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Pediatric Intensive Care Unit Admission Tool: A Colorful Approach
CLINICAL PRACTICE COLUMN Column Editor: Maura MacPhee, PhD, RN
Pediatric Intensive Care Unit Admission Tool: A Colorful Approach Amy Biddle, BSN, RN
This article discusses the development, implementation, and utilization of our institution's Pediatric Intensive Care Unit (PICU) ColorCoded Admission Status Tool. Rather than the historical method of identifying a maximum number of staffed beds, a tool was developed to color code the PICU's admission status. Previous methods had been ineffective and led to confusion between the PICU leadership team and the administration. The tool includes the previously missing components of staffing and acuity, which are essential in determining admission capability. The PICU tool has three colored levels: green indicates open for admissions; yellow, admission alert resulting from available beds or because staffing is not equal to the projected patient numbers or required acuity; and red, admissions on hold because only one trauma or arrest bed is available or staffing is not equal to the projected acuity. Yellow and red designations require specific actions and the medical director's approval. The tool has been highly successful and significantly impacted nursing with the inclusion of the essential component of nurse staffing necessary in determining bed availability. © 2007 Elsevier Inc. All rights reserved.
U
NPLANNED ADMISSIONS AND unpredictable changes in patient status are commonplace in the critical care environment and greatly impact critical care bed utilization and nurse staffing requirements. Our pediatric intensive care unit (PICU) census swings challenged the management's ability to provide adequate and safe staffing. Hospital administration often struggles with determining whether the PICU is capable of admitting or transferring patients. The purpose of this report was to describe our institution's PICU Color-Coded Admission Status Tool, which was designed to address safe and appropriate management of PICU patient beds. THE HOSPITAL Children's Hospital of Pittsburgh (CHP) of the University of Pittsburgh Medical Center health system is internationally renowned for its care of patients with complex diseases and its pioneering efforts with respect to the latest technology and medical–surgical procedures. Children's Hospital of Pittsburgh is the only Level 1 (highest level) pediatric trauma center in Western Pennsylvania and is a regional transplant center. THE CRITICAL CARE UNITS The ICUs at CHP consist of a 36-bed PICU, a 20bed neonatal ICU, and an 8-bed cardiac ICU. The
Journal of Pediatric Nursing, Vol 22, No 6 (December), 2007
critical care units have specific criteria for admission in relation to age and diagnosis. Increasingly, CHP has experienced a demand for ICU beds that exceeds supply. For Fiscal Year 2005–2006, patient days increased by 5.6% from the previous fiscal year's rate (CHP, 2006). When the demand exceeds the supply, less-thanoptimum alternatives must be considered. Undesirable options include deferring patients to other hospitals, canceling elective surgeries, admitting patients older than 16 years to other hospitals, and transferring less critical patients from the PICU to acute care units. THE DILEMMA Many variables affect the PICU's admission status, such as inpatient acuity, current patient
From the Pediatric Intensive Care Unit, Children's Hospital of Pittsburgh, Pittsburgh, PA. Address correspondence and reprint requests to Amy Biddle, BSN, RN, Pediatric Intensive Care Unit, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213. E-mail: [email protected] 0882-5963/$ - see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.04.005
507
508
AMY BIDDLE
Table 1. Pediatric ICU Color-Coded Admission Tool Status
Action
Green = Open None required for admissions Yellow = PICU charge nurse and CCM fellow meet and Admission alert review patients for discharge or transfer Consult with AOD to open expansion beds if adequate staffing is available If holding acute care patients in PICU beds, the AOD will contact the chief residents and surgery service personnel regarding the need to expedite acute care discharges The AOD, PICU charge nurse, and CCM fellow will evaluate pending surgical cases CCM physicians will immediately enter transfer orders Transport team notified “caution required” Close scrutiny of all transports required Medical director's considerations: Deferral of patients older than 16 years to UPMC Deferral if transport greater than 90 miles Transport delay if potential transport is in another PICU Red = Admissions Medical director's approval required on hold PICU charge nurse and AOD must notify the director of critical care services and PICU patient service manager Elective PICU admissions on standby Deferral of patients as per the medical director Note: CCM indicates critical care medicine; UPMC, University of Pittsburgh Medical Center.
