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Presented byNena Bonuel, PhD, RN, CCRN-E, CNS, ACNS-BC
Nurse Specialist IICenter for Professional Excellence
Houston Methodist Hospital
A New Concept of In-Patient Care: Acuity-Adaptable Patient Room Promotes a Healing Environment
•One of the nation’s largest private non-profit hospital – 1,517 beds
•Member of the Texas Medical Center – 42 not-for-profit medical institutions
• Magnet Hospital since 2002 – currently 3 times-designated, on the way to 4th re-designation
•American Board of Nursing Specialties 'Award for Nursing Certification Advocacy (97% certified nurse leaders & 34% direct care nurses)
• 2006 -2013 Fortune 500 “100 Best Companies to Work For”
• Site of numerous medical breakthroughs
•Among the country’s top hospitals (U.S. News and World Report)
• Medical staff include physicians listed in The Best Doctors in America
• Medical affiliations – Weill Cornell Medical College and NewYork-Presbyterian Hospital
At the conclusion of this presentation, the participant will be able to:
Describe the relevance of the acuity-adaptable patient room concept in patient care delivery.
List two benefits of this room concept in relation to our current health care challenges.
OBJECTIVES
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“Describe and demonstrate the structure(s) and process(es) by which nurses are involved with the evaluation and allocation of technology and information systems to support practice or nurse’s participation in architecture and space design to support practice.
A Little History…
Texas Woman’s University Doctoral Students enrolled in Patient Room Design as an electivewent to Batesville, Indiana at the Hill-Rom Design Center to develop the Patient Room of the Future
Criteria: patient population must be homogeneous, predictable/stable
Gallant, D. (2006). The transformational hospital: patient room of the future, research on the acuity adaptable and universal room concepts. Brown, K. & Gallant, D. (2006). Impacting patient outcomes through design. Critical Care Nursing Quarterly.29(4). 326-341.
Concept of Acuity Adaptable Room
Emerging care model where patient is cared for from the same room from admission through discharge regardless of the patient level of acuity
Care is brought to the patient
Single or private room concept
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Wisdom from the Field…
A-A Patient rooms have positive clinical outcomes
Infection control
Patient preference and patient satisfaction
Nurse and physician’s satisfaction
Patient safety
Decrease noise levels
Decrease length of stay
Patient of the Future•Advance age
•Sicker- with co-morbidity like diabetes, cardiac disease•Obese, less mobile
•Diverse ethnicity- aware of alternative medicine•Require more intensive interventions
•Educated and informed•Internet connected•Higher expectation
EMERGING TRENDS
Demographic Trends- More Boomers, Fewer Nurses
1.5
3.0
0 1995 2007 2020
Declining Enrollment
Retiring Nursing Boomers
RN’s available
20% shortfall
RN’s requiredAging
Population
U.S. demand and Supply(millions)
•Aged• Obese• Diverse
Source:Advisory Board Company,”Bridging the Productivity Gap at America’s Leading Hospitals” “Implications for an Aging Registered Nurse Workforce”
JAMA, Vol.283, No.22, June 14,2000: 2948-2954
Slides taken with permission from Dennis Gallant, Director, Design Innovations and Programs - Hill-Rom
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2020201520102006
Outpatient/Home
Med-Surg
Progressive CareStep Down
Critical CareICU
The Forecast is GLOOMY…
Slides taken with permission from Dennis Gallant, Director, Design Innovations and Programs - Hill-Rom
Higher Acuity PatientsShortage of NursesSkill Mix ChallengeAging WorkforceDemands on Infrastructure
2010 AFFORDABLE CARE ACT
“Three emerging care delivery models
1.Accountable care organization (ACO) promotes and encourages investment in infrastructure and redesigned care processes for high quality and efficient service delivery. (PPACA, Section 3022).
