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Reprinted with permission from
Nursing Management, 33(4):35–43, 2002.
As described in Part 11 of this 6-part series exclusively endorsed by the American Association of Critical-Care Nurses (AACN), PCUs provide care to stable, critically ill patients of varying acuities with a high potential for life-threatening changes. Since general care units can’t provide the continuous monitoring, frequent assessment, and specific acute and skilled care that progressive care patients need,2,3 these patients are best described as "stable, critically ill."
PCUs range in service from mixed medical/surgical patient populations to very specific, such as cardiac, respiratory, or transplant. To resolve many initial issues, hospital administrators, nurses, and physicians typically unify in the PCU decision-making process. Thus, you’ll need both a top-down and bottom-up process to begin.
Phase 1: Identify Need
When considering a startup or enhanced PCU, discuss the possibility with a multidisciplinary team that includes hospital decision-makers. Many times, hospital administrators can identify global healthcare needs by reviewing financial reports, patient satisfaction surveys, quality indicator reports, emergency department diversion statistics, and recent reports on the number of closed or capped beds. The latter costs the organization significantly in lost revenue.
Issues that impact the closure and capping of beds range from staff shortages to less than optimal systems, protocols, collaboration, and communication needed to support patients through the care continuum. Hospital leaders must examine these issues carefully at both service and institutional levels to develop an action plan. Also, hospital leaders must support the nursing and medical directors, managers, advanced practice nurses, and other ancillary personnel who spearhead such creative care solutions. Designate this group of people the leadership development team (LDT). These individuals will be directly involved with the issues that drive quality of care and patient outcomes. Each team member is a key stakeholder and, therefore, best positioned to activate the first phase of PCU development. It’s imperative that stakeholders work in tandem toward the goal of PCU development.
Data that identify difficulty in patient care delivery, such as patient access and acuity-appropriate care levels, drive the LDT. The team should proceed to identify and describe the PCU’s need and define its patient population. Once the team agrees on the goals of the PCU, the LDT can begin the second phase.
Phase 2: Collect Information and Data
The data collection phase demonstrates to the approving body or hospital’s executive board the need and justification for the new PCU. The data, which can be collected by all team members, will either support or halt PCU development. This process should include a literature review and presentation of the anticipated return on investment (ROI) or cost-benefit analysis. In times of downsizing, hospital mergers, and cost containment, Phase 2 can be the most difficult to accomplish. A fiscally sound presentation is critical to gain approval of the new unit.
Review PCU literature.
A literature review will help the LDT to learn how facilities with similar demands implement solutions. It will also identify ways to financially support the start-up PCU and sustain its ongoing cost-effectiveness. Present these findings as part of the supporting documentation to your hospital’s executive board.
Current literature shows that extended care of patients who require more than 7 days in the ICU will impact facility costs.4 Many of these stable, critically ill patients can receive care in a PCU. These types of patients range from those who require weaning from being on ventilators long term to monitored cardiac patients who require anti-arrhythmic drug infusions. These acuity levels don’t meet ICU admission criteria.
One medical center’s financial data show that DRG reimbursement for respiratory failure patients with a tracheotomy (DRG 483) averaged more than $80000.5 The cost of ventilator management was estimated at $1000 per day.6 Although PCU literature isn’t extensive, more and more information is becoming available on how they decrease costs, help to generate revenue, provide the appropriate level of care for the patient’s acuity, and decrease the utilization of scarce ICU beds.
Visit other PCU sites
The LDT should assess the need for a site visit early in the planning and data collection phase. A site visit to another hospital with a similar PCU provides the team a first-hand look at its overall operations. Be sure that the hospital visited is similar in size, patient population, and healthcare issues. LDT members at the guest facility should generate a list of topics, questions, and goals for the visit. The host facility should provide information on start-up costs, staff education, financial data, patient outcomes, and lessons learned.
Justify financials
Hospitals usually require cost justification of projects that exceed $25000. Cost-benefit and ROI analyses are needed for a project such as a start-up PCU. A completed ROI should contain these documents: project description (PD), strategic value (SV), and ROI Executive Summary and Financial Summary (ESFS).
