SummarySuburban Hospital's cardiothoracic care unit uses a multifaceted approach to patient- and family-centered care, including a universal bed care delivery model that allow rooms to be transformed to meet patient needs as acuity levels change; information and policies designed to keep patients and family members aware of and involved in the care process; and twice-a-day multidisciplinary rounds to monitor progress and ensure smooth transitions between incoming and outgoing staff. Since opening, the unit has achieved well-above-average performance with respect to mortality, length of stay, readmissions, and patient satisfaction.Suggestive: The evidence consists of post-implementation data on risk-adjusted mortality rates and other key measures of patient outcomes and satisfaction, including comparisons with national and state averages.
Developing OrganizationsJohns Hopkins Medical Institutions; National Institutes of Health; Suburban Hospital
Date First Implemented2005
Planning started in September 2005, and the unit opened in May 2006.
Vulnerable Populations > Intensive care unit patients; Medically or socially complex
Problem AddressedTypically, patients are transferred between units as their acuity level changes, which can result in communication problems, delays in receiving the appropriate level of care, increased risk of medical errors, longer length of stay (LOS), frustration for staff and patients/family members, and backups in the emergency department (ED) and other areas.
- A common, error-prone process: Patients typically transfer between units three to six times during a hospital stay.1 These transfers create an increased risk of communication problems (both between providers and between provider and patient/family member) and medical errors; for example, 22 percent of all medication reconciliation errors occur during unit transfers.2 One study of the universal bed care delivery model found a 70 percent reduction in medical errors after the unit converted to the universal bed care delivery model.1
- Growing mismatch between needs and capabilities, leading to backups, delayed discharge: Over the past decade, acuity levels have increased, resulting in many patients being too sick to be adequately managed on medical–surgical units, but not sick enough to warrant admission to the intensive care unit (ICU). In response, many hospitals have created progressive care units. Other hospitals opt to keep moderately acute patients in high-acuity units (e.g., the ICU) for continued monitoring, which can lead to bottlenecks in the ED and other units as more acute patients wait for an ICU bed.1 Patients who are in the ICU but do not require a high level of care often do not progress as quickly as they would in a lower level of care, where staff are more focused on helping the patient recover and prepare for discharge.2
- Staff, patient, and family frustration: Unit transfers increase nurses workload but do not add value to the patient's outcomes,1 and patients are often distressed about moving to a new unit where they do not know the staff.3 Patients and families often become frustrated by the rules governing family visitation (which vary across units) and by limited participation in and communication with the patient's treatment team. This lack of communication frequently leads to a lack of knowledge among patients and family members about what to expect on a given day and how the patient is progressing.
Description of the Innovative ActivitySuburban Hospital's cardiothoracic care unit uses a multifaceted approach to patient- and family-centered care, including a universal bed care delivery model that allow rooms to be transformed to meet patient needs as acuity levels change (thus preventing the need for transfers to other units); information and policies designed to keep patients and family members aware of and involved in the care process; and twice-a-day multidisciplinary rounds to monitor progress and ensure smooth transitions between incoming and outgoing staff. Key elements of the program include the following:
- Acuity adaptable room: Use of a universal bed care delivery model allows Suburban to bring the appropriate level of care to the patient, rather than transferring the patient between units as needs change. All unit rooms are adjustable to the patient's acuity level by using portable medical equipment (e.g., ventilators, respirators, dialysis machines, and an intra-aortic balloon pump) that can be used added or removed based on the patient's status. As a result, after surgery, patients remain on the cardiothoracic care unit with the same care team for the entire hospitalization. Patients progress through several levels of care, as described below:
- ICU and stepdown phase: At any given time, roughly 20 percent of patients are in the acute ICU phase, where they remain for 12 to 18 hours after surgery. During the first 12 hours, patients receive one-on-one nursing care, after which time they are "stepped down" to two patients per nurse. Unit staff, in conjunction with respiratory therapy, encourage quick extubation, with patients typically taken off the respirator within 6 hours of surgery, which helps speed recovery.
- Progressive phase: Patients transition to the "progressive" or recovery phase in approximately 12 to 18 hours. At this point, all unnecessary medical equipment (e.g., the ventilator) is removed from the room, and the staffing ratio becomes roughly three to four patients per nurse, depending on patient acuity and care needs. All allied health professionals, such as cardiac rehabilitation therapists, come to the unit to care for patients during this phase, rather than the patient leaving the unit to go to the provider.
