10/2/2012. D04: Help Nurses Help the Smallest Patients: How Infant Care is Reorganized Tuesday, October 2, :30 PM - 4:30 PM

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1 D04: Help Nurses Help the Smallest Patients: How Infant Care is Reorganized Tuesday, October 2, :30 PM - 4:30 PM Presenters Richard M. Katz M.D., MBA, Vice-President, Medical Affairs, Mount Washington Pediatric Hospital James Albert AIA, Principal, Hord Coplan Macht, Inc. Learning Objectives To understand how the needs of post-acute, long-term infant care drives a distributed staffing model. To learn how specialized design elements, such as distributing core functions, provided necessary configurations for the patient care model. To evaluate how design elements improved patient safety and security through better visibility and infection control. To assess how this unique method of distributed nursing increased staff morale and efficiency. Who is MWPH? 80-Bed Pediatric Specialty Hospital in Baltimore, MD Partnered with University of MD and Johns Hopkins University Hospitals 1

To learn how specialized design elements, such as distributing core functions, provided necessary configurations for the patient care model.

2 Maryland s Unique System Waiver from the federal DRG system of payment from Medicare A state commission sets rates for each hospital All payers must pay these rates Hospital rate setting covers reasonable costs for uncompensated care Maryland s Unique System There is no disincentive to take Medicaid or Medicare patients the hospital gets the same rates from them as from private payers Most hospitals are on a charge per case system similar to the DRG system they are paid per admission, according to diagnosis and acuity MWPH and the Maryland System Our partner hospitals have an incentive under charge per case to move patients to a less acute setting as soon as they are medically ready This system allows the feeder hospitals to more quickly take new patients, and Payers save money as patients are cared for in the least intensive appropriate setting The system allows a specialty hospital like MWPH to survive and thrive in the current environment Infant Care Unit Center for Pediatric and Neonatal Transitional Care: Birth to 2 years 42 beds; ADC 37 at Rogers Ave Provides care predominantly for Neonates (premature infants) Small infants with chronic lung disease/feeding-gi issues/cardiac anomalies/ventilator dependent Drug withdrawal 2

hospitals are on a charge per case system similar to the DRG system they are paid per admission, according to diagnosis and acuity MWPH and the Maryland System Our partner hospitals have an incentive

3 Infant Unit Populations (0 1yr) Small Infant Program (SIP) NICU Upperclassmen Medical Management - Clinical Pathway 375 Admissions / yr Most frequent length of stay: 2-3 Weeks Admission Criteria Includes: May have complicating issues including: Post NICU less than 42 wks gestation and > 1250 grams 2 days of pre-admission weight gain Medically stable Drug withdrawal Oxygen/isolette weaning Cardiorespiratory monitoring Feeding issues, GE reflux Ventilator management Extensive caregiver training Infant Unit Populations (0 1yr) Pediatric Chronic Illness (PCI) - Mostly PICU graduates Medical Management Individualized 165 Admissions / year Most frequent length of stay: 2-4 Weeks Admission Criteria Includes: Peritoneal dialysis Central line management Cardiac, pain or HIV management Total Parental Nutrition/Intralipid Therapy Feeding dysfunction/pre-cardiac surgery Ventriculoperitoneal shunt Oxygen weaning Tracheostomy/ventilator mgmt Lung disease Extensive caregiver training Existing Patient Unit Existing Patient Room 3

Cardiorespiratory monitoring Feeding issues, GE reflux Ventilator management Extensive caregiver training Infant Unit Populations (0 1yr) Pediatric Chronic Illness (PCI) - Mostly PICU graduates

4 Patient Needs Constant Observation 1:3 or 1:4 Nursing Ratio Low Stimulation for Drug Withdrawal NICU vs. Non-NICU Clinical Program Philosophy Nurse at the bedside 24/7 Supplies close at hand Nurses support one another Initial Research Site Visits Focus Groups Parent Surveys Peer Research Charettes Included: President Executive Team Physicians Nursing Rehab Child Life Nourishment Pharmacy Respiratory Therapy Materials Management Facilities Housekeeping Security Infection Control I.T. / I.S. Foundation Architect Engineer Construction Manager 4

Visits Focus Groups Parent Surveys Peer Research Charettes Included: President Executive Team Physicians Nursing Rehab Child Life

5 Mock-ups New Patient Unit Distributed Nurse Station Distributed Supplies 5

6 Modular Room Design Flexibility for Patient Needs PC at every bed Modular Components Isolated Lighting Side-to-Side Nursing Technology Assistance 6

7 No Central Nursing Station Enhanced Security Enhanced Security Enhanced Security Rendered plan of Original Lobby Security Desk Existing New Existing New 7

8 Staff Satisfaction Getting nurses out of the patient room Staff Satisfaction Nurses can support one another Existing New Staff Satisfaction The right thing where it is needed Meds Travel Distances From Nurse Work Area Before After % Reduction To Medication Room Average Distance % Longest Distance % To Clean Supply Room Average Distance % Longest Distance % To Infant Clothing Room Average Distance % Longest Distance % Staff Satisfaction Bringing Child Life onto the unit Supplies 8

Average Distance 86.33 38.92 55% Longest Distance 107 65 39% To Clean Supply Room Average Distance 67.83 49.

9 Staff Satisfaction Generous off-stage space Conclusions Post-Acute, Long-term infant care requires de-centralized nursing Conclusions Conclusions Distributing core functions supports de-centralized nursing Design Elements improved patient safety and security 9

nursing Conclusions Conclusions Distributing core functions

10 Conclusions Thank You Unique method of de-centralized nursing increased staff morale and efficiency Dr. Richard M. Katz Mount Washington Pediatric Hospital Jim Albert, AIA, ACHA Hord Coplan Macht

Katz Mount Washington Pediatric Hospital Rkatz@MWPH.

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