JONA
Volume 39, Number 1, pp 4-7
Process Improvements
What Can An Intermediate
Care Unit Do For You?
Andrew D. Harding, MS, RN, CEN
In a competitive healthcare envi-
ronment with inflationary pressure
on healthcare costs twice that
of the national consumer price
index,1 creative cost containment
solutions are essential. Likewise,
an aging nursing workforce with
the average age of a registered
nurse (RN) being 46.8 years and
with 51% of the workforce older
than 50 years2 mandates strategies
to replace experienced profession-
als leaving the workforce.3 One
strategy used in my institution to
address these issues was the ini-
tiation of the progressive care
unit, which is called an intermedi-
ate care unit (IMCU). The IMCU
also presented new opportunities
and experiences for educating
highly skilled critical care nurses.
The IMCU is now referred to as
the ‘‘farm league’’ or training
ground for future intensive care
unit (ICU) RNs. The realized
economic advantages to using the
IMCU for part of the patients’
hospital stay is that it decreased
patients’ ICU length of stay (LOS)
and decreased throughput from
Author Affiliation: Director, Patient
Care Services, Morton Hospital and Medi-
cal Center, Taunton, Massachusetts.
Correspondence: Morton Hospital
and Medical Center, 88 Washington
St, Taunton, MA 02780 (AHarding@
MortonHospital.org).
4 JONA  Vol. 39, No. 1  January 2009
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the emergency department by
reducing time on ICU diversion.
Hours Per Patient Day
The IMCU is a 16-bed unit with 9
designated IMCU beds and 7 telem-
etry beds. The hours per patient
day (HPPD) in the IMCU is 9.1.
This 9.1 HPPD is benchmarked
against the local urban teaching
hospital standard for IMCUs in
the city.4 The 9.1 HPPD is in the
25th percentile for comparative
institutions. The skill mix of 85%
RNs and 15% nurse assistants is
also within the local regional
range for similar units. The goal
is to have 1:3 RN-to-patient aver-
age ratio. However, deference to
clinical decision making by the
multidisciplinary care team led by
the unit charge nurse may allow
for 1:2 or 1:4 RN-to-patient ratio.
This practice is also supported
by the American Association of
Critical-Care Nurses (AACN).5,6
The existing telemetry unit
was modified into the IMCU but
was not budgeted for the fiscal
year of the transition. Therefore,
budgetary restraints prevented the
expansion of staffing and the com-
plete use of all of the beds on the
unit for IMCU-designated patients
in the current fiscal year. However,
in the upcoming fiscal year, the
budget will allow 15 beds to be
Copyright B 2009 Wolters Kluwer Health |
Lippincott Williams & Wilkins
used in the IMCU, with 5 beds
remaining for telemetry units.
Space for the extra 4 beds will be
taken from a current clinic in this
shared clinical space that will be
relocated in the medical center.
Admission Criteria
The patient admission criteria pro-
vide an objective means of judging
the appropriateness of the patient
for the IMCU. Criteria develop-
ment started with the Society of
Critical Care Medicine intermedi-
ate care admission guidelines7 as a
reference. The critical care team
then included the expected nurs-
ing skill sets and admission crite-
ria outlined by the AACN text,
AACN Essential of Progressive
Care Nursing.8 The criteria were
evaluated by each of the physician
teams who would have patients or
consult patients in the IMCU. The
criteria also specify devices that
are not appropriate, such as arte-
rial lines. We also specify diagno-
sis with clinical situations that are
not appropriate, such as hyper-
tension urgency with acute kidney
injury. We also have an outline by
organ system to guide the admit-
ting team. However, the AACN
states that IMCUs ‘‘provide care
to stable, critically ill patients of
varying acuities with a high poten-
tial for life-threatening changes.’’9