2. Medical or health home
3. Nurse-managed health center
GROUP WORK ACTIVITY
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Hill-Rom Design Center Laboratory
22’-0”
16’-0”
Key changes• Reduced overall size of room width to better fit in a standard Hospital column grid layout from 18’-2” to 16’-0”
Key changes• Bathroom moved to increase line of site to outside window & family zone
Key changes• increase Depth of room to increase flow in all zones of the room Key changes
• Recessed clinical work area to improve privacy & decrease conflicts with corridor traffic & moved to foot of bed for better flow and lines of site to patient. Final Layout
Original Design
16’-0”
18.2’-0”
Patient Room Dimensions
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Visibility Between Rooms • Windows located in walls
between adjacent rooms permit staff to conveniently observe multiple patients
Hygiene Zone • Located near entry to the
room – convenient for staff hand washing
• Electronic hand washing monitoring
Key Features Modeled In The Final Design :
Staff Work Area• Decentralized work station adjacent to
patient room saves steps to bedside. • Windows provide good visibility of
patient from work area• Work area supports computer and
charting activities• Under counter pass through for linens
reduces traffic in room and cross contamination risks
Room Entry• 36” door panel with a 24” locked sleeve provide generous room entry for beds and equipment.• 36” Single door used for routine
daily passage.
Key Features Modeled In The Final Design :
Clinical Zone•Bed located in middle of the room, accessible from four sides
• Clear access to side of bed for X-Ray equipment or stretchers
• Custom Headwall provide a range of services based on patient level of acuityServices to be located on both sides of patient.
Patient Zone•Maintain adequate distance around bed for proper flow around patient to accommodate different level of equip. around patient• Provide visual stimulation for patient with Flat screen TV, customizable area at foot & line of site of exterior window.
Key Features Modeled In The Final Design :
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Bathroom Zone • Located next to exterior window area – out of clinical work area• Open shower design to maximize flexibility of entire area for Bariatric patients•Provided hand rails thru out room for maximum support for patient.•Mirror and shelf area above sink area.•48” sliding door leading into room•Dirty linen shute•Floor mounted toilet
Family Zone • Located next to exterior window area – out of clinical work area• Wardrobe, storage and shelves provided for family or patient• Include a mobile refreshment area, mini frig., microwave & coffee maker.• Flat screen TV• Pull out sleeper sofa
De-Centralized Work Area
Staff Work Area• Decentralized work station adjacent to patient room saves steps to bedside. • Windows provide good visibility of patient from work area• Work area supports computer and charting activities• Under counter pass through for linens reduces traffic in room and cross contamination risks
Patient Room
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QUE VADIS?
1. Room Design was presented to the Multi-Organ Transplant Unit at TMH
2. Nursing Director has similar vision of Acuity-Adaptable Patient Room concept
3. Full support from the Medical Director of Transplantation to the idea of Acuity-Adaptable care delivery to start with renal transplant patients.
4. Transplant Unit develop the High Acuity Transplant Unit Criteria for admissioncriteria, presented and approved by CMPI and TMH P & P. (1-19-07)
5. Collaborative team developed Kidney Transplant Curriculum to address staff nurses competency (Implemented December 2006-May 2007)
Transdisciplinary Team to TeachKidney Transplant Nursing CORE Curriculum (KTNCC)
Two Clinical Pharmacists- (ICU/Transplant)
Transplant Physician Assistant
Surgical ICU Clinical Leader
CPE Nurse Specialist- LEAD
Clinical Development Specialist
Nursing Director
Associate Chief of Nursing
THE PROCESS
5-day classroom didactic (with pre & post tests)
Final examination is closed book ( 95% passing score)
Continuing education hours were awarded per class
3 months Clinical preceptorship in the ICU
11 tenured transplant nurses completed the program(5-30 years experience in Transplant Nursing)
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Kidney Transplant CORE Curriculum
2- day Advance Cardiac Life Support
Challenge Basic ECG Exam- for score below 85%- staff take the 3-day Basic ECG Class
12 LEAD ECG
The Kidney Transplant Today
Ethical Consideration of Kidney Transplantation
Acute Renal Failure
Treatment Options for Acute Renal Failure
Physiologic Roles of Fluid and Electrolytes
Hemodynamic Monitoring
Pressure Monitoring Set-up
Glucose Control in Transplant patient
Post-Operative Management of the Kidney Transplant Patient
Transplant Infectious Diseases
Transplant Immunotherapy
Surgical Complication of Kidney Transplantation
Chronic Allograft Nephropathy
High IMC Protocol
Transplant Nurses in Training
Transplant Nurses in Action
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APPROVED!
