Facility Infrastructure: Configuring your Capacity for Success

James B. Sherwood, MHA, Consultant, John Goodman & Associates, Inc., Las Vegas, Nevada
James B. Sherwood, MHA, Consultant, John Goodman & Associates, Inc., Las Vegas, Nevada
Warning signs of a suffering cardiovascular program due to a lack of capacity include the following: Occupancy of inpatient units, especially telemetry and intensive care units, is greater than 80% during non-peak seasons; Emergency Department has been on diversion; Elective surgeries and catheterization lab procedures are cancelled or rescheduled; Volumes for invasive and noninvasive cardiac and vascular procedures are flat or declining; Increased competition for services, particularly competition for physicians. If a cardiovascular program manifests any of these warning signs, cardiovascular program leaders must take action. Leaders must increase their capacity immediately by maximizing the space that is available and evaluating if additional hospital construction is needed. They should closely examine how operations might be improved. The purpose of this article is to present methods that hospitals have successfully implemented to configure their existing capacity. Establish Dedicated Inpatient CV Units “ The 5-Unit Model Cardiovascular patients are often located throughout a hospital that lacks capacity. As stated by one Cardiovascular Service-Line Vice President, Patients are placed where a bed is available, not based on their disease. The results of patient mixing often result in the following negative consequences: Physician, nurse, and patient frustration; An inability to garner clinical expertise of nursing and ancillary services; Minimal disease management; Accountability for clinical and fiscal success is limited or non-existent. Hospitals that are addressing their cardiovascular facility needs have created dedicated units. One model that has been implemented successfully in many hospitals is the 5-unit model.1 Specifically, the creation of the following five nursing units: Cardiovascular Surgical Intensive Care Unit Cardiovascular Medical Intensive Care Unit Cardiovascular Surgical Step-down Unit Cardiovascular Medical Step-down Unit Vascular Unit Cardiovascular Surgical Intensive Care Unit (CSICU) A CSICU provides nursing care to patients who are immediately post-op from a cardiovascular procedure. Specifically, patients flow from the operating room to the CSICU, thereby avoiding any time or placement in a recovery area such as a post-operative anesthesia care unit (PACU). Examples of cardiovascular procedures that patients would be recovering from include coronary artery bypass (CABG), valve repair, and abdominal aortic aneurysm (AAA). Patients spend a very limited time in this nursing unit. An average length of stay for patients in the unit is approximately one day. However, the nursing care provided is intense. Often two nurses are required per patient for the first 15 to 18 hours from the time of admission. The number of beds dedicated to a CSICU varies based on volumes. For example, a program performing approximately 400 heart surgeries annually requires roughly five to seven beds. The key is to dedicate enough beds to accommodate patients already in the unit as well as patients flowing from the operating room. Cardiovascular Medical Intensive Care Unit (CMICU) Patients who have had a complex diagnostic catheterization, coronary intervention, or require pharmaceutical drips and intensive monitoring for a medical condition belong in the CMICU. Patients flowing into this unit generally originate in the emergency department or the catheterization lab. Size of the facility, number of emergency department visits, and demand for medical cardiology services are factors that determine the size of a CMICU. For example, this unit will average six to 10 beds for a facility that performs approximately 400 heart surgeries annually. Many hospitals have a Coronary Care Unit (CCU) that serves a similar purpose as the previously described CMICU. Unfortunately, these units are highly challenged, because noncardiac patients often occupy the unit’s designated beds. For any unit that is designated, protocols must be established for proper patient placement. This may mean that the House Supervisor is more of a police officer than a friendly advisor when working with patient placement, physicians, and nursing staff to find a bed. Cardiovascular Surgical Step-down Unit (CSSU) The CSSU delivers care to post-surgical patients after they have been stabilized in the CSICU. From this unit, patients are discharged to their home. An average program performing approximately 400 heart surgeries will dedicate six to eight beds for this unit; however, if length of stay is greater than the national average, additional beds may be required. Cardiovascular Medical Step-down Unit (CMSU) The primary purpose of a CMSU is to provide care for patients who have been given a cardiovascular medical diagnosis that do not require pharmaceutical drips and intense hemodynamic monitoring, or patients who have had one of the following procedures performed: diagnostic catheterization, coronary intervention, and electrophysiology study or intervention. These patients usually originate from the CMICU, emergency department, and catheterization lab. A CMSU is generally a large unit. An average cardiovascular program that performs 400 heart surgeries annually will require 18 to 20 beds to accommodate patient volume. Nurse attrition is often the critical issue for these units. Maintaining adequate staffing to ensure nurse-to-patient ratios are appropriate is essential to minimize nurse attrition, while maximizing physician satisfaction, and care delivery. Vascular Unit (VU) The primary purpose of a VU is