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Universal patient floor increases patient flow, decreases handoffs, improves patient safety


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In 2007, Cedars-Sinai Medical Center in Los Angeles rolled out a “universal floor” during an expansion project. Cedars-Sinai’s innovation has since lowered wait times for patients being admitted from the ED and elsewhere, reduced the number of patient safety events, and increased staff member satisfaction.

A universal floor is one on which most patient consultations can take place. Rooms are created with multiple types of patient care in mind, and staff members are trained in many specialties to facilitate patients’ needs on one floor, reducing the need for patients to travel throughout the hospital.

The idea for developing a universal floor came at a time when the hospital was designing a new critical care tower. Staff members decided to trial the idea after hearing of the success of a universal floor at Methodist Hospital of Clarian Health in Indiana.

“We thought we could have a unit where we could ensure that all of the staff were capable of providing the levels of care that included a step-down unit as well as a general medical unit and a tele-unit,” says Linda Burnes Bolton, DrPh, RN, FAAN, vice president and chief nursing officer at Cedars-Sinai. “Second, in terms of the construction of the unit, [it] would facilitate idealized design … about creating units where you minimize the amount of time staff are out of the patient’s room and maximize the amount of staff [who] are in direct care with the patient.”

A growing body of data show that increasing the amount of time nurses are in direct contact with patients leads to the best patient outcomes. Nurses are better able to rescue patients and prevent harm from occurring, says Burnes Bolton.

Additionally, Cedars-Sinai wanted to address patient flow issues due to a lack of available beds and a constant influx of patients needing beds, similar to many hospitals in the country. Ideally, the universal floor would be able to accept patients who were visiting with their doctors and complaining of chest pain, for example, without having to go through the ED. Often, physicians will send patients to the ED as a last resort because of the lack of open beds.

“We were thinking of the things that were barriers to getting patients in as soon as possible, making sure we had the appropriate resources to be able to provide them care, and also be as flexible as possible in terms of meeting our patients’ needs,” says Burnes Bolton.

Design pays off

In addition to improving patient flow throughout the hospital and reducing patient safety errors, the universal floor has allowed staff members to spend more time with patients, making for a more comfortable patient stay.

“The most important piece is that the units [were] designed [to] facilitate the ability of the team to intervene early and to provide more time for direct patient care,” says Burnes Bolton.

Because of the work flow redesign on the universal floor, staff members on the floor have significantly cut down on wasted time. Nurses are encouraged to be active players in patient care and share their creative ideas for new programs and procedures on the floor. For their creative ideas to flourish, however, the hospital needed to allow them time for development and implementation.

“Nurses can’t do that if they’re spending so much time on documentation or spending so much time hunting and gathering supplies,” says Burnes Bolton. “They have to have time to be able to educate patients and engage families.”

Creative ideas encouraged

Examples of how staff members on the universal floor have been encouraged to contribute ideas for better patient care can be seen in the efforts they have taken to reduce readmission.

Cardiac patients on the universal floor are given special attention before and after discharge because of the known high rate of readmission with that population. A team of nurses on the floor works with cardiac patients to ensure that when they are discharged, they have the proper tools to help keep them from returning to the hospital. This includes a home visit by a member of the staff to evaluate risks in the home, as well as interviews with the patient and his or her family.

One nurse developed a unique teaching aid to help cardiac patients learn best practices upon discharge. Called the “Deck of Cards” program, the initiative requires staff nurses to create a unique deck of cards (like playing cards) that act as a teaching aid. The content of the cards is based on findings from the home visit and interviews conducted, as well as patient preference.

Because of the home visit portion of the program, nurses discovered that many patients did not have scales in their house.

“When you give a patient an instruction that says, ‘Weigh yourself, and if you observe a change in your weight or fluid retention, that’s a warning sign that you need to adjust your diet and notify your physician,’ well, they were bouncing back because by the time they had observed that [they had gained weight], they were already back in [heart] failure,” Burnes Bolton explains.

To prevent this scenario from occurring, Cedars-Sinai began to weigh cardiac patients on certain scales while they were in the hospital and gave them those same scales to take home at discharge.

In addition to helping patients weigh themselves and become more familiar with the scale, using the same scale resulted in more accurate weight readings. Not all scales show the same weight. This way, patients could be sure their weight after discharge was based on the same number recorded as an inpatient.

Staff satisfaction leads to satisfied patients and families, enhanced communication

Nurses on the universal floor carry PDAs to keep track of the many requests coming in from other players in patients’ care. Because there are often multiple physicians involved in a patient’s case, family members who want to stay up to date with the patient’s condition, and lab results waiting to be read, Cedars-Sinai decided to make the task of communicating with all of these parties easier for nurses, who often end up acting as the coordinator.

PDAs allow nurses direct communication with physicians and families, instead of through a unit head. PDAs also allows nurses to check lab results on their own, with one device.

“You can stay on top of what’s happening with the patient, you can facilitate communication between the interdisciplinary team, and the patient and family feel like they have a connection with the person caring for their loved one,” says Burnes Bolton.

Because nurses are given time to develop creative ideas to facilitate patient care, such as the one pertaining to readmissions for cardiac patients, they are able to be more available for patients and families. This has been a priority for those involved with creating the universal floor, says Burnes Bolton.

“We spent a lot of time and effort on engagement,” she says. “We literally support staff by providing [an] opportunity for them to come up with ideas, test those ideas. Once you get them engaged and allow them to test out ideas, you have to support them by providing them with time to be able to do those things.”

Because the universal floor has helped reduce errors, Burnes Bolton was able to get the chief financial officer on board. The floor produces good clinical as well as economic outcomes, she says. Of course, having a supportive leadership team is a must.

“Healthcare is a team sport,” Burnes Bolton says. “You can’t do this just by one discipline alone.”