Creation of a Canadian Intermediate Care Unit in an Accountable Care Unit Framework: First Year Outcomes
A focused look at a recent award-winning submission to the Canadian Society of Hospital Medicine’s annual conference 2017. The submission is made available here with approval from the study authors (details below) and it highlights the outcomes of the first Canadian Intermediate Care Unit in an Accountable Care Unit framework. Congratulations to all of the MSU staff and the success they’ve been having.
The conference poster can be downloaded further down, but the two first authors have provided the following content to 1Unit as additional context and current success of the MSU.
The Medical Surveillance Unit (MSU) was established in October 2014 in conjunction with the alignment of cardiac services within the Regina Qu’Appelle Health region to a single site at the Regina General Hospital (RGH). Once the decision to amalgamate the cardiac program to the General Hospital site was finalized, the Critical Care/Cardioscience program was tasked with creating an intermediate care area to support ongoing medical management of complex patients within the Pasqua Hospital site (PH). Our review of patient characteristics and flow supported the need for non-interventional cardiac monitoring to provide enhanced patient care away from the primary cardiac centre.
Critical Care/Cardiosciences worked with their partners in Medicine to develop this integrated MSU unit. Components of the telemetry monitoring system were maintained to allow for up to 6 monitored patients at any given time on the MSU. This would allow for transitioning out of critical care, enhanced monitoring for patients coming from ED or the floors, as well as a higher trained nursing staff to support these patient care needs.
Leadership & Education
The Medical Leadership team supported by Dr. Kish Lyster facilitate care under a Hospitalist model with a small group of geographically-based physicians. Under the direction of a strong nursing leadership team managed by Marlee Cossette, the RN staff who work in MSU undertake additional training to support caring for these complex patients. Guido Schiazza (Nurse Educator) provides each staff member with a 5-6 week training program which teaches:
- interpretation and intervention of ECG telemetry abnormalities,
- how to understand and manage cardiac and other critical care medications,
- support for additional respiratory therapy modalities, and
- provide ongoing monitoring of neurological and renal function.
An enhanced level of nursing care on the MSU is enabled by this course knowledge combined with the new Acuity Tool and the integration of the Early Assessment and Response System (EARs).
ACU & SIBR
In conjunction with the roll out of the Accountable Care Unit (ACU) on 4A at PH, MSU implemented many of the processes supporting streamlined, appropriate and safe patient care. SIBR (Structured Interdisciplinary Bedside Rounds), nursing bedside handover and change of shift TEAM huddles on each shift are a few of the examples where staff utilize the tools of ACU to achieve and sustain the unit’s goals.
The EARs & Acuity Tools
The EARs has been very useful in allowing staff to intervene in a timely fashion to the subtle changes in patient vital signs. This tool aides in not only early identification of patient changes in response to treatment but also provides a standard structured response stratification to ensure concerns are escalated accordingly and addressed. We reliably utilize this tool to ultimately reduce patient mortality and save lives. The Acuity Tool has also been instrumental to quantify patient acuity and manage the requirements of appropriate staffing models related to patient needs. We are proud to report this work is embedded in our daily work.
Success & Sustainment
Since our “go-live” date of January 8, 2016, 88% of the patients admitted to MSU have consistently met the specific admission criteria. We are continuously looking to enhance our delivery of service utilizing feedback through our customised dashboard, our stakeholders and our patients, as we continuously improve the MSU. A special highlight for the team was celebrating the accomplishment of 100% SIBR certification for the MSU physician, nursing and pharmacy staff – a first in Canada.
The multiple concurrent initiatives aimed at providing high-level, safe, evidence-based care continue to positively impact the staff working on MSU. Despite more than double the patient volume in the years following implementation, morale remains high, which is demonstrated by our ability to maintain the lower staff churn, overtime and sick time hours we saw in 2016. We believe this speaks to the success of this model of care. But, we ultimately like to measure our true success by the satisfaction of our patients in conjunction with the morale of our staff. Our patient satisfaction remains unchanged, two years since we embarked on this work and despite the significant rise in patient throughput.
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Kish Lyster is the physician manager and co-lead of the MSU. It makes sense to take a look at the patient and design a system around them. We can deliver care in a way that works for patients, providers, and the system. I believe the ACU model demonstrates that.
Marlee Cossette is the nurse manager and co-lead of the MSU. Marlee is proud of the achievement seen for both patients and staff through the creation and implementation of this unique patient care delivery model that combines intermediate care with the pillars of Accountable Care Units.