As a result, additional guidelines
were developed requiring that the
RNs must be prepared to recog-
nize signs and symptoms of insta-
bility so that they can intervene,
obtain expert consultation, or ini-
tiate a ‘‘rapid response team.’’
Cost Per Patient Day
The cost per patient day (CPPD)
in the IMCU is approximately a
60% reduction from the surgical
intensive care unit (SICU) and an
almost 70% reduction from the
medical intensive care unit (MICU)
(Table 1). These cost reductions
relate to the decrease in the inven-
tory of the unit, the lower cost of
actual supplies used, and the lower
HPPD. The CPPD is maintained
by monitoring the average daily
census and unit acuity. Thereby,
the staffing team can allocate the
appropriate number of direct care
personnel for the next shift. We
are using the admission criteria as
objective rationale for admitting
and discharging patients from the
IMCU status but yielding to col-
laborative clinical judgment as
needed to provide safe comprehen-
sive patient care.
Physician Coverage
Providing an IMCU under the
umbrella of critical care provided
physician teams with confidence
Table 1. Average Monthly Costs Per Patient Day (CPPD)
in Critical Care
Unit Patient Days
Medical intensive care unit
Surgical intensive care unit
Intermediate care unit
The numbers have been changed to protect the actual institutional data.
JONA  Vol. 39, No. 1  January 2009
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Process Improvements
when transferring patients out of
the ICU earlier than previously
practiced without the prepared
IMCU nursing staff. The SICU
attending physician remains
unchanged when a patient is trans-
ferred to the IMCU and continues
to provide physician coverage for
the patient. The MICU attending
physician provides report and
passes duty to the medicine service
attending physician, but an MICU
consult is formally obtained. This
MICU medicine coverage consult
allows the MICU to reduce its
patient load but provides a safety
net for the patient, IMCU nurse,
and medicine house officers. Typ-
ically, when a patient leaves any of
the ICUs, the patients primary
service team attending physician
would accept responsibility for the
complete care of the patient, and
the ICU attending physician
would no longer be involved in
the management of the patient.
However, with the critical stable
condition of the patients in the
IMCU, the attending coverage
described above was the best sce-
nario available to meet the care
management needs of the patients.
Education
The minimum requirements for
RNs to work on the IMCU include
telemetry and intravenous insertion
A B C has intensive care education and
Total Costs (Salary CPPD
and Nonsalary (Column B/A)
280 402,084 $1436
305 525,860 $1724
455 248,368 $545
education, American Heart Asso-
ciation Basic Life Support certifi-
cation, and Advanced Cardiac Life
Support certification. Preference was
given to RN applicants who had
at least 1 year of telemetry or criti-
cal care experience. To ensure that
RNs could obtain out-of-institution
certification, paid time off was pro-
vided. As a result, each RN in the
IMCU has successfully completed
the SCCM’s Fundamentals of Crit-
ical Care Support course. Because
the unit has both SICU and MICU
patients, the Emergency Nurses
Association Trauma Nursing Core
Course was provided as an optional
education endeavor. Each IMCU
RN also completed the city’s inten-
sive care consortium core course.
The Great Boston ICU consor-
tium provides six 8-hour classes.
The consortium, comprised of the
teaching hospitals in the city, is
for critical care nurses only. The
respiratory care team provides six
30-minute courses on advanced
respiratory system assessment and
noninvasive ventilation and venti-
lator management. These classes
were offered on the unit with a
predetermined schedule agreed to
between the IMCU nurse manager
and respiratory care team manager.
The RNs on the unit covered one
another during the period of this
educational offering. The manager
will staff so that each RN every
6 weeks works in the ICU rotating
between the MICU and SICU. Dur-
ing the rotation, the IMCU RN
clinical mentorship experiences.
All of these educational offerings
are resource-intensive to coordi-
nate staff for acceptable unit
coverage for absent team mem-
bers who attend educational class
time, for the costs of providing
educational courses, and for the
5
 Process Improvements
time of the ancillary team mem-
bers who provide institutional
education. All of these costs are
included in the CPPD, which
demands strict management and
budgeting of all productive and
nonproductive hours.
Support Systems
To provide a supportive IMCU
clinical environment, the nursing
leaders in critical care complete
daily rounding, asking ‘‘on the
spot’’ questions that require critical
thinking by the assigned RN about
his/her patients’ plan of care. We
ask questions that range from the
RN’s patients’ medication to diag-
nostic findings. As these ongoing
discussions became routine, there
was increased learning and confi-
dence in our nursing staff. To ad-
dress concerns about less than
optimal outcomes in hospitals
during weekends and off-shift
hours10,11 and to further support
these newly educated IMCU nurs-
ing staff, a new nursing position
was created. The director of nurs-
ing in the critical care division
worked in collaboration with crit-
ical care nursing colleagues to
develop and implement a critical
care resource nurse. The critical
care resource nurse requires a
highly skilled ICU experienced
nurse who is typically the first
responder for rapid response team
activation and resuscitation codes.
When clinical questions arise dur-
ing evening and night shifts or
weekends, the critical care resource
nurse can be paged to provide
feedback or assist with care. Hav-
ing this expert clinician working
during the off shifts allots nursing
resources not previously available
to our nursing teams during off-
shift hours.
Outcome Measures
There were no previous compara-
ble data for this unit. Collaborative
endeavors with the information
systems and performance improve-
ment team are ensuing that reports
related to quality assurance in the
IMCU are now provided. The
nurse manager is examining ICU
readmissions within 24 hours of

Table 2. Cost Benefit Analysis of Intermediate Care Unit

Average
Hourly No. of RN Nonproductive
Costs Hours Rate Attendees Labor Cost

Initial Education ICU core 48 37 22 39,072

FCCS-C 16 37 22 13,024
TNCC 16 37 14 8,288
Subtotal 60,384
Unit coverage for 69 41 N/A 2,829
education time
Subtotal 2,829
Annual MICU and SICU 96 37 22 78,144
Rotations
Subtotal 78,144
Total costs for year 1: $141,357

Cost per Total Revenue

Diversion Hour Loss Avoidance
Benefits Hours Months (estimated) (estimated)

Average hourly 1 8 100,000 800,000

reduction in
monthly MICU
diversion
Total estimated $1,200,000
annualized
revenue loss
avoidance:
Educated skilled
critical care RNs

Abbreviations: FCCS, Fundamentals of Critical Care Support course; ICU, intensive care unit; MICU, medical intensive care unit; SICU, surgical
intensive care unit; TNCC, trauma nursing core course.
The numbers have been changed to protect the actual institutional data.

