In July 2013, the Cardiac Intensive Care Unit (CICU) and the Cardiothoracic Surgical Intensive Care Unit (CTICU) implemented new staffing models to improve patient care and efficiency.
Jason Katz, MD, MHS, Medical Director of the CICU and CTICU & Critical Care Service, spearheaded the effort to make these changes. He is the co-author of a 2012 American Heart Association Scientific Statement entitled, “Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models.”
Trained and board-certified in cardiology, critical care medicine, and advanced heart failure/transplant, Dr. Katz became director of the Cardiac ICU about three years ago. After a lot of thought and consideration, Dr. Katz made the recommendation to change the staffing structure of the CICU from an open-unit model to a closed-unit model.
“Based on a growing body of evidence that supports this type of structural change for intensive care units, plus my bias on how I think patients should be cared for, this change was made in the CICU,” explains Dr. Katz.
Previously, in the open-unit model of care, there were four teams – each made up of an attending physician, fellows, residents, and medical school students – plus a heart failure team. The teams would round on patients no matter where they were in their recovery, following their patients from the CICU to the step-down recovery floor through their discharge from the hospital.
“Our patients in the CICU have gotten sicker over time,” says Dr. Katz. “The idea that the teams could be focused enough on those patients and then care for all of the patients on the step-down/floor, I think, was becoming less and less a reality.”
Both the CICU and the step-down/floor patients needed more focused attention. Given the disease severity and acuity of the unit patients, CICU nurses needed to be able to communicate quickly and efficiently with the critical care team. Good communication and collaboration would then hopefully translate into reduced complications and more efficient and effective care.
“At the same time, the step-down and floor patients deserve physicians who aren’t being pulled all over the place, because they have their own set of unique needs,” states Dr. Katz. “The transition to the outpatient setting is complicated, and the patients deserve attention to their care, not dilution of care, particularly in light of the need to reduce readmissions.”
Dr. Katz says, “It was my hope that new staffing and structural models would help address all of these issues.”
Now, in the closed-unit model of care, there is one critical care team taking care of the entire Cardiac ICU. A team (attending, fellows, residents, and medical school students) works 12-hour shifts.
“There are actually two attending physicians that round, one that focuses on the general cardiology critically ill patients and another that focuses on advanced heart failure and transplant,” explains Dr. Katz. “Having designated teams provides the nursing staff with resources that they can go to immediately, and communication has been enhanced.”
The unit is going through the process of collecting data to show that resource utilization has improved, outcomes for patients are improved, the educational experience is improved, and nursing satisfaction has improved.
The cardiac step-down and floor are also using this model to improve care, patient satisfaction, and employee satisfaction.
The Cardiothoracic Surgical Intensive Care Unit (CTICU) has also implemented a new staffing structure, but it is a hybrid of the two traditional staffing models. The CTICU provides care for cardiac, vascular, and thoracic surgery patients.
“The CTICU is constantly at capacity, we are bringing in sicker and sicker patients, and the demands on the surgeons from an operative standpoint have increased considerably,” says Dr. Katz. “Gone are the days when surgeons could easily operate and manage their sick patients in the intensive care unit all at the same time.”
This year, when Dr. Katz was named director of the CTICU, he created a cardiovascular and thoracic Critical Care Service that is staffed by critical care providers and has its own house staff and advanced practice provider team that provides 24/7 critical care support for the surgeons. Due to the growth in Heart and Vascular surgical volumes and ever-increasing patient acuity, the CTICU beds are often full, and patients are placed in other intensive care units. The CTICU critical care team provides care for these patients as well, no matter which ICU they are in.
Dr. Katz believes that the “effectiveness of this hybrid model hinges on effective communication and collaboration between surgeons and critical care physicians as well as juggling the available resources of the house staff and nurse practitioners.”
This hybrid model is continuing to evolve, and plans are being made to hire several acute care nurse practitioners along with the addition of surgical and anesthesia residents.
“This, too, is a long time coming,” explains Dr. Katz about the CTICU hybrid model. “It follows the national trends in critical care for perioperative patients.”
Over the next year, data will be collected on length of stay, patient outcomes, and mortality in the CTICU, as well as studying the economic impact of both of the changes.