical patients remain empty and the facility must absorb the cost of staffing for the unoccupied beds. Once nurses began closing Luther’s ICU when they considered it capped, surgeons had to reschedule elective surgeries to below-peak times.

Initial Physician Concerns Disappeared

Resar says that initially, some surgeons worried about re-scheduling surgeries and retaining adequate operating room access. But when he requested that cardiologists and heart surgeons compare their practice revenues before and after capping trust took effect, and physicians found that the new policy was saving them nearly $150,000 per month by making ICU beds available when needed, the capping trust received their wholehearted support. "Our organization is owned and run by physicians," Resar says. "They want to do what’s best for the hospital as well as for themselves and their patients."

The new policy also reduced by 9.2% the number of emergency room patients unable to be admitted because of ICU bed shortages. To further control patient census variables, Luther began running all admissions, transfers and discharges through a single coordinator. Physicians can’t make "I’ll send this patient home if I can use that bed for that one" kind of side deals, Resar says. The hospital’s chief of staff, medical director for the ICU and every nursing director who has patient contact now meet at 8:30 every morning to review incoming patient demands and plan for the day.

Resar found additional ways to improve patient flow when he hired a consultant who specializes in Six Sigma, a strategy used in industry that approaches quality improvement by reducing process variations. Three hospital staff teams trained by the consultant applied Six Sigma-based approaches throughout the facility. They suggested building a separate recovery room for the cardiac cath lab and developing other alternatives to using inpatient beds for the 12-16 hours that often follow outpatient procedures. The hospital created more bed space for acute patients by sponsoring a ventilator unit at a nearby nursing home to which chronic patients can be moved. Team members also routinely attend redesign collaboratives at the Institute for Health Care Improvement seeking more ways to decrease patients’ length of stay.

Look At the Whole Journey from Health to Death

Resar stresses that improving flow between patients’ hospital arrival and departure times isn’t enough. As part of a community a hospital must evaluate and optimize the health care other community resources can provide. Patients receiving only comfort care available through a hospice, for example, should not use ICU beds. "If we don’t consider the whole journey the patient makes from health to death, our hospitals will be filled with patients who don’t need the level of care we have to offer them," Resar says. (Contact info: Roger Resar [715] 838-3311; Eugene Litvak [617] 358-1633.)


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