Four transplant rooms were converted to an Acuity-Adaptable rooms*Unit started taking patient in June, 2007
…after 13 months of operation
4 more rooms were added, May 2008
ACUITY-ADAPTABLE PATIENT ROOM
Acuity-Adaptable Care Improves Renal Transplantation Outcomes
AIMS:1.Improve patient outcomes and satisfaction through the implementation of a single-room, acuity adaptable patient room to provide care following renal transplantation.
2.Increase nurse satisfaction and an improved work environment resulting in decreased employee turnover and increased consistency of care.
3.Provide a healing environment by minimizing patient care interruptions and eliminate errors, injuries, and inefficient use of time related to patient transfers.
4.Support future patient care delivery while investigating and resolving patient flow issues.
Funded research proposal ($30,000 from HOUSTON Methodist Research Institute under NIH –Clinical Translational Science Award program
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Patients cared for in the Acuity-Adaptable Patient Room will have decreased costs for their total care experience to patient cared for in a transitional care process.
Patients cared for in the Acuity-Adaptable patient Room will have decreased lengths of stay in comparison to patients cared for in a transitional care process.
There will be no difference in patient satisfaction, nursing care, patient comfort, physiologic measures and nosocomial infection between those patients cared for in the Acuity-Adaptable Patient Room and those cared for in a transitional care process.
The inclusion criteria would be:•Renal patient with a primary diagnosis of end-stage renal disease•Must be able to read and write at a 3rd grade level•Must be 18-75 years of age.•Post-transplant patients with an American Society of Anesthesiologist (ASA) score of III or IV.
The exclusion criteria of the sample would be:•Renal patient who are intubated post-renal transplant•Renal transplant patient who developed severe hemorrhage in the immediate post-operative period.•Renal transplant patients who develop cardiac problems immediate post-operative period.•Renal transplant patient who develop other kinds of emergent conditions immediate post-operative period.
Acuity-adaptable care p-valueYes No
Age (years) 44.5 ± 2.4 48.7 ± 1.2 0.10Male 17 (47.2) 68 (63.5) 0.12Race
White 17 (47.22) 45 (42.1)Black or African American 9 (25.0) 24 (22.4)Hispanic or Latino 9 (25.0) 31 (29.0)Other 1 (2.8) 7 (6.5) 0.87
Body mass index (kg/m2) 27.8 ± 5.7 25.9 ± 4.7 0.05ASA <0.0001
2 0 (0) 1 (1.0)3 22 (71.0) 29 (29.3)4 9 (29.0) 69 (69.7)
Duration of surgery (min) 38.7 ± 21.2 41.1 ± 21.6 0.57Length of stay (days) 4.1 ± 1.3 9.6 ± 11.0 0.004CostTotal 61291 ± 11508 82859 ± 24882 <0.0001Labor 10146 ± 3477 12126 ± 7128 0.12Direct 21489 ± 4755 26308 ± 9760 0.006
Medical conditionHypertension 31 (86.1) 98 (93.3) 0.18Diabetes 32 (30.8) 6 (16.7) 0.13Anemia 22 (61.1) 71 (67.0) 0.55TB 2 (5.6) 2 (1.9) 0.27Pulmonary disease 3 (8.3) 13 (12.3) 0.76Peptic ulcer disease 3 (8.3) 6 (5.7) 0.69Hepatitis 3 (8.3) 9 (8.5) 1.0
Table 1: Baseline characteristics
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Day 0 Day 1 Day 2 Day 3Acuity-adaptable care Acuity-adaptable care Acuity-adaptable care Acuity-adaptable care
Yes No Yes No Yes No Yes NoNursing carePressure ulcer 0/36 0/102 0/36 0/102 0/36 0/102 0/26 0/101Reported medication error
0/36 0/101 0/36 0/102 0/36 0/102 0/26 0/102
Reported patient fall 0/36 0/102 0/36 0/102 0/36 0/102 0/26 0/102DVT 0/36 0/102 0/36 0/102 0/36 0/102 0/26 0/102Patient comfortPain scale
Average 1.2 ± 1.9* 1.8 ± 1.8 1.4 ± 1.7* 1.6 ± 1.2 1.1 ± 1.6* 1.2 ± 0.5 0.7 ± 1.2* 1.2 ± 0.6Maximum 3 ± 2.7 3.9 ± 3.9 3.9 ± 2.5 4.2 ± 3.2 4.0 ± 2.5 4.5 ± 3.0 3.3 ± 3.0 4.1 ± 3.5
Catheter obstruction 0/36 0/102 0/36 0/102 0/35 1/100 0/25 1/90Physiological measuresHypertensive episodes
2/34* 43/57 3/33* 43/56 3/33† 28/72 2/24 20/79
