Hospital cuts unscheduled returns to special care

National benchmarking effort pays off

When performance improvement staff at The Aroostook Medical Center in Presque Isle, ME, decided they needed to do some national benchmarking, they started with an area for which they could easily collect data. They had no idea that looking at unscheduled returns to the special care unit (SCU) would raise a red flag.

"A lot of times, you don’t know you’ve got a problem until you start to monitor it," says Gary Michaud, RN, senior manager of quality management and social service. "That’s why we wanted to do the benchmarking in the first place."

Aroostook is participating in the Maryland Hospital Association’s Quality Indicator (QI) Project, a benchmarking effort that includes more than 1,500 health care facilities across the nation. Michaud’s staff chose one of the QI Project’s inpatient indicators, unscheduled returns to a special care unit, for its first effort.

They started collecting data in 1996 and by the end of the first quarter of 1997, they found their rate of returns was 8% to 10%, more than two standard deviations above the mean in the QI Project. The return mean for Maine was 3% to 4%. Now, after implementing several process improvements, Aroostook’s rate is 1% to 2%, Michaud says.

"We’re a rural hospital in northern Maine, and the nearest tertiary care center is 165 miles away, so it’s important that our SCU is utilized correctly," Michaud says. The 105-bed hospital’s special care unit has six beds for trauma, post-surgical and coronary care patients.

The SCU committee developed a performance improvement review form that asks physicians to document the reasons for an unscheduled return, Michaud says. The committee conducted a retrospective chart review and began to routinely collect information about new SCU patients. Nurses now keep track of the initial and return diagnoses, admission date, and the name of the admitting physician. A physician reviewer assesses whether the admission was unavoidable and if census, staffing, or physician availability was a factor for the initial transfer from the SCU.

One of the findings was that the primary diagnosis for patients who continually bounced in and out of the SCU was atrial fibrillation. "We found that they were being sent back to the SCU when they could have gone to the progressive care unit [PCU], which is our step-down unit, instead," Michaud says. One solution was to develop criteria — stable patients who are on lidocaine drips, low-dose dopamine drips, or ventilators — for sending these patients to the PCU. PCU nurses were trained to manage these types of patients.

Another solution to the problem was educating physicians on admissions criteria for the SCU and PCU and encouraging the nurses and physicians to work together to assess whether patients are ready to leave the SCU. Physicians are individually informed of high rates of return, and all new physicians learn about the criteria during hospital orientation.

"We’ve heightened the staff’s awareness of making sure patients are stable enough to leave," Michaud says. "I’ve been very pleased with the collaborative effort among the physicians and nurses."

It has also helped to have a medical director for the SCU who, since taking the position in July, has been coming in daily to discuss each patient, says Shirley Labobe, RN, CCRN, senior manager of critical care services. The director provides monthly inservices and case study reviews for physicians and nurses. In addition, Labobe gives nursing staff unit-specific educational packets with research material and follow-up questions they are supposed to read and answer on their own time. That way, she can target areas in which nurses need more knowledge, and nurses can avoid coming in on days off for education.

"I’ve had 100% compliance in the SCU and PCU," Labobe says. "In the past, the nursing staff was task-oriented, and now we’re developing their critical thinking skills. They know how to troubleshoot, and they understand what the numbers mean instead of just reporting them. The nurses are really gaining more credibility with the physicians when they say they don’t think a patient is ready to go."

One strategy that has helped with that process is requiring staff members to participate in a quality committee, like patient education, and to take turns spending a month auditing a specific indicator on the charts.

"It makes it an active quality improvement process," Labobe says. "It’s a good education for them, and the documentation has improved. Also, it gets the nurses involved in the workings of the unit. They’re making decisions, for example, on new equipment."

[For more information, contact The Aroostook Medical Center, 140 Academy St., P.O. Box 151, Presque Isle, ME 04769-0151. For details on the Maryland QI Project, contact the Maryland Hospital Association, 1301 York Road, Suite 800, Lutherville, MD 21093. Telephone: (410) 321-6200.]