The project description details what the project encompasses. Major areas to address include equipment, renovation and construction, staffing, and other general criteria. The project description also includes a detailed list of existing equipment and any new equipment needed. (See "Project description.")
Also document how the utilization of existing equipment and space won’t increase the hospital’s current costs. Additional equipment needed could range from pulse oximetry equipment to complete bedside monitors. The opportunity to be able to use all current equipment resources to offset costs is helpful.
The renovation/construction portion of the ROI describes the cost to renovate an existing space or construct a new one. Since constructing a brand-new unit places a heavy financial burden on the hospital, renovating existing space is recommended. Using existing space from services or units that have closed will help to support your PCU justification. Your hospital’s engineering experts can provide the cost of renovation per square foot. It’s essential to engage a competent architectural firm that’s experienced with PCUs to receive accurate costing and design.
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Considerations for renovation and architectural design take place in early planning stages. A newly constructed, true standalone unit usually isn’t cost-effective for most hospitals. The next best option is to renovate an area adjacent to the higher level of care or the next lower level of care. Commonly, standalone PCUs are partnered with a telemetry-monitoring unit or within the confines of an ICU. A PCU within an existing ICU is a viable alternative for the care of patients who have prolonged length of stay and are less acutely ill, and it significantly improves ICU efficiency. The PCU within an ICU or the PCU combined with another level of care is the most cost-effective.7
Gains in flexibility
As PCUs continue to grow in number, the number of patients that don’t meet ICU admission criteria but currently receive care there will decrease. At the same time, direct patient and support care costs will decrease significantly. Research shows that patient care costs can decrease by an average of 50% and laboratory tests and other diagnostic tests will also decrease.8,9 PCUs reduce the frequency and variation of resources used. Hospitals can achieve real and substantial savings from the change in practice that occurs when transferring patients from the ICU to the PCU.10 Although generally not large revenue-producing centers, PCUs save costs by decreasing ICU lengths of stay and generate revenue resulting from greater turnover of ICU beds. PCUs also can flex down to accept general unit patients when needed. This flexibility allows the hospital to meet periodic high admission demands for high- and lower-acuity patients. The PCU’s skill mix and caregiver-to-patient ratio is less than that of the ICU. Personnel costs are 60% to 80% of those required in an ICU.11 All these points demonstrate how a PCU generates indirect revenue to financially justify its own startup and implementation. If a PCU increases the overall number of available beds for admissions and serves a definite patient population, then the PCU will generate revenue.
Let’s review an example of a simple process to garner support and cost-justify a ventilator-weaning PCU. (See "How to cost justify a ventilator-weaning PCU")
First, collect data over several months on ICU patients with tracheostomies needing pulmonary and ventilator support (DRG 483). A team consisting of a pulmonary physician and an advanced practice nurse would determine how many of these patients fit approved criteria for PCU admission. Once data are collected, calculate how many of these patients could be transferred to a lower PCU care level. Then calculate the number of days that these patients were cared for in the ICU but could’ve been cared for in the PCU. In our institution, the cost per bed occupancy between a PCU and an ICU is about 50%. Multiply the number of days by the reduced cost of the PCU to calculate a substantial cost savings.
You can also calculate the potential revenue generated that an additional ICU admission would create based on the number of bed days that the former ICU patient frees up by being triaged to the PCU. As in many hospitals, a PCU can help to alleviate additional capped bed days, ED diversion days, and closed bed days.
The final step to justifying a PCU is preparing the ROI ESFS report. This reviews all the data and information collected. Most hospitals have an ROI template to assist the LDT team with this step. The tool will include executive, financial, general, historical, patient revenue, and other revenue and operating expense sections.
When finished with the ESFS, it’s time to schedule the LDT’s initial presentation to your hospital’s approving body. This group of decision makers will either approve the PCU or ask for additional information and clarification.