to provide care to patients who have had a surgical procedure, such as an amputation or vein ligation, or have been diagnosed with a medical diagnosis, like deep vein thrombosis. Because cardiovascular programs have varying levels of focus or emphasis on treating vascular patients, it’s difficult to estimate the average size of a VU. A good example of a major variable is the fact that many programs will place vascular patients in with their medical/surgical units. However, establishing a VU is an important step for a cardiovascular program to both provide care to patients treated for a vascular problem, as well as strategically increasing a hospital’s vascular business. Universal Beds “ A Viable Alternative Inpatient Bed Model? The universal bed model can be simply defined as a patient being assigned to the same bed from admission to discharge. Throughout the country, cardiovascular program leaders are asking if the universal bed model is a better model for care delivery than a 5-unit model per se. Perceived advantages of universal beds include the following: Enhanced care delivery resulting in a decreased length of stay; Improved continuity of care; Increased physician, nurse, and patient satisfaction; A method for differentiating from competition. Interestingly, many hospitals, even those that are constructing new heart facilities, do not fully implement the universal bed unit model, although the perceived advantages are great. According to Joseph Sprague, Principle of HKS, Inc. a Dallas, Texas-based architectural firm that has designed and helped build heart facilities throughout the country, many programs want to discuss universal beds in the design phase of construction but rarely implement it in the construction phase. Those few programs that do implement the model will often only allocate a portion of the beds within a designated unit for universal beds, according to Mr. Sprague. In his opinion, reasons why facilities choose not to implement the model include the following: Increased capital requirements; Higher operational costs, i.e., increased amount of nursing staff required; Duplication of equipment; Limited space. Often the universal bed unit concept is implemented for surgical patients and not medical patients. Therefore, a hospital will modify an Intensive Care Unit (ICU) that provides care to post-surgical patients and not their CCU. A Service-Line Administrator of a large cardiovascular program in the Midwest that recently modified her ICU to use universal beds said that her most significant challenge in the change process was staffing. To her surprise, she had to recruit an entire new staff for the universal bed unit. Nurses who were working in the ICU were dissatisfied with the change, because they preferred to consistently work in the high-tech environment of an ICU and not in a step-down unit environment. However, once the new staff was established, according to the Service-Line Administrator, the new nurses took ownership of the universal bed unit and preferred it. The jury is still out on whether the universal bed unit model is better or will be accepted as the standard of cardiovascular care. Yet, it is clear that competitive pressures for cardiovascular services are increasing. Programs will continue to evaluate methods to differentiate their operations from competitors, and it’s likely the number of facilities implementing universal beds to some degree will increase over time. Minimize The Number of Outpatients Occupying Inpatient Resources Outpatients occupying inpatient beds is a critical issue affecting cardiovascular programs that have limited bed capacity, because an outpatient often occupies a needed inpatient resource longer than he or she may need. Nurses must prioritize their assignments, and all too often an outpatient’s care needs are a lower priority than the typical inpatient. A brief outpatient stay may be increased by hours or a day, depending on a nurse’s ability to manager his or her assignment(s). Interviewed nurses often make statements such as [I] feel like a mouse on a treadmill that is set at too fast of a pace. According to these nurses, paperwork, patient teaching, and care delivery are difficult to balance with patients who have significant differences in acuity, resulting in many nurses leaving their shifts feeling frustrated. An entire cardiovascular program is often impacted by the inefficiency of mixing patients and often leaves care providers feeling frustrated. Examples of the inefficiency of mixing inpatients and outpatients include the following: Catheterization lab schedules run behind, because patient is difficult to locate or physician is looking for patient to discharge on unit; Patients are confused, because they do not know where to go when being first admitted to the hospital; Inconsistent patient registration, which can affect patient billing and collections. Successful programs have responded to this problem by establishing Intervention Units and Chest Pain Observation Centers. Intervention Unit (IU) An IU establishes a dedicated area for the preparation and recovery of outpatients having a catheterization-based procedure performed. An IU is more than a typical preparation and holding area that has two to four beds. An average IU has eight to 12 beds. One program in the mid-Atlantic area has approximately 25 beds in its IU. This program maintains four busy catheterization labs. Although inpatient beds are used to establish an IU, these resources are wisely used. Benefits of an IU include the following: Outpatients originate at a single point, thereby minimizing patient confusion and streamlining the catheterization lab schedule. Nurses are dedicated to the delivery of outpatient care. Therefore, patients are prepared and recovered