6 JONA  Vol. 39, No. 1  January 2009

Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

transfer to the IMCU, in-hospital
LOS, ICU LOS, emergency depart-
ment throughput, core measures,
mechanical ventilator weaning suc-
cess rates, as well as the patients
disposition, covering physician
teams, and LOS on IMCU status.
Each of the LOS datasets is
gathered from our institution’s
electronic patient tracking sys-
tems. Analysis of these data helps
to understand the usefulness of the
IMCU to provide critical care beds
to the patients we serve. By bring-
ing patients of greater acuity out
of the ICU setting, it allows the
most critically ill patients to have
appropriate beds available. The
expectation is that the institution’s
ICU LOS will increase related to
caring for higher acuity patients in
the ICU setting. However, a
patient transferring from the ICU
to a decreased level of care that is
for ‘‘stable, critically ill’’ can be
safely cared for outside of the ICU
sooner in the IMCU. Therefore,
patients using the IMCU should
have a shorter ICU LOS.
Because initiation of the
IMCU allowed patients to be
moved from the ICU while still
being ventilated and/or weaning
off from mechanical ventilation,
mechanical ventilator weaning
success rate was a chosen metric.
Recently extubated patients who
require frequent monitoring and
chest physical therapy were
another group of patients who
have been safely transferred from
the ICU to the IMCU. Weaning
success rates are actually the rate
JONA  Vol. 39, No. 1  January 2009
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Process Improvements
of reintubation during a patient
admission of any patent who had
a period of that stay in the IMCU
during that patient’s discrete hos-
pital admission. Reviewing the
core measures from The Joint
Commission in the IMCU was the
most relevant of publicly reported
quality outcomes. Staff perceived
this as a highly valuable indicator
of success for the IMCU.
Conclusion
The IMCU provides a safe area for
emergency department admissions
that do not meet ICU admission
criteria yet are too ill for admission
to the medical-surgical unit. These
cost savings and emergency
department throughput improve-
ment via the reduction of MICU
diversion hours related to the
increase acuity admission option
of the IMCU pay for the increased
expense of sustaining the labor
costs on the IMCU and the initial
education costs (Table 2). The
strategy of having the IMCU as
the educational arena for future
ICU RNs is working to mediate
the anticipated migration of aged,
experienced critical care RNs. In-
termediate care should be consid-
ered as an option for healthcare
issues such as costs, emergency
department throughput, and as-
surance of an adequate supply of
educated critical care nurses.
Acknowledgment
The author acknowledges Kathryn C.
Whalen, MSN, RN, for her general
and technical support.
REFERENCES
1. Department of Labor. Measuring price
change for medical care in the CPI.
http://www.bls.gov/cpi/cpifact4.htm.
Accessed June 20, 2008.
2. National Center for Health Workforce
Analysis, Bureau of Health Professions,
Health Resources and Services Admin-
istration, U.S. Department of Health
and Human Services. United States
health personnel factbook. 2003.
http://newsroom.hrsa.gov/releases/
2007/nursing-survey.htm. Accessed
June 16, 2008.
3. Dychtwald K, Erickson TJ, Morison R.
Workforce Crisis: How to Beat the
Coming Shortage of Skills and Talent.
Boston, MA: Harvard Business School
Press; 2006.
4. Massachusetts Hospital Association.
Patients firstVstaffing plans. http://
www.patientsfirstma.org/staffing07/
hospitals.cfm. Accessed June 19, 2008.
5. Lewis PS, Latney C. Achieve best prac-
tice with an evidence based approach.
Crit Care Nurse. 2003;23(6):67-69.
6. Chapman J, St. Onge C. Creating a
healthy work environment with col-
laborative team meetings. Crit Care
Nurse. 2006;26(2):1-40.
7. Task Force of the American College
of Critical Care Medicine, Society of
Critical Care Medicine. Guidelines for
ICU admission, triage, and dis-
charge. Crit Care Med. 1999;27(3):
633-638.
8. Chulay M, Burns S. AACN Essentials of
Progressive Care Nursing. New York,
NY: McGraw-Hill Medical; 2007.
9. Quintero JR. Achieve cost benefits
with innovative care management.
Crit Care Nurse. 2003;23(2):
109-113.
10. Redelmeier D, Bell C. Weekend wor-
riers. New Engl J Med. 2007;356(11):
1164-1165.
11. Peberdy M, Ornato J, Larkin G, et al.
Survival from in-hospital cardiac
arrest during nights and weekends.
JAMA. 2008;299(7):785-792.
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