- Patient and family involvement in care: The cardiothoracic care unit has adopted policies designed to keep patients and family members informed of and involved in the care process, as outlined below:
- Transparent clinical pathway: A step-by-step standardized clinical pathway (used by staff to monitor the patient's progress) is posted on the walls in patient rooms so that the patient and family members understand the expectations for progression after surgery and are equipped to participate in the care process. The pathway utilizes routine standing orders to govern certain aspects of care as the patient transitions from ICU to step down to recovery care. Additionally, the pathway delineates clear roles for the members of the care team.
- Patient information board: Along with the patient’s pathway, the nurse's name and phone number and the patient's daily schedule (e.g., physical therapy at 1 p.m.; cardiac rehabilitation at 3:30 p.m.) are also posted on the wall. This information lets the patient and family members plan their day and also allows family members to be present to ask questions of the physician, physical therapist, or other providers if necessary.
- 24-hour visitation: No restrictions are placed on visiting hours, and all rooms have a reclining chair or extra bed so that family members have the option of staying overnight (although staff recommend that families go home to rest).
- Multidisciplinary rounds to discuss and facilitate care transitions: Twice a day (at 7 a.m. and 4 p.m.), a team of cardiothoracic surgeons, intensivists, advanced practice nurses, pharmacists, and bedside nurses conduct rounds to discuss patient progress on the clinical pathway. These rounds also serve as a vehicle for patient handoffs from outgoing to incoming shifts (staff work 12-hour shifts that begin and end at these times), so as to ensure seamless care transitions.
References/Related ArticlesGuterl G. Auspicious beginnings: the path from formation to prize winners wasn't an easy one for the cardiothoracic unit at Suburban Hospital. Advances for Nurses. 2008 May;10(9):14. Available at: http://nursing.advanceweb.com/Editorial/Content/Editorial.aspx?CC=133604.
Contact the InnovatorBarbara Jacobs, RN, MSN, CCRN, CENP
NIH Heart Center at Suburban Hospital
8600 Old Georgetown Road
Bethesda, MD 20814
Phone: (301) 896-3100
Innovator DisclosuresMs. Jacobs has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsSince opening, Suburban's cardiothoracic care unit has achieved well-above-average performance with respect to mortality, LOS, readmissions, and patient satisfaction (they use data from national databases sponsored by the Society for Thoracic Surgery and The American College of Cardiology for benchmarking their results).
Suggestive: The evidence consists of post-implementation data on risk-adjusted mortality rates and other key measures of patient outcomes and satisfaction, including comparisons with national and state averages.
- Low risk-adjusted mortality: The hospital's risk-adjusted mortality rate for cardiac surgery (which includes all surgeries that require a heart or lung bypass machine) is 1.5 percent, well below national and state averages (2 percent and 2.1 percent, respectively).4
- Low LOS: Average LOS for coronary artery bypass graft (CABG) surgery is 4.5 days at Suburban, compared with a 6.3-day national average and a 7-day state average. Average LOS for valve replacements is 4.3 days at Suburban, again well below the 6-day national and 6.3-day state average. Finally, Suburban's LOS for combined CABG/valve replacement procedures is 6.5 days, versus 7.5 days nationally and 8 days in Maryland.4
- Few readmissions: Suburban's cardiothoracic patient (including all patients whose surgeries required a heart or lung bypass machine) 30-day readmission rate is 6.2 percent, compared with 9.3 percent nationally and 10.3 percent in Maryland.4
- High patient satisfaction: Since opening, Suburban's cardiac care unit has consistently achieved patient satisfaction scores in the 99th percentile.4
Context of the InnovationSuburban Hospital is a 228-bed, community hospital in Bethesda, MD, that handles more than 14,000 admissions annually. The hospital partnered with the National Institutes of Health (NIH) and Johns Hopkins University Medical Center to create the NIH Heart Center at Suburban Hospital, which provides cardiac surgery, angioplasty, cardiac diagnostic services, and cardiac rehabilitation services. The center also provides training for cardiologists and is involved in several research initiatives. Before the unit's opening in 2006, Suburban had only a noninvasive cardiac program. While designing the new program, the chief of cardiothoracic surgery championed the use of a universal bed care delivery model and other patient-centered programs.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Creating a team: Suburban's leadership convened a cardiothoracic team to design the cardiac program. From September 2005 to May 2006 (when the unit opened), this team worked daily to recruit properly trained staff, select appropriate mobile medical equipment, and develop unit processes. The team was guided by an external cardiovascular service line consultant.