with increased consistency, as well as discharged to home sooner. Inpatient bed utilization improves Physician, nurse, and patient satisfaction increases, especially for physicians, because they can assess patients between catheterization cases if they desire. Patient flow is predictable. Specifically, a patient is admitted to the IU before a scheduled procedure, then flows to the catheterization lab, then flows to the IU, and then is discharged or admitted to a dedicated inpatient unit. The challenges of establishing a successful IU include the following: Preferably, an IU should be proximal to the catheterization labs, which often requires the movement of another care unit. The scheduling of patient’s arrival times should be consistent with their scheduled procedure time. (Meaning, the IU will overflow into another unit if all outpatients arrive at the same time.) If the hospital is full and IU beds are used for inpatients during the night, a dedicated number of beds must be available for patients arriving in the morning for their scheduled procedure. Chest Pain Observation Center (CPOC) According to a recently performed research study done by the American Hospital Association (AHA), 62% of 1,500 surveyed hospitals have reached or exceeded their emergency department capacity. Richard Pollack, AHA Executive Vice President, says, This is ˜Code Blue’ for America, and we need to respond.2 An internal study performed by John Goodman & Associates, Inc. found that approximately 10% of emergency department visits are patients with a chief complaint of chest pain, which for many programs translates to eight to 16 patients per day. Therefore, many hospitals have responded to their capacity limitations by creating a CPOC. The primary purpose of a CPOC is to provide care to patients entering the Emergency Department with a chief complaint of chest pain. Operational components of the CPOC include the following: Creation of treatment protocols and patient forms; Noninvasive testing capability, including echo and treadmill in Emergency Department; Six to 12 designated beds. The benefits of a CPOC include the following: Chest pain patients receive more cardiac-focused and consistently applied diagnostics, resulting in a higher quality of care when entering an Emergency Department with a CPOC. The diagnosis of an acute myocardial infarction (AMI) occurs more rapidly and consistently usually resulting in fewer patients admitted into the hospital, which increases the number of inpatient beds available. Fewer cardiac patients are inappropriately discharged from the Emergency Department results in fewer deaths and a reduction in repeat visits. The cost of providing care decreases (Traditional AMI rule-out strategies approach $8 billion annually). The University of Maryland Medical Center published a study related to their experience with a CPOC. A few of the results from their study found that: Average age of patient seen was 50.3 years old; 58.4% of patients were women; 55.2% of patients admitted were women; 78% of patients discharged from CPOC; Charges decreased by one third for patient discharged via the CPOC; After six months, phone calls were made to patients treated in the CPOC. No patient was found to have experienced an adverse event due to quickened discharge. The challenges related to establishing a CPOC include the following: Determining if the CPOC is operated by hospital cardiologists or emergency department physicians; Determining if a separate unit should be established or if beds within the current emergency department can be allocated to the CPOC. This question is largely related to determining the best staffing and space strategy for an individual hospital. Taking Action Begins With Proper Planning Cardiovascular program leaders must take action if their programs are facing facility or capacity restraints. A prolonged capacity crisis will have multiple adverse effects on a program, which may include any or all of the following: Loss of diagnostic and interventional volumes; Inability to meet to the community’s demand for cardiovascular services; Change in physician loyalty and referral patterns; Increase in competition for services, which may include creation of new physician competitors. However, configuring capacity and sizing requires proper planning if it is going to be done successfully. Proper planning includes the following: Understanding a given market’s current and future demands for cardiovascular services. Determining operational and facilities requirements to accommodate volumes: - Operating rooms - Catheterization labs - Noninvasive equipment - Inpatient beds per cardiovascular unit Establishing a Task Force to determine short-term and long-term plans as they relate to dedicating and configuring space, units, staff, and equipment. Task force members may include the following: - Hospital leadership team - Physicians and staff representatives - Architect (potentially) - Hospital facility planner Establishing an organization that supports clinical and fiscal accountability, as well as creates a formal vehicle for the development of clinical protocols. Developing a cardiac-specific business plan that provides specific strategic initiatives to meet the cardiovascular needs of the market, projected reimbursement, operational expenses, capitalization, and timeline. Cardiovascular program leaders that undergo a comprehensive planning process will likely be a top-performing program, maximize their existing capacity, and ultimately meet their hospital’s mission.
References1. Based on the experiences of John Goodman & Associates, a cardiovascular business consulting firm in Las Vegas, Nevada.2. Modern Healthcare Daily Dose, April 8, 2002. http://dailydose.messagecontent.com/20020408.htm#TopStory1