SIUH integrates respiratory therapists into multidisciplinary teams that provide patients with quality care.
For 3 years running, Staten Island University Hospital (SIUH), Staten Island, NY, has been chosen from a group of 3,575 acute care facilities as one of Modern Healthcares top 100 US hospitals. Modern Healthcare notes that its selections collectively achieved lower mortality rates, reduced complications, shorter length of stay, significant shifts from in-hospital to outpatient care, and increased revenue.
How did SIUH achieve these goals? Nicholas Caruselle, MPA, RRT, a former respiratory therapist who is now vice president of operations and administrative head of cardiopulmonary services, observes that SIUH is known in the community for quality patient care and cutting-edge technology. But the facility also employs a multidisciplinary team approach to patient care that incorporates the use of respiratory therapists and clinical pathways to treat patients.
Such a comprehensive approach makes the institution stand out on a national level and goes a long way toward explaining how SIUH manages to consistently achieve such high marks.
The History of SIUH
SIUH was founded in 1861 as the Samuel R. Smith Infirmary, a one-room hospital dedicated to the islands medically underserved poor. As the needs of the islands expanding population grew over the years, so did the hospital. When the population rose to 80,000 in 1910, the hospital relocated to a 6-acre site in New Brighton and added an operating room, emergency medical service, x-ray darkroom, and 40-bed maternity unit. To reflect the fact that it now served all residents of Staten Island, the hospital became known as the Staten Island Hospital in 1916. That name changed to SIUH in 1987 when the hospital, which now encompassed two campuses, consolidated with Richmond Memorial Hospital.
Today, SIUH is a not-for-profit regional health care delivery system serving a local population of 410,000, plus a regional population extending into Brooklyn. It is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is sponsored by the North Shore Long Island Jewish Health System, and is a major affiliate with the State University of New York (SUNY) Health Science Center in Brooklyn. SIUH has 633 beds on its two campusesUniversity Hospital North in Ocean Breeze and University Hospital South in Princes Bay.
The hospital has been using its multidisciplinary team approach and its method of tracking patients according to clinical pathways for several years with much success.
The team, which includes respiratory therapists, nutritionists, pharmacists, nurses, and social workers, goes on rounds every day in acute and subacute areas, says Theodore Manniatis, MD, director of critical care medicine. That way, everyone knows what is going on with a patient from every level, and at all times. We think it is important that these patients be followed from minute one that they are in the building.
Whether patients have asthma, chronic obstructive pulmonary disease (COPD), or pneumonia, there is a guide for what should be done on each day of their stay from the moment they enter the hospital. A system of checks and balances is in place to ensure that each step is accounted for, Manniatis says.
Everyone is involved with each patient from their admission to the time they go home. Thats 90% of the reason for our continued success, which is also a way to absolutely ensure quality care, he says. No matter how hard we try, there are always times when you get a little lax. But that becomes hard to do when everyones watching you.
The Department of Pulmonary/ Critical Care Medicine
The use of a team approach and clinical guidelines for each patient is especially effective within the Department of Pulmonary/Critical Care Medicine, which oversees the functioning of all intensive care units (ICUs) in the institution. That includes the 10-bed Chronic Ventilatory Unit, where two full-time respiratory therapists are heavily involved in patient education and communication.
This unit is the best-staffed area in the hospital, and is covered 7 days a week, 365 days a year. It is for a range of patients, from those who are very likely to leave the hospital, but have a longer-term wean time than we can deal with in critical care, to those we are sure are going to die, Manniatis says. Here we can at least provide them with a place to die with dignity, and in a pain-free and anxiety-free manner.
Though patients are admitted to the department with conditions ranging from community and nosocomial pneumonia to bronchogenic carcinoma, COPD ranks as number one among the reasons patients are admitted. The next highest number of patients are those who have survived multi-organ failure and adult respiratory distress syndrome (ARDS). SIUH admits very few asthmatics, because care is now delivered outside the hospital.
In order to ensure continuity of care, SIUH works with home care companies, nursing homes, and other services outside the acute care facility, and has instituted the family critical care conference. Since it is often used in cases where the patient is mechanically ventilated and critically ill, Manniatis says the program really helps the families, because they get to discuss their family members care and ask questions of anyone on the patient care team.
Manniatis adds that one of the most important reasons for patients readmissions is not that they get sicker and need to come back for care, but that they or their families do not feel comfortable dealing with the illness at home.
Overall, the factor that is much different today compared to 5 years ago is the level of intensity of illness, he says. Managed care makes us be very efficient. You have to be horribly sick to be in the hospital, and when you are well enough to leave, you are released and treated in the home.
Proper education, like that administered by the Chronic Ventilatory Units respiratory therapists, has led to the shorter stays and more successful outpatient care cited in Modern Healthcare.
We have not seen an increase in our return rate. If patients leave here confident that they understand whats going on, and can deal with small problems, they are much less likely to come back to the hospital, Manniatis says.