- Developing clinical pathways and order sets: The team researched the care needs of patients and drew on both prior experiences and best practices from the literature to develop the standardized care pathways and order sets (for more information on clinical pathway development, see the Tools and Other Resources section).
- Selecting equipment: Unit staff investigated and tested available portable medical equipment before selecting the new equipment for the unit.
Resources Used and Skills Needed
- Staffing: Suburban's cardiac program employs 82 full-time staff; use of the universal bed and other patient-centered concepts created no additional need for staff.
- Costs: Capital expenditures to build the new universal bed cardiothoracic care unit were approximately equivalent to what it would cost to build a traditional cardiothoracic unit.
Funding SourcesNational Institutes of Health; Suburban Hospital
Tools and Other ResourcesThe following references were used to develop the clinical pathways, and standardized order sets:
More information on clinical pathways is available in the following article:
- Hemmer JH, Richenbacter WE, Vlahakes GJ. Handbook of patient care in cardiac surgery. 6th ed. New York: Lippincott Williams & Wilkins; 2003.
- Bojar RM. Manual of perioperative care in adult cardiac surgery. 4th ed. Oxford: Blackwell Publishing; 2004.
- Todd BA. Cardiothoracic surgical nursing secrets. 1st ed. St. Louis: Mosby; 2005.
Every NR, Hochman J, Becker R, et al. Critical pathways: a review. Circulation. 2000;101:461-5. [PubMed] Available at: http://www.circ.ahajournals.org/cgi/content/full/101/4/461.
For more information on the NIH Heart Center at Suburban Hospital, visit: http://www.suburbanhospital.org/services/cardiaccare.aspx?msid=2.
Getting Started with This Innovation
- Consider use of outside consultants: Outside consultants can help implement the universal bed care delivery model, standardized pathways, and other patient-centered components of cardiothoracic care.
- Seek out experiences of others: Other organizations that have implemented similar programs can be valuable sources of information.
- Clearly define team member roles: Create clear roles for team members when developing standardized orders and care pathways, thus allowing physicians and staff to see that everyone has something to contribute.
- Cross-train nurses to handle different acuity levels: Nurses typically work with only one acuity level, such as high-acuity ICU patients or lower-acuity patients on the general medical or surgical units. Not surprisingly, they often prefer that approach and thus may resist the concept of working with patients at different acuity levels. Suburban initially hired ICU nurses to staff the unit but found they had difficulties adjusting to caring for lower-acuity patients. Since then, Suburban has hired telemetry nurses as well and has initiated cross-training so that all nurses on the unit will be more comfortable with their patient assignments.
Sustaining This Innovation
- Monitor patient outcomes and make refinements accordingly: Suburban voluntarily participates in national databases that track outcomes, including those sponsored by the Society for Thoracic Surgery and The American College of Cardiology. Information provided through these programs helps to identify opportunities for improvement in a timely manner.
- Monitor resources and staffing: Unit management must constantly monitor staffing and equipment to make sure that adequate resources are available to meet the needs of the current patient population. Particular attention should be paid to nurse staffing, because needs can change quickly. As noted, patients initially require one-on-one nursing care, but, as acuity levels drop, nurses can handle up to four patients at a time.
Hendrich A, Fay J, Sorrels A. Effects of acuity-adaptable rooms on flow of patients and delivery of care. Am J Crit Care. 2004;13(1):35-45. [PubMed]
Joint Commission on Accreditation of Healthcare Organizations. Sentinel event alert: using medication reconciliation to prevent errors. Jt Comm J Qual Patient Saf. 2006;32(4):230-2. [PubMed]
3 Brown K. The universal bed care delivery model. Patient Safety and Quality Healthcare e-newsletter. 2007 Mar/Apr. Available at: http://www.corazoninc.com/downloads/articles/cub_psqh.pdf
4 Society of Thoracic Surgeons National Cardiac Database (2006-2007).
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Service Delivery Innovation Profile
Original publication: September 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 24, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 10, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.