Urine output<200 in 8 hr
0/36 3/95 1/35 5/96 0/35 5/96 0/26 3/98
Glucose level>110 30/6 73/15 34/2 72/17 34/1¶ 66/23 23/3† 61/32Heart rate<110 or <60 9/22 33/68 8/23 32/69 8/22 21/80 2/21 17/84
Temperature>100 2/29 12/89 6/25 18/83 6/25 10/91 2/21 5/96Nosocomial infectionsUrinary tract infection
0/31 0/102 0/31 0/102 0/31 1/101 0/23 2/100
Pneumonia 0/30 0/102 0/30 1/101 0/30 1/101 0/22 1/101Central line infection 0/29 0/102 0/29 0/102 0/29 0/102 0/21 0/102
Data was presented as yes/no for categorical variables or mean ± SD for continuous variables.* P<0.0001 for comparison between acuity-adaptable care and no acuity-adaptable care at each day based on Kolmogorov-Smirnov test for continuous variables or Chi-square test for categorical variables.† P<0.05 for comparison between acuity-adaptable care and no acuity-adaptable care at each day based on Chi-square test.¶P<0.01 for comparison between acuity-adaptable care and no acuity-adaptable care at each day based on Chi-square test.
Table 2:
Rationale for the StudyCare of renal transplant patient is complex
Large Southwestern Magnet Medical Center was challenged to innovate and create 4 acuity-adaptable patient rooms
Innovation is aligned with the Accountable Care Act 2010
No qualitative studies were found that examine the experiences of nurses caring for a patient in the acuity-adaptable patient room
2009: QUALITATIVE STUDY
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Philosophical Foundation: Husserl
Phenomenology
Universal Essences
Transcendental subjectivity
Bracketing
RESEARCH QUESTION
What are the experiences of the transplant nurses caring for renal transplant patients assigned to acuity-adaptable rooms?
STUDY DESIGN: Descriptive Phenomenology
Setting: 1500-bed Tertiary Hospital
3-times MAGNET designated
30-bed multi-organ transplant unit
16 acuity-adaptable patient rooms
Participants: n=10
Purposeful sampling
“Lived” Experience
Characteristics N=10
Age (years)
Range = 35-55
Race
ChineseIndian
FilipinosCaucasianEducation
ADNBSN
MSN/NPCertification
CCTNNo Certification
Years in Transplant Nursing8 years and >
1253
181
91
10
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Protection of Human Subject
Formal Ethical Approval was provided by two Institutions
TEXAS WOMAN’S UNIVERSITY IRB
THE METHODIST HOSPITAL RESEARCH INSTITUTE (TMHRI) IRB
STUDY DESIGN: Descriptive Phenomenology
Interview Schedule
1. Tell me about your experiences in caring for a patient in an acuity-adaptable room.-How do you think you care for patients differently in an acuity adaptable room than a traditional room?
-What do you like about it?-What do you not like?-Tell me about how you use the technology that is available in acuity adaptable rooms
2. What would you change about the room design?
3. What do you think the future holds for the acuity-adaptable patient room?
Tell me in as much detail as possible about how you cared for your last renal transplant patient using an acuity-adaptable patient room.
DATA ANALYSIS/PROCEDUREINTERVIEWS
Significant statements
Formulated meanings
Formulated meaning grouped, based on interview structure
Themes
Theme Clusters
Exhaustive description of the phenomenon
Return to participants to validate descriptionIncorporate new data to the exhaustive description of the phenomenon
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TRUSTWORTHINESS
CREDIBILITY – PI went back to the study participants and check both data and the interpretation
TRANSFERABILITY – PI collected sufficiently detailed data to report data with accuracy.
Purposive sampling was used so the range of specific information about the experience can be maximized.
TRUSTWORTHINESS
DEPENDABILITY – members of the dissertation committee, colleagues expert in qualitative research examined documentation, the data, findings, interpretations, and recommendations--and attests that it is supported by data and is internally coherent.