The Sleep Apnea Center
SIUHs Division of Pediatric Pulmonology, along with the Department of Pulmonary/Critical Care Medicine, provides diagnosis, treatment, and follow-up for asthma, chronic bronchopulmonary dysplasia, sickle cell lung disease, and tuberculosis. Fiberoptic laryngoscopy and bronchoscopy testing and follow-up of infant apnea are available, as are spirometry and pulmonary function testing for young children; an evaluation of children with chronic cough, recurrent pneumonia, chest pain, and shortness of breath; and sleep studies for obstructive sleep apnea (OSA).
A diagnosis of insomnia, narcolepsy, periodic limb movement disorder, and OSA is made through SIUHs Sleep Apnea Center, also directed by the Pulmonary Department and staffed 7 days and nights a week by pulmonologists, otolaryngologists, neurologists, psychiatrists, urologists, polysomnographers, and respiratory care practitioners. A growing number of hospitals are now including sleep laboratories in their facilities, although SIUH is the only one on Staten Island. Last year the SIUH center received a 5-year accreditation by the American Association of Sleep Disorders.
SIUHs Sleep Apnea Center is currently a four-bed laboratory that will expand to eight beds by March 2000. Patients are monitored mechanically as they sleep in the centers treatment rooms, which feature comfortable beds and amenities like remote control television and private bathrooms. If a problem is detected, the center initiates bilevel positive airway pressure therapy immediately to see if it has any positive effect. This eliminates the need for patients to come back a second night, and is successful about 85% of the time.
Its a very active program, Caruselle says. Anywhere from 5% to 9% of the population is thought to have a sleep disorder like OSA, but it is often undiagnosed because people are largely unaware of it. There is a huge calling for such education, so we are going to the community and educating physicians.
SIUH is starting to see the fruits of that labor. Manniatis estimates that the Sleep Apnea Centers usage has doubled in volume every year since it was opened 4 years ago, and Caruselle expects that it will be consistently filled to capacity when we have eight beds in the clinic next year.
The Neonatal Intensive Care Unit
SIUHs neonatal intensive care unit (NICU)a New York State-designated level-3 unit, which means it offers the full scope of neonatal intensive careis another division that sees a large volume of patients with serious respiratory issues. So many, in fact, that 4 years ago, a full-time respiratory care section was established within the unit, and it is now staffed 24 hours a day by respiratory therapists credentialed in neonatal care.
Whereas a few years ago graphic displays of patients pulmonary functions were used to adjust patient ventilation, the practice of daily rounds now draws upon everyones expertise and skills, and allows them to offer suggestions in terms of managing respiratory conditions, says Philip Roth, MD, neonatology director. That includes respiratory therapists, who play an integral role in directing the respiratory care of these young patients.
Because the NICU is level 3, it sees all birth weights, gestational ages, and specialty care, Roth says. We treat newborns, premature infants, and full-term babies who are readmitted to the pediatric floor after acute or near sudden infant death syndrome episodes.
The most common problem treated in the NICU is respiratory distress syndrome (RDS), but Roth notes that with the availability of surfactant therapy and the widespread use of continuous positive airway pressure early on, we are probably seeing a population of patients whose RDS is requiring less prolonged ventilation.
That means we are seeing a shift downward into earlier gestational-age patients, and smaller patients, he says. Today, the challenges are babies who weigh under 750 grams, or are the earliest gestational age, like 24 or 25 weeks.
The NICU is about to add high-frequency ventilation to its services. This type of therapy delivers tiny volumes of gas in small pulsations delivered at frequent intervals, and can aid respiratory failure patients who do not respond to conventional ventilation. While the technology has been around for a while, Roth says it is certainly not available in all neonatal wards.
This type of therapy is found in most level-3 neonatal wards, but it requires a very well-established, coordinated team to manage those types of patients, who are typically more acutely ill and whose care is more complicated, he says. To set it up in every unit would be problematic.
SIUHs dedication to the latest technology and most cutting-edge treatments extends to its Center for Clinical Research and Technology, part of an alliance of medical research facilities investigating new treatment modalities that may help understand, treat, and control many disorders. With more than 100 investigators on staff, it is one of the largest private research facilities in the country, and this year the center will receive more than $6 million in external contracts and other revenues.
In each study, patients receive study-related medical care, including tests and medications, at no cost. In the respiratory/pulmonary field, studies cover respiratory failure, asthma, bronchitis, COPD, emphysema, pneumonia, pulmonary fibrosis, and other lung diseases. Studies currently are under way on the safety and efficacy of the recombinant platelet activating factor for the prevention of ARDS in patients with severe sepsis or traumatic injuries, as well as on the safety and efficacy of a two-antibiotic regimen to treat patients with nosocomial or community-acquired pneumonia.
SIUH has continued to grow in order to keep up with the pace of technology and the growing patient base in and around Staten Island. The hospitals most recent project is the development of a buidling designated for an open heart surgery program, a joint venture between SIUH and Sisters of Charity, which is also located on Staten Island. The new building, set to open in August 2000, will be on SIUHs North Campus, while Sisters of Charity will do the rehabilitation and screening part of the program with the new addition and the commitment to research and development, the hospital continues to work toward its goals of lower mortality rates, reduced complications, shorter length of stay, significant shifts from in-hospital to outpatient care, and increased revenue.
Liz Finch is associate editor of RT Magazine.