Plans for EverCare expansion in 1997 include sites in Denver and New York City.

Flexibility is name of ventilator game

Best to build from the ground up

One of the best ways to design and build a ventilator unit in a subacute facility is to start from the ground up. And that’s just what one corporation did when it rebuilt an acute hospital into a freestanding subacute hospital.

Transitional Hospitals Corp. (THC), a Las Vegas-based company, opened its newest freestanding subacute hospital in Chicago last October. What makes the 103-bed North Shore facility unique is that all rooms within the five-story building have head wall units that meet intensive care unit certification codes for the state of Illinois, says Keith Bakken, RN, BSN, director of public relations and managed care at the facility.

"Most [providers] take the view of building up from a skilled nursing facility (SNF), but we take the approach of scaling down an acute care hospital," explains Bakken.

Whether a separate unit is built or an existing unit is adopted, there’s no doubt that respiratory therapy programs are gaining popularity among subacute care providers. The average length of stay in a for-profit facility for respiratory therapy in 1995 was 62 days, according to the Washington, DC-based American Health Care Association’s (AHCA) Survey of Subacute Care Providers, 1995. (For information on ordering the report, refer to the editor’s note, p. 7.)

AHCA’s definition includes the assessment, diagnostic evaluation, treatment, management, and monitoring phases of a respiratory therapy program. To meet the AHCA qualifications, these services must be performed by a respiratory therapist, technician, physical therapist, nurse, or other trained staff. (For more data on respiratory therapy, see the chart, p. 6.)

Make program user-friendly

Another consideration when developing a ventilator unit is its degree of operating difficulty. "The biggest complaint I get is that ventilator equipment is not user-friendly," says Jim Murry, MA, RRT, senior director for respiratory operations at LifeCare Hospitals in Shreveport, LA. "The manufacturing community is listening to the needs of subacute providers and making smaller pressure-supported equipment that’s easier to operate. What we used in the past was not user-friendly and was hard to operate," he adds.

Equipment that’s easy to operate will become an even greater necessity as health care shifts acutely ill patients from the hospital to the subacute hospital or skilled nursing facility, says Murry. "The market is shifting, and the hospitals are giving the patients to subacute and skilled facilities sooner," he explains.

Finally, Murry advises planners to develop a program where therapists, nurses, and other staff work as a team when providing care to a ventilator patient. "Learn to use your respiratory therapists in a cost-effective way. If that means having them on the unit during the day only, then be sure to have enough inservices to train other staff on what to look for, how to monitor the equipment, and when staff should contact the therapist," he adds.

An important component to adequately trained staff is the appropriate therapist, adds Murry. "Good programs require therapists who go beyond their regular duties. You have to be selective. Look for a certain level of independence, good competency skills, and how well the therapist interacts with staff," he advises.

Because North Shore is a subacute hospital, its respiratory therapy program operates differently. University of Illinois pulmonary and critical care physicians are on staff, and specialists from the Chicago area offer consultations. A physician is available in-house at all times for patients requiring immediate physician intervention, adds Bakken. (For more tips on how to build and open your ventilator unit, see the related story, p. 7.)

North Shore also claims the distinction of being the only freestanding subacute hospital in a demonstration project approved by the Springfield-based Illinois Department of Public Health. The five-year project called the Subacute Care Demonstration Program involves 13 facilities. (For more information on the Subacute Care Demonstration Program, see the related story, p. 10.)

The only requirement for admission to North Shore’s ventilator unit is that the patient be medically stable for transport from the acute facility. In fact, all ventilator patients admitted to North Shore are first placed in the hospital’s ICU for overnight observation.

Post-surgical care programs offering rehab also are becoming more common, according to AHCA’s 1995 survey. Patients can be admitted to a post-surgical care program directly from a hospital operating room or recovery room after stabilization or from an ICU to meet AHCA’s definition of a post-surgical care program.

"It’s very unsettling for a patient to be put in an ambulance and transferred, so in order to prevent any complications, we observe the patient overnight as a function of our care process," says Bakken.

Not unit-specific

Because North Shore equipped each room with respiratory therapy outlets, staff can provide care in a patient-focused model rather than developing a niche unit specifically for ventilator patients, explains Bakken. "We can care for a complex wound care patient in one room and a ventilator patient in the adjoining room," he adds.

This flexibility allows new staff to become accustomed to caring for different patient groups. "Right now, we have 17 patients, and until we get a large percentage of one particular patient type, we probably won’t develop specialty units," says Bakken.

Before North Shore opened its doors to new patients, it underwent a $9.4 million renovation. North Shore’s building is the former site of Rush-Presbyterian St. Luke’s Medical Center. St. Luke’s was an acute care facility that closed in 1989.

"The building needed a lot of work to be fitted for high-tech care. We completely gutted the building and put in the required amount of emergency power, equipment outlets, and a new nurse call system," says Bakken.

Next, senior managers within the THC organization began recruiting staff for the subacute hospital. A core staff from THC’s existing Chicago facility was brought in to open the hospital, says Amy Miller, RN, director of education at Transitional Hospital of Chicago, North Shore’s sister facility. (For more information on how North Shore trains its staff, see related story, p. 8.)

Nurse/patient ratio high

Staff to patient ratios at North Shore reflect the more demanding needs of sicker individuals such as ventilator patients, notes Bakken.

"We have one RN and CNA for every seven patients on the floor, which is pretty comparable to an acute care hospital. It should be because these patients are still sick and require nursing care," he explains.

North Shore also maintains one respiratory therapist to every six patients ratio. As the number of ventilator patients increase, however, respiratory therapists will care for 10 to 11 patients, says Bakken.

[Editor’s note: The AHCA report was derived from a questionnaire mailed to a random sample of subacute care providers. Returned surveys were merged with the Health Care Financing Administration’s On-line Survey, Certification, and Reporting (OSCAR) data.

Copies of the Survey of Subacute Care Providers 1995 can be obtained by contacting AHCA. The report costs $29.95 for AHCA members and $69.95 for onmembers. Refer to catalog number 5602 when ordering. Write: AHCA Publications, Department D, P.O. Box 96906, Washington, DC 20090-6906. Telephone: (800) 321-0343. Fax: (800) 525-5562.]