Phase 3: Market It to Others
It’s essential to market the PCU to others who will support it. Be sure that the LDT includes and welcomes the champions within the facility. Champions are those influential individuals who can embrace the PCU’s vision and goals and support it at all levels of the hospital. Relay ongoing information on the PCU’s progress to the champions. This gives the LDT the ability to educate hospital leaders about the PCU’s care strategy and how it can impact health care delivery. The LDT should invite all support service directors who’ll be involved with the PCU project to an education session. Be sure to include:
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These support individuals will have various responsibilities. For example, the human resource department will begin recruiting all support staff for the unit. The unit manager and nursing director should internally recruit a core group of nurses that volunteer to staff the PCU. This automatically provides the unit with nursing leadership, seniority, and expertise. It will also provide a smoother care transition for progressive care patients. The medical director, in turn, will select the house staff primarily responsible for PCU patients. The LDT collaborates with the support service directors to redefine their roles and responsibilities within the scope of the PCU. The support service directors can then designate the staff who will care for these patients.
Phase 4: Gaining Hospital Approval
By this stage, the LDT has gathered all necessary data and finalized the ROI to present to the hospital’s capitol programs approval body. Keep in mind when you’re calculating your ROI, that most hospitals only collect on an average 55% of the total charges. Most hospital decision makers will require a quarterly report to review the PCU’s financial progress. Often, the approving body will want to see a return on investment within 1 to 3 years, which is the payback period.
Phase 5: Plan Equipment, Staff, and Function
Once hospital leaders approve the PCU, the LDT can finalize the level of monitoring needed to care for PCU patients. This need ranges from completely non-invasive to limited invasive monitoring such as arterial pressure monitoring. Many PCUs employ non-invasive monitoring compared to invasive monitoring. Knowing exactly what’s required will help caregivers deliver the highest quality care and keep costs to a minimum.
When budgeting for direct care personnel, unit managers typically determine the PCU’s hours per patient day (HPPD). The LDT can actively participate in determining the HPPD, as well. The common formula to determine direct care staffing takes into account the average daily census multiplied by the HPPD divided by 8 then multiplied by the constant 1.4, relief for the 24-hours/7-day coverage and then multiplied by the constant 1.1, relief for the weekend coverage.
Next, the LDT sets the PCU’s functional framework. The team agrees on a practice model, which can range from a primary care model to the team care model. Regardless of the practice model chosen, it must be congruent with the hospital’s overall philosophy of care. It’s imperative that you base the care model on collaborative, interdisciplinary practice. Professional organizations and accrediting bodies recommend an interdisciplinary care approach that focuses on evidence-based practice to enhance positive patient care outcomes. Integrating an interdisciplinary care approach supports positive patient outcomes and decreases length-of-stay and overall hospital costs.12 Clearly define the roles and responsibilities for LDT members early in the process, and evaluate and modify them based on the PCU’s changing needs. The interdisciplinary team will set care and practice standards and determine outcome measures. The LDT can initiate changes that impact all PCU operations.
To give specific overall direction to PCU staff members, the LDT must create a vision, mission, and values statement. The statement determines scope of practice; it must be clear, succinct, goal-directed and support the hospital’s vision, mission, and goals. The LDT can then make decisions on the admission and discharge criteria, which is vital to the unit’s success. Begin with documented admission and discharge guidelines, which can be modified to meet your PCU’s needs.13,14
Other important items for the LDT to consider before fully implementing the PCU include:
It Takes Time
Once you set the timeline for implementing the PCU, ensure that the LDT meets regularly to review and address all aspects related to PCU operation. Developing a PCU takes careful planning by experienced health care professionals, a committed multidisciplinary team, and a supportive leadership and administrative group. As hospitals pursue alternative care strategies to meet the ever-changing demands of health care, progressive care will continue to grow to significantly impact patient care and outcomes.
References
This article has been cited by other articles:
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  P. J. McCabe and P. Kalpin Bold Voices in Progressive Care: Using Shared Decision Making to Implement Evidence-Based Practice in Progressive Care Crit. Care Nurse, April 1, 2005; 25(2): 76 - 87. [Full Text] [PDF]
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