Courage to Heal: Comprehensive Cardiac Critical Care
This is the story of what happened in one health system that dared to combine technology and humanism, ingenuity and accommodation, and to respond to pres-ent challenges and future care delivery needs. This is the story of what happened when one healthcare organization, determined to find solutions, sought to create a better environment for patients and caregivers. The result: the Comprehensive Cardiac Critical Care unit (CCCC) in Methodist Hospital of Clarian Health Partners in Indianapolis. Opened in the winter of 1999, this acuity-adaptable, 56-bed unit incorporates futuristic designs to combine the coronary-medical critical-care unit (22 beds) with the partnering step-down unit (41 beds). The impact of the CCCC's design and care-delivery model has resulted in significant improvements in cost, patient safety, and nursing and patient satisfaction within a healing environment.
As conceptualization for the unit began during the late 1990s, existing shell space, timing and research-based knowledge about the inefficiencies in the current environments were blended to create a unique prospect. Throughout the design process, we were aware of the aesthetic inadequacies and inconveniences of the existing hospital environments. Moreover, we faced imminent internal and external challenges, such as cost of patient transfers, the patient and fiscal impact of the nursing shortage, inefficient use of nursing time, an aging population, high critical-care utilization and emerging disruptive technology (Figure 1.)
Data from a large time-and-motion video study on a nursing unit1, and human-factors analysis from patient and staff focus groups, were merged with a futuristic vision-building process to set the stage for evidence-based design. The time-and-motion study demonstrated that most patients in the hospital moved three to six times as their acuity levels changed. Consequently, caregivers were faced with the inefficiencies of multiple handoffs and duplication of tasks by more than one caregiver. These moves also introduced an increased error factor, resulting from patients' multiple contacts with caregivers (50 to 100) and facing potential delays in treatment.
The study also indicated that most nurses were traveling several miles each shift to “hunt and gather” supplies. To best solve these issues, an evidence-based approach was used to create a highly flexible environment to support changing levels of acuity within the same private room. This reduced the caregiver workload index, which has demonstrated improvements in nursing efficiency. At the same time, an improved patient care model was created. Incredibly, the final design alleviated waste and inefficiencies associated with the previous healthcare delivery process without taking care hours away from the patient.
Each 400-square-foot patient room is designed with three main areas, or “zones”: the family zone, the patient zone and the caregiver zone. The family zone offers many unique features, such as: a chair bed for nighttime visitation, a refrigerator, a computer hook-up, voice mail and a TV/VCR. Waiting areas are designed to provide more soothing features: an indoor garden, an aquarium, a kitchenette and lockers for small belongings (Figure 2).
Technologically, the rooms are all state-of-the-art, and they are all private. Within the patient zone, all equipment and supplies required for the medical needs of the critical-care and/or medical patient are easily accessible. This includes acuity-adaptable, transforming headwalls, as well as advanced computer technology located directly on the patients' beds, allowing staff to record weight and other vital data without disturbing the patients. In addition, patients can control lighting, temperature and privacy as their condition improves. A full window view allows more interaction with nature even within an urban setting. Patient education is delivered via a television and VCR, along with some computer-based training. Healing characteristics, such as interior design, décor, lighting and patient control, were important elements throughout the design phase (Figure 3).
The caregiver zone offers similar aesthetic and practical conveniences. Because we knew most of the distance traveled by nurses on a typical patient unit consisted of back-and-forth travel to the nursing station or to get patient supplies1, we purposefully arranged for all necessary supplies to be located in the patient room. Nursing stations are decentralized, with computers outside each patient room. These now accommodate partial electronic records; plans are being made for complete computerization in the near term.
Additional nurse and caregiver workspace areas are located just outside the patient rooms. Corridor design allows for emergency equipment, such as defibrillators and supplies, to be hidden behind doors. This creates a less intimidating atmosphere for patients and families, without sacrificing the nursing staff's ready access to technologic and medical equipment and supplies (Figure 4).
