Published in the July 2017 issue of Today’s Hospitalist
WHEN GWINNETT MEDICAL CENTER-LAWRENCEVILLE in suburban Atlanta decided to staff its ICU exclusively with intensivists, the center’s hospitalists noticed a gap they could fill: provide much more focused leadership to the existing step-down unit.
The progressive care unit (PCU) was designed for patients whose care needs fall between what must be delivered in the ICU and what can be handled on most general medical floors. But unlike many similar units—also known as intermediate, transitional care or high-dependency units—the hospitalists’ goal in improving the unit in 2015 was “not to simply get patients a little bit better, then send them out to the floor,” explains hospitalist and PCU director Pinkesh A. Bhuta, MD. “Our aim is to provide a multidisciplinary approach to care during patients’ stay and to safely transition them to the appropriate setting, whether that’s their home, a skilled facility or a general medical ward.”
One goal of the 20-bed PCU is to provide both better continuity and quality for patients stepping down from critical care. But the hospitalists were certain the unit could also improve other aspects of patients’ hospitalization, such as reducing the rate of bouncebacks between the ICU and the general wards.
“What is essential for these patients is continuity of care.”
Other goals included being able to provide noninvasive high flow oxygen in advanced lung disease, insulin drips for diabetic ketoacidosis, or intensive saline infusion for electrolyte abnormalities such as hyponatremia. The unit also handles high-acuity patients with heart failure, sepsis, serious adrenal insufficiency or hypotension. It’s also the place where doctors provide palliative care to patients who are declining and do not wish to be placed on a ventilator or resuscitated, but who require close monitoring.
“The unit,” Dr. Bhuta says, “is for people improving from their acute illness or progressing in their chronic disease.”
In addition, many patients in the unit are those at high risk of readmission, increased hospital-related complications and long lengths of stay that often result in potentially poor patient satisfaction. “Our unit provides further value to the hospital system by reducing costs through effective resource utilization.”
Unit ground rules
To handle step-down patients in a cost-effective manner, Dr. Bhuta says the hospitalists made several decisions about how the unit would operate. Those include:
• Continuity is paramount. The physicians limited the number of clinicians who staff the unit. Currently, only two of the 30-plus hospitalists—Dr. Bhuta and James Lee, MD, the lead physician—work there regularly. Nocturnists cover the unit at night, and occasionally other group physicians fill in.
“What is essential for these patients is continuity of care,” Dr. Bhuta says. “It serves patients and families better to have one physician who understands them from the beginning.” That allows the doctors to identify more quickly “what changes are taking place.” It also permits unit physicians to more readily intervene and prevent patients from deteriorating—and to develop better rapport with patients and families.
Closing the ICU to hospitalists shone a spotlight on these needs, he adds. Hospitalists used to be able to follow their own patients in and out of the ICU, but they lost that ability in the closed ICU system. That made the need for the step-down unit “even more obvious.”
• It is nurse-centric. When Dr. Bhuta first began thinking about the unit, he decided “to have the nurses be more involved.” He and his colleagues selected a subset of nurses and provided them with additional training to “improve their comfort level in dealing with these sick patients.” In addition, the unit nurses are responsible for “being proactive in identifying patients who are deteriorating.”
“We want them to notice acute changes in mental status, to pick up on changes in urine output, to understand the sepsis bundle and know when is it unsafe for a patient to be on BiPAP,” Dr. Bhuta says.
“Those things can really have an impact.” Moreover, each nurse has the responsibility of “presenting” patient-care nursing issues to the rounding team. With each nurse caring for between two and four patients, the nurses feel they have “some patient ownership.”
• Daily multidisciplinary rounds are a must. Teamwork starts with daily 10 a.m. “walking rounds.” Accompanied by a computer on wheels, the hospitalist, charge nurse, nurse clinician, social worker, dietitian and pharmacist walk from room to room. “While the nurses are presenting these patients, we look at any diagnostics and clinical reports and place orders,” Dr. Bhuta explains. “The pharmacist is keeping track of antibiotic days, and we can identify any drug-drug interactions immediately. We also develop a disposition plan for patients during rounds.”
Fewer codes and complications
In addition, says Dr. Bhuta, the interdisciplinary team follows a checklist that includes DVT prophylaxis, Foley catheter indications and delirium prevention.
“We noticed that we improved our rates of hospital-acquired complications like pressure ulcers, catheter-related urinary tract infections and central line-associated bloodstream infections,” he says. Plus, fewer codes are being called. “I think it’s because we are more hands-on with patients.”
Dr. Bhuta is currently compiling data about the unit’s resource utilization and accomplishments, including the number of patients kept out of the ICU and from bouncing back to the hospital after discharge. He says data show that “we’ve made improvements in patient satisfaction and improved levels of communication between the consultants.” The average length of stay in the unit is between four and five days.
One patient whom he cared for in the early days of the PCU’s operation, Dr. Bhuta recalls, is what he calls the “poster child” for the step-down model. The man, who had lymphedema and underlying cardiac disease, had been admitted with severe cellulitis in both legs. He didn’t need an ICU bed, but he did require more intensive care than was possible on a regular medical floor.
Dr. Bhuta says he is convinced that PCU care prevented the following, somewhat predictable, course: “He may have been admitted to the ICU due to hypotension. Following fluid resuscitation, he may have gone to the floor. But due to delayed fluid shift, he may have later developed pulmonary edema, gone back to the ICU, gotten diuresed and gone back to the floor. It creates distress for the family and increases resource utilization.”
Instead, Dr. Bhuta says, “we were able to keep him in one place the whole time, have the same doctor and nurses involved, and really focus on what he needed.”
That meant not just treating the patient’s cellulitis, but optimizing his cardiac management and helping him become more mobile. “We feel our care goes beyond simply watching patients to make sure they are stable enough to go to the general medical floor.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.