The Future of Cardiac Surgery Recovery

by Philip Pandolph, RN, BSN, CCRN 

Using the one-stop approach allows the patient to remain stationary while the acuity and nursing care level adapts to accommodate changing care needs. The cardiac one-stop model is similar to the LDRP (labor, delivery, recovery, and postpartum) concept for obstetrical care. This method of care delivery integrates the acute ICU and step-down phases of care, thus changing the paradigm for nursing care of the open-heart surgery patient. The positive feedback the One Stop Post Op model has received from nurses, patients, families, physicians, and hospital administrators has been great.

The One Stop Post Op concept of postoperative open-heart surgery care provides patient-focused care across the continuum, through the preoperative and immediate postop periods and discharge. During this period, the level of patient care and equipment needed change, but the patient remains in the same room with care provided by the same nursing staff. Although this is not a new concept to healthcare, it is relatively new to postoperative open-heart surgery recovery. In traditional open-heart surgery recovery models, patients are transferred from an ICU to an intermediate care unit and, possibly, to a nonmonitored bed before discharge. The traditional process moves the patient to the care source instead of applying a patient-responsive approach that delivers services directly to the hospital’s customer.

What’s So Good about It?

The One Stop Post Op model has reduced care costs by eliminating inefficiencies associated with transfers. Streamlin-ing care delivery reduces length of stay by providing consistent caregivers who are familiar with the patients and their conditions. These caregivers also have the critical care knowledge to recognize and immediately respond to patient complications. The nurses in one-stop cardiovascular units are clinical specialists in pre- and postoperative open-heart surgery care, experts in early recognition of clinical complications that need rapid intervention, know how to optimize clinical pathway variance monitoring, and are experts in management.

Additionally, One Stop Post Op nursing and ancillary staff address patient discharge issues of home care, family support, and skilled facility placement, thus eliminating a fragmented planning process that frequently occurs when patients are transferred to several postoperative care units.

The One Stop Post Op patient rooms are designed to accommodate every level of patient acuity. All rooms meet the regulations for critical care room design, but this is where the aesthetic similarity can end. It is recommended that patient rooms be designed to convey a warmer, more healing environment conducive to recovery, rather than the traditional ICU setting. One Stop Post Op rooms have cabinets designed to cover medical gas equipment, as well as private bathrooms and comfortable furnishings that help create a patient-focused environment.

Nurses, physicians, and ancillary staff members have the opportunity to bond as a continuous quality-improvement team that experiences the success of discharging patients who have recovered from open-heart surgery. Satisfaction isn’t limited to patients and families; nurses, physicians, and other staff members also appreciate this innovative approach to care. The One Stop Post Op model provides an environment that facilitates staff empowerment and ownership with all caregivers focusing on the entire recovery process.

Key Advantages

The benefits of the One Stop Post Op model run the gam-ut of the entire hospital care environment. Members of the healthcare team and patients all thrive in this new paradigm.

• Better results for patients, nurses, and physicians. The One Stop Post Op cardiovascular recovery unit has documented results that patient satisfaction can increase with this innovative care-delivery model. Nursing retention rates are higher and may be attributed to increased job satisfaction with the one-stop model. Physician survey scores reported excellent grades for patient care and nurse response to postoperative complications.

• Employee ownership. A rather unique feature of The One Stop Post Op model is that it creates an empowering environment that fosters ownership. The nursing and ancillary staff assigned to these units tend to refer to the open-heart patients as “our patients.” The opportunities for bonding between staff, patients, and families are extraordinary. Medical direction provides for a defined understanding of duties and responsibilities so unit performance expectations are clear and achievable for caregivers.
   
• Quality outcomes. Patients in the One Stop Post Op are cared for by nurses with advanced critical assessment skills and cardiovascular recovery care experience who are prepared to identify postop complications and address care needs immediately. Complications are identified and resolved quickly with all members of the team understanding their roles. The One Stop Post Op facilitates continuous quality enhancement in one setting. Staffing is flexed to optimize resources and can be adjusted every four hours.
  
  The nursing care provided in the One Stop Post Op cardiovascular unit is highly specialized. Nurses who traditionally worked in short-term recovery units are caring for patients throughout their hospital stays and are encouraged to approach patients from a holistic platform. Caregivers interact with patients and families through the continuum of care and are able to appreciate the success of patient discharge.
   

• Shorter lengths of stay. The one-stop model provides the ideal setting for cross-trained multifunctional teams to review each patient’s clinical progress and care needs daily. The timely attention to clinical variances result in improved pathway management. Patient progress is reviewed with aberrations addressed, often resulting in no delay in the patient’s progression. This real-time process permits patients to “catch up” to their expected course of recovery, resulting in shorter lengths of stay and lower costs of care.
  
