L-R: Alison Tai, Velma Bailey, Nicolae Lungu
(L to R): Clinician-teacher Alison Lai, 3B Fell Nurse Manager, Velma Bailey, and registered nurse Nicolae Lungu stand outside the General Internal Medicine High Acuity Unit at Toronto Western Hospital – four beds dedicated to treat patients needing more intensive care, but not so much they require admission to the Intensive Care Unit. (Photo: UHN)

A unit within UHN's General Internal Medicine (GIM) Department is helping to fill the gap for patients needing higher acuity care, but not so much they should be admitted to the Intensive Care Unit (ICU).

In October 2021, Toronto Western Hospital's (TWH) 3B Fell Unit opened four beds to care for high acuity patients with certain conditions. Known as the high acuity unit (HAU) these beds not only allow for more intensive care, but also provide both nurses and GIM trainees access to a patient population with more intensive needs, which helps enhance their skill set.

"This is a great collaboration between the ICU, GIM, and Emergency Department (ED) that provides the right amount of care for patients while also bringing something new to the table in terms of training opportunities for nurses and trainees," says Alison Lai, clinician-teacher at TWH, who has been working on the education side of the project by creating all the supporting materials as well as the website.

The GIM program at TWH admits over 4,400 patients per year. A significant subset of these patients are admitted with conditions needing more intensive monitoring than is currently possible on the GIM wards, but not to the extent of a Level 3 (L3) bed in the ICU.

Before the HAU opened, these patients would be cared for in the ED, attended to by an ICU physician and ED staff. It's a situation where a patient's needs aren't compatible with a medical department's capacities and can lead to adverse events.

GIM's 3B unit was identified as ideal to support the HAU because it already supports the Cardiology Acute Care Unit (CACU), a unit that cares for cardiology patients with intense needs and where nurses already have enhanced acuity training.

Since October, only one patient needing readmission within 14 days

For Nicolae Lungu, a registered nurse on 3B, working on the HAU has been a challenging but rewarding experience.

"It was overwhelming at first because these patients need a lot of attention and, although we had the training, we still had to review all the education materials with the educator to get familiar with the conditions these patients have," he says. "But working with these patients has been eye-opening, and as I become more familiar with their treatment and care I've been inspired to think about getting more training and possibly pursuing high acuity care as part of my career."

For now, the HAU is only focusing on a specific list of high acuity conditions that are seen often in GIM – such as diabetic ketoacidosis and alcohol withdrawal – but also require a lot of monitoring, and tend to need only a few days to resolve. After a few days on the HAU, a decision is then made on whether the patient is stable enough to be cared for on a GIM unit or if an admission to the ICU should be considered.

As of Feb. 2, the unit has cared for 64 patients since it opened last October with only one patient needing to be readmitted within 14 days of discharge.

"It has definitely been hard to take this on during the pandemic since we had to pivot our staffing and the way we work," Nicole says. "But our manager has been really supportive and there are a lot of resources available for us.

"As my knowledge and skills increase, I feel more comfortable caring for these patients and it is nice to know we are helping to alleviate the pressure on the ED."

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