CONFIRMABILITY – adequate audit trail is preserved to support the conclusions, interpretations, and recommendations and can be traced to their sources.
The FINDINGS:INTERVIEWS (n=10)
Significant statements (n=158)
Formulated meanings (n=135)
Formulated meaning grouped, based on interview structure
Themes (n= 14 )
Theme Clusters ( n=3 )
Exhaustive description of the phenomenon
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Findings: 14 ThemesTHEME 1: The experience is perceived as positive (16 Coded Formulated meanings)
THEME 2: Patient satisfaction is improved (7 Coded Formulated meanings)
THEME 3: Sense of empowerment (41 Coded Formulated meanings)
THEME 4: Adequate education preparation improve the skills of the nurse (17 Coded Formulated meanings)
THEME 5: Early patient education (7 Coded Formulated meanings)
THEME 6: More privacy to the patient and the family (2 Coded Formulated meanings)
THEME 7: Positive perception of technology in the room (38 Coded Formulated meanings)
THEME 8: Improve patient outcome due to lower nurse to patient ratio (4 Coded Formulated meanings)
THEME 9: Support patient safety (7 Coded Formulated meanings)
THEME 10: Calm environment to heal (4 Coded Formulated meanings)
THEME 11: Insights of nurses to improve room (11 Coded Formulated meanings)
THEME 12: An emerging care model in the future (5 Coded Formulated meanings)
THEME 13: Importance of the family presence in the room (7 Coded Formulated meanings)
THEME 14: Future potential for the room concept. (10 Coded Formulated meanings)
Findings: 3 Theme ClustersTHEME CLUSTERS # 1-(47 Formulated Meanings)
The acuity-adaptable patient room provides comfort to both patient and family.
THEME CLUSTERS # 2-(62 Formulated Meanings)
Nurse felt a sense of empowerment in the care of renal transplant patient in the acuity-adaptable patient room.
THEME CLUSTERS # 3 –(26 Formulated Meanings)
There is a future potential for the acuity-adaptable patient room.
Findings: Examples of Statements and Meanings
Theme Clusters Significant Statements Formulated Meaning
A-A room provides comfort to both patient and family
“We’re able to give our patient’s privacy. They can rest through the night, and we can monitor them with a minimum amount of interruption.”
The nurse viewed that the acuity-adaptable patient room provide a healing environment for the patient and the family by allowing them a place of respite at the same time their recuperation is vigilantly watched.
Nurse Empowerment “These patients—I can see them, whether they are improving or their status changes as quickly as they change, I don’t have to rely on telemetry to call me. I don’t have to rely on labs. I don’t have to rely on a lot of things, external factors, which warn me. I have the art lines. We’re capable of handling those. I have the CVP. I know exactly when my patient is a little dehydrated or overloaded”.
The nurse felt she has a handle on her patient with the help of the monitoring equipments in the acuity-adaptable patient room. She is able to observe closely the healing process of her patient.
Acuity-Adaptable has future potential
“I think there certain type of patients that the AA room could be very beneficial. Your orthopedic patients, most of the orthopedic patients come in same room and discharge and surgery in-between.”
The nurse acknowledges that the AAroom could be use to certain patientpopulation.
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What are the experiences of the transplant nurses caring for renal transplant patients in acuity-adaptable patient rooms?
Nurses felt empowered in caring for patient in the acuity-adaptable patient room. It
is this empowerment that they are able to build partnership with their patient and
the family in providing quality care; transforming the environment so the renal
transplant patient is put in the best position to heal.
Because a healing environment is created with the acuity adaptable patient room
concept, the feasibility of this room in the future is promising .
CONCLUSIONS
Acuity-adaptable patient room concept shows promise in providing a healing environment for the patient and family.
Limitation of the study: purposive sampling
Findings will provide a foundation for the design of further studies using either qualitative or quantitative studies.
Replication of the study is needed to strengthen the support for this kind of patient room in the future
Implications for Nursing
Affordable Care Act, 2010
The Future of Nursing, 2010
NDNQI: A-A pt. room is an emerging unit-type
Hybrid Nurse…?