census, patient acuity for planned and unexpected admissions, and the availability of nursing personnel for staffing. Our critical care leadership team was charged with identifying a way to quickly and efficiently determine the maximum number of safely staffed PICU beds. The team, consisting of the medical director of critical care medicine, the director of critical care services, and the PICU patient service manager, created a color-coded PICU tool that provides a quick and easy at-aglance communication indicating the state of the PICU and its ability to admit patients (Table 1). THE TOOL The color-coded admission tool consists of three levels (green, yellow, and red). Green indicates open for admissions; yellow, admission alert; and red, admissions on hold. Color status is determined through frequent communications among the critical care medicine fellow, the PICU attending physician, and the PICU charge nurse. The PICU's status is routinely reviewed every 12 hours or more often, as necessary. The PICU charge nurse communicates
the PICU color status with the administrator on duty (AOD). The AOD receives reports from all inpatient hospital units and has a global view of the state of the hospital in relation to occupied beds, patient placement, and nurse staffing. Effective communication can be especially challenging for those working in highly stressful and fast-paced environments such as the PICU. The new color-coded admission status tool and an explicit chain of communication have produced a reliable system for focusing relevant data. A consistent flow of communication is necessary to provide high-quality care with attention to details and patient safety (Cowen, Lindberg, Egol, & Rainey, 2005). The tool has already made a positive impact on communications and staffing/admission outcomes. When the admission status is yellow or red, for instance, the AOD can quickly summon the attention of the medical and nursing directors, and viable options are discussed and acted upon by the key administrative players. FUTURE CONSIDERATIONS The PICU admission color status is typically shared exclusively among PICU and hospital management staff. Other PICU staff, including nurses, physicians, respiratory therapy, and pharmacists, among others, are not aware of the color status decisions being made by the management. Future considerations include a color bar posted in an inconspicuous manner within the PICU indicating the current level of alert. Additional considerations include the development of a similar tool and status identification for other critical care units (e.g., cardiac ICU and neonatal ICU) and acute care services. SUMMARY The tool has been highly successful as evidenced by less communication challenges with the administration, less time and energy put forth defending nurse staffing needs, and increased understanding of the fluctuating ability of the PICU to meet admission demands. As described by Thorgrimson and Shoyer (2005), a PICU involves many challenges. Strong collaboration among nurse leaders and physicians is essential. The color-coded admission tool is a result of a team approach to improve and simplify the complexities surrounding bed management and staffing needs in a critical care environment.
PEDIATRIC INTENSIVE CARE UNIT ADMISSION TOOL: A COLORFUL APPROACH
509
REFERENCES Children's Hospital of Pittsburgh. (2006). Inpatient nursing report card. Pittsburgh, PA: Author. Cowen, J., Lindberg, J., Egol, A., & Rainey, T. (2005 February). Tools for effective team communication. Critical Connections, 4. Retrieved July 15, 2006 from http://www.sccm. org/sccm/publications/critical+connections/archives/February+ 2005/communicationfeb05.htm.
Thorgrimson, D., & Shoyer, S. (2005). Nurse staffing at an urban pediatric medical center: A model for stabilizing the team. Critical Connections, 4. Retrieved July 15, 2006 from http:// www.sccm.org/SCCM/Publications/Critical+Connections/ Archives/April+2005/stableizingapril05.htm.
Pediatric Intensive Care Unit Admission Tool: A Colorful Approach Amy Biddle, BSN, RN
This article discusses the development, implementation, and utilization of our institution's Pediatric Intensive Care Unit (PICU) ColorCoded Admission Status Tool. Rather than the historical method of identifying a maximum number of staffed beds, a tool was developed to color code the PICU's admission status. Previous methods had been ineffective and led to confusion between the PICU leadership team and the administration. The tool includes the previously missing components of staffing and acuity, which are essential in determining admission capability. The PICU tool has three colored levels: green indicates open for admissions; yellow, admission alert resulting from available beds or because staffing is not equal to the projected patient numbers or required acuity; and red, admissions on hold because only one trauma or arrest bed is available or staffing is not equal to the projected acuity. Yellow and red designations require specific actions and the medical director's approval. The tool has been highly successful and significantly impacted nursing with the inclusion of the essential component of nurse staffing necessary in determining bed availability. © 2007 Elsevier Inc. All rights reserved.
