The Journey of Adopting Acuity Adaptable Unit Model of Care and Impact on Outcomes (RD)

Friday, 20 July 2018: 4:10 PM

Erin McCalley, MS, RN, CCNS, CCRN
Patient Care Services, Stanford Health Care, Palo Alto, CA, USA
Carole Wilson, MS
Center for Education and Professional Development, Stanford Health Care, Stanford, CA, USA
Nancy Becker, MSN
Center for Education and Practice, Stanford Health Care, Stanford, CA, USA

Purpose: Acuity Adaptable Unit (AAU) model of patient care delivery has been adopted by a few medical centers nationwide with the intent to improve efficiency and patient care outcomes. The AAU model of care has been shown to improve nurse satisfaction, patient satisfaction, length of stay, and positively impact patient safety, fall and, medication error incidence (Drexler, D., & Newman, N. 2011; Chindhy, S.A., et al., 2011; Ramson, K.P., et al., 2013). The University of Wisconsin adopted the AAU model on a cardiothoracic surgical unit and showed a decrease in patient length of stay and a reduction in patient complications compared to the traditional model of care (Hennon, M.W., et al., 2011 and Chindhy, S.A., et al., 2011). In addition the AAU model has led to a reduction in patient transfers and a decrease in staff injuries related to patient transfers (Hendrich, et al., 2004). Cost-savings related to staffing changes has also been reported (Bonuel, N., Degracia, A., & Cesario, S. (2013).

The AAU model combines more than one level of care within the same unit. Depending on the institution, this can include all levels of care from medical-surgical to intensive care within a single unit. This model of care allows for levels of care to adjust to patient acuity thus allowing the patient to stay within the same unit and cared for by the same clinical team. The purpose of this presentation is to share the planning, adoption and implementation of an innovative AAU model of care inclusive of medical-surgical level and Intermediate Intensive Care (IIC) level within a single unit.


The initial search for a new model of patient care began out of the immediate necessity to improve patient flow and the long-term plan to build a new hospital. The institution’s patient population continues to grow, causing a bottleneck of patient’s requiring admission to a telemetry capable unit from the emergency department (ED) as there is a shortage of inpatient telemetry capable beds. This has a negative impact on both the delivery of patient care and patient satisfaction. Adopting the AAU model of care adds additional telemetry capable beds and helps to improve patient flow from the ED to admission. The decision was made by a previous nursing administration to adopt the AAU model of care delivery across all medical-surgical units within the institution.


Not-for-profit Academic Medical Center in Northern California. All 10-inpatient medical-surgical nursing units completed education and training in preparation for the adoption of the AAU model of care. Approximately 470 nurses completed AAU training: 7.3% have an Associate’s degree, 79.6% have a Bachelor’s degree, and 12.7% have a Master’s degree and 40% have at least one nationally recognized certification (e.g. Progressive Critical Care Nurse, Certified Medical Surgical Registered Nurse, Oncology Certified Nurse).


In preparation for the transition, each of the organization’s 470 medical-surgical nurses completed the Basic Knowledge Assessment Tool for Telemetry/Progressive Critical Care Nursing (BKAT-9S) © prior to beginning the educational program. The results obtained from the knowledge assessment tool enabled individualized assignments of online learning modules.

The e-learning modules, Essentials of Critical Care Orientation 3.0, progressive care track, were developed by the American Association of Critical Care Nurses (AACN) (2015, 2016). AACN’s e-learning ECG modules, Basic ECG Interpretation 2.0, were also assigned to all staff. Following completion of e-learning, nurses attended two eight-hour interactive sessions, consisting of case studies, lab-and-learn elements, and flipped classroom methodologies.

After the didactic education, nurses were given four weeks (three, 12 hours shifts per week) precepted orientation time on an Intermediate Intensive Care Unit (IICU) unit, followed by Advanced Cardiac Life Support (ACLS) training within six months (American Association of Critical Care Nurses, 2016). Intermediate competencies, including ECG rhythm recognition, were demonstrated during preceptorship. Completion of the program took approximately 12 weeks per individual nurse. When 75% of a medical-surgical unit’s nurses were deemed competent to care for intermediate care patients, the units converted to the AAU care delivery model. Conversion of each medical-surgical unit took approximately nine months, which included performing knowledge assessments, e-learning and in class didactics, precepted orientation, and equipment upgrades.


AAU training program competencies focused on preparing the learners to care for patients at an Intermediate Intensive Care (IIC) level of care. Precepted clinical time on an existing IIC unit allowed the AAU training staff to experience caring for patients at an IIC level of care. AAU training staff obtained validation of the existing IIC competency packet during their precepted clinical time. All AAU training staff had to pass a dysrhythmia assessment, required of all nurses caring for patients on an electrocardiogram monitor. Communication was another competency that was reinforced throughout the two didactic sessions and clinical precepted time. The Situation-Background-Assessment-Recommendation communication model was reviewed, practiced and emphasized to enhance the staff’s ability to effectively communicate with all disciplines of the care team (AHRQ, Patient Safety Network, 2017).

Results: Completed in October of 2017, the last of all ten medical-surgical units in our academic health care organization converted to adaptable acuity units (AAUs). Post-implementation data show a 27% decrease in patient transfers. In addition, post-implementation BKAT-9s © scores improved between 9% and 16% per nursing unit from pre-test to 12 months post AAU training and unit conversion. Other data collected include patient length of stay, RN turnover and sitter use, number of patient falls and medication error rates, as well as measures of both patient and staff satisfaction.

Conclusion: Though in its early stages of adoption the AAU model of care house-wide, initial indications are that the AAU is an innovative model of patient care which we hope will improve efficiency, flow, patient and staff satisfaction.