Efficient utilization of the ICU beds, Patient transfer decrease,
bed control minimize
Acuity-Adaptable room – hot topic in conferences
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OUTCOMES
Results of the study is now in publication
Bonuel, N. & Cesario, S. Experiences of the Transplant Nurses Caring for Renal Transplant Patient in an Acuity-Adaptable Patient Room. Crit Care Nurs Q. 2013 Apr-Jun;36(2):195-213.doi:10.1097/CNQ.0b01e31828410b8
Bonuel, N. & Cesario, S. Acuity-Adaptable Patient Room Improves Length of Stay and Cost of Patients Undergoing Renal Transplant, A Pilot Study. Crit Care Nurs Q. 2013 Apr-Jun;36(2):181-194.doi:10.1097/CNQ.0b01e318283d0f3
Bonuel, N. & Cesario, S. Review of the Literature: Acuity-
Adaptable Patient Room. Crit Care Nurs Q. 2013 Apr-Jun;36(2):252-272.doi:10.1097/CNQ.0b01e31828d63c7
Other Publications on Acuity-Adaptable Patient Room
Bonuel, N., Cesario, S., & Degracia, A. (2010). The need for critical care nursing skills in an acuity-adaptable care delivery system. Critical Care Nursing Quarterly, 33(4),, 356-360.
Bonuel, N., Degracia, A. & Cesario, S. (2012). A new concept of in-patient care: acuity-adaptable patient room decreases length of stay and cost-results of a pilot study. In: Toward Healthcare Resource Stewardship. Nova Publishers: 115-138.
PRESENTATIONS on ACUITY-ADAPTABLE PATIENT ROOM
Oral Presenter –“Acuity-Adaptable Care Delivery Improves Renal Transplantation Outcomes” in the 21st
International Nursing Research Congress, July 12-16, 2010, Orlando Florida.
Oral Presentation –‘Using Technology to support an Acuity-Adaptable Care Delivery in a Renal Transplantation: An Innovative Patient Care Delivery of the Future”
at the 20th Sigma Theta Tau International Annual Research Congress , July 13-17, 2009, Vancouver, Canada
Invited Speaker- “Acuity-Adaptable: Patient Room of the Future” at the 2nd Planning & Creating the Patient Room of the Future Conference held in Dallas, Texas, March 26-27, 2009.
Invited Speaker- “Acuity- Adaptable: Patient Room of the Future” at The Quality Celebration 2008 held at the Michael E. DeBakey VA Medical Center, Houston, Texas, October 21, 2008.
Invited Speaker- “Acuity-Adaptable: Patient Room of the Future”, Planning & Creating the Patient Room of the Future Conference held in Houston, Texas, September 26, 2008.
Poster Presentation- “Acuity-Adaptable: Patient Room of the Future” at the 17th Annual International Transplant Nurses Society Symposium in St. Louis, Missouri, September 25-27, 2008
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PRESENTATIONS on ACUITY-ADAPTABLE PATIENT ROOM
“A Kidney Transplant CORE Curriculum for Acuity-Adaptable Care Delivery” -Abstract selected for the Inaugural ANCC Magnet ™ Practice Innovation at the Virginia Henderson International Nursing Library (VHINL), posted July 1, 2008.
Invited Speaker -“Acuity-Adaptable: Patient Room of the Future” speaker at the 13th Far Eastern University Alumni Association Grand Reunion held in Orlando, Florida, June 29, 2008.
Oral presenter-“Using Technology to Support Acuity-Adaptable Care Delivery of Renal Transplant Patients”speaker at the Go for the Gold-Regional Learning Exchange held in Houston, December 7, 2007 at the Hilton Hotel.
Oral Presenter in the concurrent session -“An Educational Strategy to Support an Acuity-Adaptable Care Delivery”,at the 16th Annual International Transplant Nursing Society Symposium held at Denver, Colorado, October 3-6, 2007
Speaker -“Acuity-Adaptable Care Delivery Improves Renal Transplantation Outcomes” speaker at The Methodist Hospital Research Institute Investigator Colloquium held in Houston, Texas, September 24, 2007 at The Trevisio.
Concurrent speaker -“Acuity-Adaptable: Patient Room of the Future”, 18th International Nursing Research Congress Focusing on Evidence-Based Practice-Collaboration: A Transdisciplinary Roadmap to Discovery held in Austria Center, Vienna, July 11-14, 2007.
Concurrent session speaker -“Patient Room of the Future” at the National Indian American Conference held in Houston, May 5, 2007.
Acknowledgements
Acknowledgements
