Acuity-Adaptable Inpatient Rooms Eliminate Most Patient Transfers, Leading to Enhanced Safety, Satisfaction, and Efficiency

Problem Addressed

• A frequent occurrence: On average, 40 to 70 percent of patients on the typical inpatient nursing unit in the United States are transferred each day.¹ The Methodist Hospital of Clarian Health faced this problem as well, with the typical patient being transferred three to six times during the hospital stay.¹ 
• Leading to delays, disruptions, and other problems: Nursing shortages and a lack of adequate bed capacity often create significant delays for those being transferred, including missed or delayed treatments and the potential for medication errors due to problems during patient handoffs. In addition, continuity of care suffers because frequently transferred patients often end up dealing with 50 or more caregivers during a single stay. At Methodist Hospital, leaders became concerned about the potential negative impact of frequent transfers, including on safety, patient satisfaction, and costs.¹

Description of the Innovative Activity

In the fall of 1999, Methodist Hospital built and opened the CCCC unit, a "balanced-care" unit that is configured to provide care to patients with critical conditions throughout their hospital stay. The unit has 56 acuity-adaptable rooms (28 per floor), along with a treatment room on each floor. The unit provides a healing, patient-centric atmosphere where rooms can periodically be reconfigured to provide nurses and staff access to all equipment and technology needed to care for the patient throughout his or her entire stay, thus eliminating the need for most patient transfers. Key features of the unit and the rooms are described below:

• Room configuration and equipment: Each room is approximately 400 square feet and consists of three main areas: 
  • The patient zone: Advanced computer technology is located directly on the patient’s bed so that vital data can be recorded without disturbing the patient.
  • The family zone: Features providing added comfort include a combination chair-bed for overnight visits (the unit allows visitors 24 hours a day), refrigerator, computer connection, voicemail, and television/videocassette recorder.
  • The caregiver zone: Each room contains the most commonly used supplies, thus minimizing the need for staff to travel back and forth to the nurse's station. 
• Room adaptability: Each room can be adjusted to match a patient's acuity, including the addition or removal of medical equipment. The headwall of each bed is equipped with intensive care unit–level medical gases, electrical outlets, and communication and data ports that can be used as needed. In addition, a patient monitor and other equipment are mounted on the wall and can also be used as needed.
• Waiting areas: The unit includes a waiting area that is designed to provide a relaxed atmosphere with soothing features such as an indoor garden, an aquarium, a kitchenette, and small lockers.
• Patient education kiosks: Customized educational kiosks and computer-based education are available to patients on the unit. These materials serve to orient patients and families to the unit and provide individualized education for self care.
• Reconfigured staffing and work areas: The unit provides decentralized workspaces (outside each patient's room) and nursing/supply stations for critical care nurses, floor nurses, and other staff. These features allow nurses to get supplies and perform documentation responsibilities without traveling long distances. Other resources available to staff on the unit include a computerized education center, lounge, and paging and identification tracking system.

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Results

A pre- and post-implementation comparison of key measures (2 years of baseline data, followed by 3 years of post-implementation data) shows that the CCCC unit significantly reduced patient transfers, patient dissatisfaction, medication errors, and patient falls and enhanced bed and staffing efficiency.¹

• Drastically fewer patient transfers: The number of patient transports fell by more than 90 percent, resulting in greater continuity of care for patients. 
• Enhanced safety: Medication errors dropped by 70 percent; patient falls decreased by two-thirds, from six to two falls per 1,000 patient days, a national benchmark for this measure. These improvements were thought to be the result of fewer patient transfers and handoffs and an overall improved workflow.
• Lower levels of dissatisfaction: Overall patient dissatisfaction declined by 3 percent, as measured by Patient Expectation Project standardized tool (developed by Arbor Associates, Inc.). This tool assesses how well patients’ experiences meet their expectations and their overall willingness to choose the hospital again.
• Bed efficiency and capacity: Acuity-adaptable rooms allowed the hospital to care for more patient days with fewer overall beds. 
• Fewer paid nursing hours, more time for direct patient care: Although not a stated goal of the project, reductions were observed in the number of paid nursing hours, due largely to the more efficient design of the unit. In addition, nurses were able to spend more time providing direct patient care.¹

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

Key steps in the planning and development process include the following:

• Steering committee formation: Recognizing an urgent need to plan for additional bed capacity because of consolidation across several hospitals, an interdisciplinary team was constituted to design a plan for two floors of unconfigured space. Using a futuristic view of models for delivery of progressive critical care, they consulted with accrediting and regulatory bodies (e.g., the Joint Commission, the Indiana Department of Health) to challenge existing standards in the new design. Findings from prior studies on work process and patient flow guided the team's planning.
• Education group to design clinical care model: A subgroup of nurses, managers, and educators designed the clinical content for the new model, including how to provide care to cardiac patients with varying levels of acuity on the same unit.
• Cross-training: Nurses in critical care and other units shadowed each other to allow cross-training on how to function and operate in the new unit for several months prior to its opening. 
• Budgeting and planning: To budget and plan for staffing on the new unit, analysts developed a median blended nursing hours per patient day estimate based on staffing and patient census for existing coronary medical stepdown and critical care units. Actual and projected census and nursing hours were monitored closely after the unit opened to identify any needed changes in staffing models.

Resources Used and Skills Needed

• Staffing: The new care model primarily utilized existing staff from both units, with only a handful of new nurses joining the unit. Nurses who joined the unit were asked to pledge their support of the unit's "vision statement," which was developed by the existing nurses.
• Space: Methodist Hospital had space available to house the 56 rooms, each approximately 400 square feet.
• Costs: Total costs to build and equip the unit were between $18 and $19 million.

Funding Sources

Robert Wood Johnson Foundation

Getting Started with This Innovation

• During planning, renovation, and construction, analyze and develop strategies for addressing the root causes of bottlenecks and work environment inefficiencies in the flow and care of patients. Then, develop an advanced care staffing model for the intended service line that can take advantage of acuity-adaptable rooms and bolster staff skills.
• Form strong alliances with medical staff leadership to create a collaborative culture focused on meeting patient needs and achieving operational efficiencies.
• Develop strategies to make sure that some critical care beds remain available for acute cases, even as many patients "step down" to lower levels of acuity (but remain on the unit).
• Train staff in how to use and benefit from the new technology, which will enable them to accept it as an enhancement rather than view it as an obstacle. Staff initially underused some of the technology because they were unfamiliar with it.
• Be aware of human factors and patterns of activity when decentralizing nursing stations; decentralization initially contributed to a sense of isolationism and promoted individual rather than team decisionmaking. In addition, some staff were concerned about disruptions to their (familiar) workflow. To avoid potential feelings of isolation and loss, provide staff with space on the unit where they can interact.

Sustaining This Innovation

• Encourage leaders to visibly support the program on an ongoing basis, which is essential to managing this type of transformational stage. Successfully merging the culture of critical care and medical unit nurses, for example, takes tremendous amounts of time and energy from leaders.
• Elicit and respond to staff input on the program, including making small adjustments that can be critical to maintaining their support of the program.

Additional Considerations and Lessons