   
• Seamless care. Due to the specialized nature of postoperative open-heart surgery care and the need for a dedicated care team, the caregivers share a common goal and have a constant opportunity to communicate. The patient is not moved, and the same nurses, physicians, and support staff care for them during his or her entire stay. Active family communication and involvement is a cornerstone of this delivery model, making patients and their families the focus of all activity. Patients and families receive education from the same staff that is administering the postoperative care. They are encouraged to question therapies and treatments and are involved in care decisions throughout the patients’ hospital stays.
  
   
• Families and staff become partners. The One Stop Post Op unit fosters an environment centered on patient and family. Family visiting is open and supported with rooms optimally designed to address this unit’s approach. The family is included in the preoperative teaching and continues to be an active participant in the educational process through patient discharge. Interactions with familiar nursing staff promote active communication. Families have also found that the surgeons are frequently in the unit and available to discuss patients’ recovery processes and answer their questions.

Most hospitals use the traditional care delivery method of transferring patients based on acuity. By implementing the One Stop Post Op approach to open-heart surgery recovery, hospitals can offer differentiated and distinguish care. Reduced length of stay and exemplary clinical outcomes are the benchmarks of a successful program that will be attractive to the community and payers of healthcare. The satisfaction achieved by patients and stakeholders will clearly set this type of open-heart surgery program apart from the others.

In order for the one-stop concept to be implemented properly and to realize the potential benefits of the model, there are several considerations and obstacles to overcome. Change never comes easily, especially in hospitals. The One Stop Post Op approach may not be right for every organization. Review of the following areas will provide guidance and insight —

• Facility planning and patient volumes. Whether your hospital is presently using a traditional model for open-heart recovery or implementing a new program, faculty design and space always seem to be a limiting factor. It will obviously require more designated open-heart recovery beds to use the one-stop approach.
  
  For example, your open-heart program may presently recover 400 procedures using a six- or eight-bed unit — this would be inadequate for the one-stop approach. Pam Monaghan, RN, CCRN, nurse manager of the CVU at St. Clair Memorial Hospital in Pittsburgh, says sufficient capacity to accommodate scheduled and emergency surgeries is one of the most important aspects in maintaining the integrity of the one-stop model. Patients and families may become disappointed if they expect to remain in one location throughout their stay and then must be transferred due to insufficient bed capacity. Lori Cihon, RN, BSN, the unit manager of a one-stop unit at Parma Com-munity General Hospital in Parma, OH, also agrees that appropriate sizing of the unit is essential for success.
  
   
• Getting key stakeholders to buy in. Nurses and physicians can be resistant to change. It may be very difficult to convince seasoned ICU or CVICU nurses that taking care of patients from admission to discharge is desirable. In my experience and research, however, very few nurses who have experienced this model do not like it. One unit reported an unofficial “waiting list” of nurses interested in a One Stop Post Op unit.
  
  Physicians are also receptive to the idea. Improved comfort with the nursing staff, convenience, continuity of care, and patient satisfaction make excellent selling points to get physicians to buy in.
  
   
• Patient focused vs. customer sensitive. The One Stop Post Op model is much more than keeping the patient in the same room from admission to discharge — it is a new way of thinking. One example is liberal visiting hours. Other than the immediate postop period, some units have no restrictions. However, all units do require visitors to call before entering the patents’ rooms. Some units have been designed with recliners that enable family members to sleep in the room with the patient. This level of family access can make some nurses and physicians apprehensive.
  
   
• Staffing based on acuity. Another challenge may involve convincing ICU nurses who are accustomed to staffing ratios of 1:1 and 1:2 that they can manage ratios of 1:3 or 1:4. I am unaware of any one-stop unit using a greater than 1:4 nurse-patient ratio on a routine basis. As we all know, there are some different skill sets associated with higher patient ratios. One nurse said the greatest initial challenge of implementing the one-stop approach was the transition of ICU nurses taking care of less acutely ill patients. Classes that focused on meeting transitional care needs were held for the nursing staff.
  
  Another aspect that is gaining popularity is incorporating postinterventional patients into the one-stop patient mix. Similar to the open-heart surgery patients, these patients are maintained in the same room until discharge. This can further challenge staffing schedules.

The One Stop Post Op model for caring for open-heart surgery patients is quickly becoming the future standard of heart care. The One Stop Post Op cardiovascular recovery model has been successfully implemented in at least 12 hospitals in the US. It has proven to be a good recipe for success for many institutions providing state-of-the-art cardiac services. Implementing this model requires new ways of addressing and responding to patient care needs. Organizations must be willing to support the changes at all levels but will find the rewards to be significant and well worth the effort.