The patient journey to progressive care

The need for progressive care may occur during a number of points on the acute care
illness continuum. One point may occur within the recovery period of critical care, when
technology and intervention have brought an individual to a plateau level. The patient is
stable with the current high level of interventions, but has failed to progress to wellness.
If therapies (e.g., ventilation, airway maintenance, enteral nutrition, and dialysis) are
reduced or withdrawn, clinical deterioration will follow. This patient has become
“chronically critically ill”.
End of life discussions are pivotal at this time. It is important to review the intensity of
illness and the potential for recovery. These discussions assess the elements of quality and
quantity of life with the individual and relevant family/ significant orhers. The primary
care team members are all esential contributors to this discussions. Assessing and
providing for spiritual support may be helpful.
For the individual who chooses not to continue the chronically critically i'll lifestyle, the
choices available for end of life care are many. Limiting current and future interventionis
within the scope of choice. Choices range from allowing natural to total withdrawal of
care. Specific issues relative to this can be referenced in chapter 54, end of life care.

Box 2-2
If patient and their support system accept the current situation and necessary support,
the team begins a plan of care that includes strategies for adaptation to a limited lifestyle
with technology for life support. The venue of care in the hospital environment at this
point of the illness has continuum is either a critical care unit or a PCU. A Second point
on the acute care illness continuum may a occur when patients are the directly admitted
to a PCU from the ED or other general medical-surgical units. These patients generally
require close monitoring or a specific therapy that the general unit is unable to provide.
Table 2-1 provides examples of PCU admission criteria. Admission criteria are set to
ensure care needs are matched with the nurse competencies and resources available in
the progressive care venue.

PROGRESSIVE IN THE HOSPITAL SETTING

Assessment and triage are pivotal for appropriate patient placement in the PCU. In a
PCU, the RN-to-patient ratio varies from 1:3 to 1:4 ratios vary depending on the specific
patient population and acuity levels. Usually, different levels of licensed nurse are
available to provide care; unlicensed assistive personnel may also be part of the care team.
The delivery models selected for PCUs optimize resources and each caregivers's ability
to practice with in his or her scope. Successful model implement the team approach. The
RN as charge nurse or team leader, delegates tasks to licensed practical nurses and
unlicensed caregivers as appropriate to their ability and within their legal scope of
practice. The RN collaborates which members of the multidisiplinary team, including
the physical, occupational, speech, and respiratory therapist; dietitian; chaplain or
pastor; and social worker. Optimal plans of care revoive around meeting the holistic
needs of each patient.
In addition to the multidisiplinary focus, each unit's leadership determines the tools
necessary to deliver care. Devices for oximetry, ventilation, and cardiac monitoring are
option to assess vital parameters, individualized for each patient. Equipment to assist
with lifting, moving, or transferring patient support the caregiver team and ensure
optimal mobility with savety awareness. Many device that once required a patient to be
prescribed bed rest have progressed to allow mobility for the patient, thus
echancing,recovery. Fir example smaller, more protable mechanical ventilators may
enhance mobility.

Pleural drainage, once reserved for acute care settings, can now be used with water seal
drainage systems or intermittent sampling of fluid by aspiration. Small, self-sealing chest tubes
allow egress from the acute care environment. Standardized plans of care or pathways are
useful in this population guide and then evaluate care and can offer an opportunity for the team
to measure success compared to national benchmarks.
Patients transitioning from a tradisional critical care to a PCU typically move from a less
physically demanding to a more physically demanding environment. The PCU's philosophy is
to maximize the patient's own capabilities while promoting increased physical independence.
This requires a multidiciplinary approach related to all aspects of care.
Collaboration between unit leadership within the institution can achieve adherence to
admission standards among the PCU. The critical care area, ED, and general medical-surgical
units must be familiar with admission criteria for this patient population. Adminission and
discharge should be congruent among all step-down unit for consistency. Documentation of
these standard can also improve continuity across care units. The result of the coordinated
efforts will be effective patient flow.
Nursing competency should be assessed upon here and on an annual basis for each staff
member. Skill competency assessment should be based on the needs of the specific unit and
patient population (highrisk/ low-volume). As outlined previously (see box 2-1), core
competencies for PCUs should be include, but not be limited to, the following mechanical
ventilation, and sheath removal (Figure 2-1). In addition, a variety of medications not usually
seen outside of critical care is often used in progressive care unit. An example of one unit's use
of medication is seen in the medication table on p. 27. Decisions on the level of care and
interventions provided on any given PCU will need to be made at the institutional level AACN
has a variety of resqurces available to support nurses working in progressive care unit (Box 2-
3)