Outcomes Intermediate Unit 3

[Kenya Ahyet]

Asa go-between unit, an intermediate care unit (IMCU) fulfills several roles in a hospital system. It can take less acute patients who would normally be in an intensive care unit (ICU) bed. They can also help keep a closer eye on patients too critical for the general ward.

IMCUs can be a general medical or surgical unit or specific to certain specialties like cardiology or pulmonary and focus only on patients with those conditions.1 Other uses of an IMCU include admitting patients directly from post-surgical recovery or the emergency room.1

A nurse working on a general ward may have an average of six patients per shift.[2] In the ICU, this ratio drops substantially to one to two patients for every nurse. Some guidelines state the ratio in the ICU should be 1:1 for ventilated patients and 1:2 for non-ventilated patients.2

In the IMCU the ratios fall in the middle with 2.5 to four patients for every nurse. This follows with the role of the IMCU where patients have a higher acuity than the general ward but not quite as high as in the ICU.[3]

One study looking at data from ten hospitals found a benefit of utilizing an IMCU for patients with a higher illness severity. A significant reduction in mortality, ICU readmission (but not hospital readmission), and hospital length of stay was seen with these patients. Although patients with a higher illness severity did not have a reduction in hospital readmission, patients with a lower acuity did have a reduction in hospital readmission when an IMCU was in place.3

One challenge in determining benefits of IMCUs or SDUs is the difficulty in determining patient severity or acuity. ICUs use validated scoring tools to measure severity, but these are not always applied in the IMCU. This discrepancy makes it hard to compare IMCU outcomes to ICU outcomes.[4]

A study looking at patients who had percutaneous coronary intervention found patients managed in the IMCU had a significantly lower inpatient cost, even if patient characteristics were similar to those in the ICU.[5]

Another study looking at patients undergoing neurological procedures found patients admitted to the IMCU did not have more complications compared to those admitted to the neurological ICU and overall cost per patient was reduced if they went to the SDU.[6]

Three studies looking at pulmonary ICU patients did not find the use of an IMCU to be cost-effective, however one study looking at patients with chronic obstructive pulmonary disease found costs to be reduced.[7]

The benefits of IMCU could be more abstract and holistic to the health system. A study looking at 167 ICUs across 17 European countries found a significant reduction in mortality in hospitals who have an IMCU.

However, less than 25% of those ICU patients spent time in the IMCU. Researchers concluded IMCUs must somehow improve care for patients in the ICU that never get admitted to the IMCU.7 While the reason for this improvement was not expounded upon in this study, optimizing hospital resources may be one factor.

Another benefit of an IMCU is that they have been associated with an increased ability to perform elective surgical procedures. This in turn can reduce costs and improve outcomes by reducing delays in elective surgery which are known to increase admission costs and postoperative risk.4

It's clear more research is needed to discover and define benefits of IMCUs/SDUs. These units help alleviate the strain on ICU capacity limits but may not reduce overall hospital strain by simply reallocating patients to a new unit.

[5] Chou, Y et al. (2020). Step-down units are cost-effective alternatives to coronary care units with non-inferior outcomes in the management of ST-elevation myocardial infarction patients after successful primary percutaneous coronary intervention. Intern Emerg Med, 15(1):59-66.

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Methods: Demographic data, admitting diagnoses, illness severity, comorbid conditions, lengths of stay, and hospital mortality were characterized for all emergency medical patients admitted directly to an intermediate care unit from July through December 2012.

Conclusions: Emergency medical patients with moderate severity of illness and comorbidity can be admitted to an intermediate level of care with relatively infrequent transfer to intensive care and relatively low mortality.

For their unique teamwork and success, TMU/3C have earned a Silver Beacon Award for Excellence from the American Association of Critical-Care Nurses. The award is the highest achievement in critical care nursing.

TMU and 3C are each 40-bed units that care for high acuity, complex patients, including those leaving intensive care and emergency departments. Their collaborative efforts were stretched even more during the COVID-19 pandemic when the units transitioned to private rooms to better accommodate patients requiring a higher level of care.

The Beacon Award for Excellence recognizes caregivers in units who set the standard for excellence in patient care environments by collecting and using evidence-based information to improve patient outcomes along with patient and staff satisfaction. TMU earned a Bronze Beacon Award in 2017 and a Silver Award in 2020, making it the only progressive care unit in the state of Delaware to earn such recognition.

Of the five Beacon Award-winning patient care units currently in Delaware, all are at ChristianaCare. The others are the Surgical Critical Care Complex (silver); Transitional Surgical Unit (silver); and the Cardiovascular Critical Care Complex (three-time gold winner); and the Medical Intensive Care Unit at Christiana Hospital (a record-setting five-time gold winner).

In 2022, when the time came for TMU staff to submit its application for Beacon recognition, the unit was already working as a team with 3C, led by Heckman with Jessica Tagliaferro, MSN, RN, PCCN, and Kim Prouse, RN, PCCN, as assistant nurse managers. Given the unusual circumstances and collaboration, nurse leaders asked for special approval for the two units to complete a Beacon application together.

Community Based Vocational Training (CBVT) allows students with disabilities that are of transition age to learn employment and transferable skill. A job mentor assists the student to prepare for employment outcomes at various work sites throughout Luzerne County. CBVT sites are selected based on student interest and abilities. Students participate in on to three 10 week cycles with a maximum of three students assigned to each mentor. Students are assessed based on a task analysis of each specific job.

The Community Living Transition Class (CLTC) at LCCC is a transition opportunity for youth with disabilities 18 years of age or older with a post-secondary goal of employment or education/training and independent living. The curriculum content of this program includes: social skills, budgeting skills, banking, shopping management/organizational sill, public transportation skill, employability skill and job shadowing activities. Because the class is located on a college campus, students are afforded an opportunity to interact with college age peer, to audit a class, as appropriate, while still in high school. Students are assessed using student portfolios, interest inventories, situational assessments and formal assessments. A special education teacher and para-educator help students reach their full potential.

The Document Destruction Depot (DDD) is a paid employment transition opportunity for youth with disabilities who have a post-secondary goal of employment.. The DDD is operated by the Luzerne Intermediate Unit. This program teaches students various employability skills and job skills specific to warehousing. Student must be at least 18 years of age to operate the shredder. Students work a maximum of three days per week. A job mentor guides the student and ensures safety while at the DDD Safety and job training is provided to students prior to beginning employment.

The REAL (Rewarding Education Adult Living) Academy is a community living transition opportunity for youth with disabilities. The program helps students develop independent living skills while supporting students who may have a post-secondary goal of employment. The REAL Academy operates as a full day program for the entire school year. The curriculum of this program includes functional living skills including the following: social, budgeting, banking, shopping, cooking, housekeeping, management/organizational, public transportation, and employability. Opportunities for job shadowing/training activities occur both in the community and at the REAL Academy. Students are assessed using student portfolios, interest inventories, situational assessments and formal assessments. A special education teacher and a para-educator help students to reach their full potential.

Class Rotations for LIU and District Special Education classes are geared for teachers and students to utilize the REAL Academy facility to further enhance their transition instruction. Classes are scheduled to attend one full week each quarter for a total of four weeks. During the first week the students participate in kitchen activities and following recipes. The second week is devoted to housekeeping activities including making beds, washing windows, etc. The 2nd floor of the REAL Academy is set up for the student to work on skills such as table setting, stocking shelves, folding linens and office etiquette during the third week. Finally, during the fourth week the students participate in a transition project selected by their classroom teacher. This setting is appropriate for high school Life Skills, Physical Support, and Autistic Support classes.

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