U
NPLANNED ADMISSIONS AND unpredictable changes in patient status are commonplace in the critical care environment and greatly impact critical care bed utilization and nurse staffing requirements. Our pediatric intensive care unit (PICU) census swings challenged the management's ability to provide adequate and safe staffing. Hospital administration often struggles with determining whether the PICU is capable of admitting or transferring patients. The purpose of this report was to describe our institution's PICU Color-Coded Admission Status Tool, which was designed to address safe and appropriate management of PICU patient beds. THE HOSPITAL Children's Hospital of Pittsburgh (CHP) of the University of Pittsburgh Medical Center health system is internationally renowned for its care of patients with complex diseases and its pioneering efforts with respect to the latest technology and medical–surgical procedures. Children's Hospital of Pittsburgh is the only Level 1 (highest level) pediatric trauma center in Western Pennsylvania and is a regional transplant center. THE CRITICAL CARE UNITS The ICUs at CHP consist of a 36-bed PICU, a 20bed neonatal ICU, and an 8-bed cardiac ICU. The
Journal of Pediatric Nursing, Vol 22, No 6 (December), 2007
critical care units have specific criteria for admission in relation to age and diagnosis. Increasingly, CHP has experienced a demand for ICU beds that exceeds supply. For Fiscal Year 2005–2006, patient days increased by 5.6% from the previous fiscal year's rate (CHP, 2006). When the demand exceeds the supply, less-thanoptimum alternatives must be considered. Undesirable options include deferring patients to other hospitals, canceling elective surgeries, admitting patients older than 16 years to other hospitals, and transferring less critical patients from the PICU to acute care units. THE DILEMMA Many variables affect the PICU's admission status, such as inpatient acuity, current patient
From the Pediatric Intensive Care Unit, Children's Hospital of Pittsburgh, Pittsburgh, PA. Address correspondence and reprint requests to Amy Biddle, BSN, RN, Pediatric Intensive Care Unit, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213. E-mail: [email protected] 0882-5963/$ - see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.04.005
507
508
AMY BIDDLE
Table 1. Pediatric ICU Color-Coded Admission Tool Status
Action
Green = Open None required for admissions Yellow = PICU charge nurse and CCM fellow meet and Admission alert review patients for discharge or transfer Consult with AOD to open expansion beds if adequate staffing is available If holding acute care patients in PICU beds, the AOD will contact the chief residents and surgery service personnel regarding the need to expedite acute care discharges The AOD, PICU charge nurse, and CCM fellow will evaluate pending surgical cases CCM physicians will immediately enter transfer orders Transport team notified “caution required” Close scrutiny of all transports required Medical director's considerations: Deferral of patients older than 16 years to UPMC Deferral if transport greater than 90 miles Transport delay if potential transport is in another PICU Red = Admissions Medical director's approval required on hold PICU charge nurse and AOD must notify the director of critical care services and PICU patient service manager Elective PICU admissions on standby Deferral of patients as per the medical director Note: CCM indicates critical care medicine; UPMC, University of Pittsburgh Medical Center.
census, patient acuity for planned and unexpected admissions, and the availability of nursing personnel for staffing. Our critical care leadership team was charged with identifying a way to quickly and efficiently determine the maximum number of safely staffed PICU beds. The team, consisting of the medical director of critical care medicine, the director of critical care services, and the PICU patient service manager, created a color-coded PICU tool that provides a quick and easy at-aglance communication indicating the state of the PICU and its ability to admit patients (Table 1). THE TOOL The color-coded admission tool consists of three levels (green, yellow, and red). Green indicates open for admissions; yellow, admission alert; and red, admissions on hold. Color status is determined through frequent communications among the critical care medicine fellow, the PICU attending physician, and the PICU charge nurse. The PICU's status is routinely reviewed every 12 hours or more often, as necessary. The PICU charge nurse communicates
the PICU color status with the administrator on duty (AOD). The AOD receives reports from all inpatient hospital units and has a global view of the state of the hospital in relation to occupied beds, patient placement, and nurse staffing. Effective communication can be especially challenging for those working in highly stressful and fast-paced environments such as the PICU. The new color-coded admission status tool and an explicit chain of communication have produced a reliable system for focusing relevant data. A consistent flow of communication is necessary to provide high-quality care with attention to details and patient safety (Cowen, Lindberg, Egol, & Rainey, 2005). The tool has already made a positive impact on communications and staffing/admission outcomes. When the admission status is yellow or red, for instance, the AOD can quickly summon the attention of the medical and nursing directors, and viable options are discussed and acted upon by the key administrative players. FUTURE CONSIDERATIONS The PICU admission color status is typically shared exclusively among PICU and hospital management staff. Other PICU staff, including nurses, physicians, respiratory therapy, and pharmacists, among others, are not aware of the color status decisions being made by the management. Future considerations include a color bar posted in an inconspicuous manner within the PICU indicating the current level of alert. Additional considerations include the development of a similar tool and status identification for other critical care units (e.g., cardiac ICU and neonatal ICU) and acute care services. SUMMARY The tool has been highly successful as evidenced by less communication challenges with the administration, less time and energy put forth defending nurse staffing needs, and increased understanding of the fluctuating ability of the PICU to meet admission demands. As described by Thorgrimson and Shoyer (2005), a PICU involves many challenges. Strong collaboration among nurse leaders and physicians is essential. The color-coded admission tool is a result of a team approach to improve and simplify the complexities surrounding bed management and staffing needs in a critical care environment.
PEDIATRIC INTENSIVE CARE UNIT ADMISSION TOOL: A COLORFUL APPROACH
509
REFERENCES Children's Hospital of Pittsburgh. (2006). Inpatient nursing report card. Pittsburgh, PA: Author. Cowen, J., Lindberg, J., Egol, A., & Rainey, T. (2005 February). Tools for effective team communication. Critical Connections, 4. Retrieved July 15, 2006 from http://www.sccm. org/sccm/publications/critical+connections/archives/February+ 2005/communicationfeb05.htm.
Thorgrimson, D., & Shoyer, S. (2005). Nurse staffing at an urban pediatric medical center: A model for stabilizing the team. Critical Connections, 4. Retrieved July 15, 2006 from http:// www.sccm.org/SCCM/Publications/Critical+Connections/ Archives/April+2005/stableizingapril05.htm.