Additional features designed for nursing staff include an education center equipped with a battery of computers for uninhibited access to information and training. Also, because of the open nature of the unit and the unit's 24-hour visitation policy, a relaxing staff lounge, private shower, bathroom and lockers are offered. Other staff features include convenient supply rooms and a personal paging and ID-tracking system that pinpoints staff locations.
Outcomes and Results
The impact on patient care has been remarkable. Two years of baseline data from the two units prior to the new design and consolidation were compared with three years of data collected following the opening of the CCCC. Hospital unit-to-unit transfers have decreased by 90%, and the overall number of patient days per bed has increased because of the elimination of nearly all patient moves. All of this has been accomplished with eight fewer beds after the move—a very important consideration as one deliberates the impact acuity-adaptable rooms can have on existing full hospital capacities, efficiency, patient safety, labor costs and healthcare worker shortages.
Moreover, the decrease in patient transfers and the nurses' more consistent knowledge of each patient's condition have contributed to decreases in patient falls and an improved medication error index (number of errors per 1,000 patient days). The patient fall index decreased to two, compared to the former fall index of six; the medication error index improved to three, a decrease from ten (errors/patient days) in the two previous units.
Other significant accomplishments also have been noticed. For example, decentralized nursing stations and multiple observation points are credited for improved patient safety, as well as patient fall reduction. Also, errors, waste of supplies, and delay and duplication of services have been minimized in proportion to the reduction in transfers. In addition, staff and patient satisfaction have improved. The dissatisfaction rate among patients and families is down to less than 3%, and a simultaneous improvement in the category of “exceeding patient's expectations” has been noted.
Initially, an increased number of critical-care nurses transferred off the unit. Many attributed their decisions to the new design (not typical critical-care appearance) and decentralized nursing stations. The overall staff turnover, however, has been stabilized, and a new care-delivery model for the future has emerged. All of these results—directly related to the new environment—demonstrate enhanced patient and clinician safety, the ability to deliver various levels of care within the same private room and improvements in patient, family and caregiver experiences.
Based upon the outcomes data discussed, we believe this unit provides an opportunity to positively impact clinical outcomes, cost and operational efficiency, staff and patient satisfaction, staff and patient education, and personal growth for professional practice. The success of the CCCC reinforces the concept that innovative designs can address dissatisfaction with the current work environment, while at the same time allowing for future care delivery trends.
A recent study, Reversing the Flight of Nursing Talent2, identified three predictors of nursing retention: (1) competitive pay, (2) flexible schedules and (3) a reasonable workload index. Leveraging the design process to positively impact the third factor for all healthcare workers is a nearly untapped opportunity for administrators, designers, architects and engineers. Hospitals today face not only a significant healthcare worker shortage, but also shrinking capital funds and market pressure to become the employer and health system of choice, all the while keeping costs and errors down. These acuity-adaptable rooms can help organizations meet each of these challenges without adding cost per square foot. We simply spent the money differently and used the design as the vehicle for a care-delivery model and for cultural change that better matches a hospital template for the future. HD
Ann Hendrich, RN, formerly senior vice-president/nurse executive for Clarian Health Partners, Methodist Campus, currently heads Ann Hendrich & Associates in Greencastle, Ind., a national healthcare consulting firm. Joy Fay, RN, is director of the Comprehensive Cardiac Critical Care unit at Clarian Health Partners' Methodist Hospital, Indianapolis. Amy Sorrells, RN, AMWA, formerly with Clarian Health Partners, currently operates a consulting firm, Five Star Innovation, providing graphic design and writing services. For more information, contact Ann Hendrich: phone (765) 653-3531, fax (765) 653-8382 or e-mail
- Hendrich A. A Video Time and Motion Study: How do Healthcare Workers Spend Their Time? Manuscript in progress; study conducted at Methodist Hospital, Indianapolis, 1995-1999.
- Hendrich A.. Advisory Panel. Reversing the Flight of Nursing Talent. Washington DC:The Advisory Board Company; 2001.