Nurses find challenges and rewards in LTACH
Nurses find challenges and rewards in LTACH
Slower pace and softer setting could be a plus
When most nurses hear that St. Elizabeth Ann Seton Hospital of Central Indiana is located within a hospital, they respond with a puzzled frown. "Everyone including the medical staff gets confused," says Peter Alexander, MHA, executive director of the 38-bed long-term acute care hospital (LTACH).
You’ll find it on the second floor of St. Vin cent Hospital and Healthcare Services’ Carmel campus, a large tertiary-care facility near Indianapolis. But it isn’t on any road map.
The hospital-within-a-hospital is notable more for its unique services than its location. Every day, it delivers a full range of high-quality, 24-hour acute long-term care, says Melanie G. Holt, RN, director of patient care services. The typical patient is the one who otherwise would be considered critical.
Standing room only for patients
From a patient management standpoint, St. Elizabeth fills an important niche, one that hasn’t been properly filled in critical care — until now, says Holt. And referrals from surrounding intensive care units prove Holt to be right. "We opened almost two years ago, and there’s a full patient waiting list," Alexander says. But the LTACH isn’t a novelty. Far from it, it has many useful characteristics, such as the following:
• Although housed within another hospital, St. Elizabeth has its own nursing staff, physician specialists, and administration. It also operates its own surgical services, X-ray department, biomedical equipment, food service department, and maintenance staff. And legally, the LTACH operates under separate licensure and Medicare certification.
• Many of St. Elizabeth’s patients are those who’ve been discharged from ICUs but return for projected long inpatient stays due to clinical complications. Most patients are in their 50s, but the facility can treat older admits. One in 10 is a patient with serious cardiac problems.
Most are ventilator-dependent, nutritionally compromised, and unable to walk when first admitted. But the hospital makes a point of getting them to participate actively in their own recovery. The goal, according to Holt, is to stabilize the patient sufficiently for discharge to a subacute setting that is less intensive.
Patients often are transferred to another facility where they can be closer to their families. Conversely, the LTACH will refuse an admission if it isn’t appropriate for either the patient or family, Holt says. The LTACH is still adjusting to its case mix. Its average length of stay, therefore, ranges between 21 and 34 days.
• For nurses, the chance to work with long-term critically ill patients presents unusual opportunities. "It takes a special kind of nurse to succeed in LTACH," says Holt, "The individual has to be attracted by the tempo of an emergency department."
But "it’s also important to have a good, solid ICU nursing background and a keen interest in bedside care. There’s lots of personal involvement here with both patients and their families," says Sandra K. Aurs, RN, patient care services manager.
The level of care also is quite comprehen sive. Initially, the hospital experimented with a staff ing ratio of 3:5, or three staff (two nurses and one tech) for every five patients. Manage ment since has raised the bar incrementally and now finds that by hiring ICU-trained nurses, the staffing ratio can be relaxed.
Yet, in intensity, the staff still record an average of 14 nursing hours per patient day. But the atmosphere is much more relaxed than the typical ICU. "It’s a quieter, more supportive environment," says Holt.
• Financially, the hospital negotiates prices for each contract separately. But payments are based on set per diems, says Alexander. It isn’t cheap. The per diem rate ranges between $1,200 and $1,500. Seventy percent of cases are Medi care. The balance is composed of Medicaid, commercial insurance, and managed care.
Finally, LTACHs are a new phenomenon, says Aurs. Nurses will need to adjust, especially if they’re accustomed to the rhythms of an ICU. "Life moves a little slower in an LTACH, but then there’s more time left to devote to patients," Aurs says.
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