Changes on Transitional Surgical Unit boost value, satisfaction

All across Christiana Care Health System, physicians, nurses, staff, volunteers and even patients and families are sharpening their focus to find more value in health care resources. The 12-bed Transitional Surgical Unit (TSU) is an excellent example of how some efforts succeed in making the most of health care resources. Thanks to a dynamic, innovative initiative, the TSU was able to help reduce patient upgrades to the Intensive Care Unit by 50 percent.

The TSU’s diverse patient population has conditions ranging from traumatic brain injury to gunshot wounds, and includes other high-acuity patients in need of specialized treatment, but not necessarily an intensive care unit.

“Our goal was to learn how we could care for these higher-acuity patients in ways that both benefit the patient and reduce the expenses associated with upgrades to the ICU,” says Nurse Manager Danielle Weber, BSN.

Education was an important part of the plan. All nurses are Advanced Cardiac Life Support certified and can give Level C medications.

Some improvements, such as bedside reporting at shift changes, involved changes in routine that did not require additional technology or funding. Bedside reporting better enables nurses to detect when patients are not improving or are mentally confused.

“By taking a more visible approach, it is more readily apparent if there is a change in the patient’s condition during the shift,” Weber says.

Each day, a friend or relative designated as the family spokesperson is invited to visit at 9 a.m., when nurses—frequently accompanied by doctors—make bedside rounds. That gives families an opportunity to ask questions or voice concerns.

“In the TSU, we strive to promote patient and family centered care,” says Joan Pirrung, APRN, Trauma Program manager, who was the TSU nurse manager until last November. The unit’s medical director, Gerard Fulda, M.D., says initially doctors worried that the new rounding procedure would be a drain on time. Not so.

“What we have found is that [bedside reporting] is actually more efficient, because often doctors can talk to patients and families at the same time instead of separately,” Dr. Fulda says. “There also are occasions in which a relative volunteers an important observation or piece of information about the patient that helps the doctor to determine the best plan of care.”

The project also presented an opportunity to more clearly define the mission of the TSU. Under the initiative, heightened standards were rolled out, including:

Taking vital signs every two hours and reading EKG strips every eight hours or sooner if there is a change.

Focused assessment every two hours, including wounds, IV drug drips or drainage systems.

Full, head-to-toe assessment of patients every four hours.

Enhanced whiteboards (dry-erase boards used to convey information among staff, patients and families) brought the unit a Focus on Excellence Award and high marks from patients and relatives, with an 88 percent improvement in satisfaction in communication from post implementation surveys specific to the whiteboards. The boards include such essential patient information as scheduled tests, diet, activity level, and appointments for physical therapy, occupational therapy and speech therapy. A message center enables patients and relatives to write notes to doctors and nurses.

“Our pre- and post-survey results showed improved staff, physician, patient and family satisfaction in regards to the communication board,” Pirrung says. “The transformation of the unit has been incredible and will only get better with the patient always placed at the center.”

In a six-month span in 2010, the 50 percent decline in ICU upgrades resulted in savings of $45,500, based on one day of care and the difference between the TSU daily charge of $1,400 and ICU charge of $2,700. In addition, patient falls fell 66 percent.

“Christiana Care has empowered nurses to have a say in how their units are run,” Weber says. “As a nurse of 16 years, I can say that is a wonderful feeling. We are making a difference for patients, their families and the health care system,” Weber says. “It’s not easy to change your whole way of thinking, but we did it as a team.”