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Reprinted with permission from
Nursing Management, 33(6):31–35, 2002.
In larger facilities, these units can be structured to care for specific patient populations, or the unit is more generic and encompasses many diagnoses and patient populations. Often, caregivers must prepare for overflow from one PCU to another. As the patient population diversifies, nurse managers must clearly define appropriate care protocols for each PCU.
PCU Positives
In addition to freeing up precious ICU beds, PCUs have many positive implications.2 Nurses in PCUs report increased job satisfaction because they’re developing new skills. Patients and families are comforted as they perceive signs of the patient’s progress and enjoy more open visitation. Primary care providers (PCPs) appreciate the continuous monitoring of their patients. And hospital administrators support a two-tiered, critical care approach because it lowers costs and employs less-invasive technology. PCUs have a lower, less expensive caregiver-to-patient ratio than ICUs, commonly 1:3 or 1:4, compared to 1:2.3
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Critical care outcomes have shown that many patients are either too sick or not sick enough to benefit from the care level provided in the ICU. Discharging patients from the ICU to the PCU instead of to a general floor may lower mortality rates because patients receive the appropriate care level for their acuity.5,6 Reportedly, post-ICU mortality is as high as 23% to 31%.7
Model Adult PCUs
In 1999, the Society of Critical Care Medicine (SCCM) offered three models to help hospitals develop admission and discharge criteria for critical care. (The SCCM guidelines use the term intermediate care, but for consistency the term progressive care appears throughout this series.) The three models are:
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The discharge criteria from any unit should be similar to the admitting criteria for the next care level. For example, discharge criteria from the ICU should match admission criteria to the PCU, although not all patients require progressive care after discharge from the ICU.10
Diagnosis Model
In 1998, SCCM published admission and discharge criteria for progressive Model.11 The guidelines assert that patients must be hemodynamically stable to be admitted to the PCU. Patients who require more than 12 to 24 hours of nursing care per day have acuity levels that are critical and considered too high for PCU admission. Potential PCU cardiac patients include:
According to the SCCM, pulmonary patients who are appropriate PCU candidates:
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Some neurosurgery patients who require observation for vasospasm or hydrocephalus can be admitted to the PCU. Stable patients awaiting neurosurgical intervention may be more closely observed in the PCU before surgery, for example: patients with Grade I or II subarachnoid hemorrhage or those who await V-P shunt. Patients undergoing intracranial pressure monitoring and those with status epilepticus, however, must receive care in the ICU.
Patients who require frequent neurologic, cardiac, or respiratory monitoring following drug ingestion qualify for PCU admission. Those with gastrointestinal (GI) disorders, such as GI or variceal hemorrhage or acute liver failure, are also appropriate.
Various endocrine diagnoses typify PCU patients, including diabetic patients receiving insulin drips or needing frequent injections during recovery from diabetic ketoacidosis or hyperglycemic hyperosmolar non-ketotic acidosis, and those in severe hypothyroid states who require frequent monitoring.
Other post-operative patients who require frequent nursing assessment in the first 24 hours are appropriate PCU admissions, such as those recovering from kidney transplantation, carotid endarterectomy, and peripheral vascular reconstruction.
According to SCCM guidelines, PCU beds are for patients expected to live. Patients receiving comfort measures only or those with catastrophic brain illness or injury who are "DNR" and not candidates for organ donation might not benefit from PCU care.12 Your health care administrators can address the remaining moral and economic care considerations for the terminally ill in line with the facility’s mission and values.
Progressive care patients can be discharged to the medical/surgical area when they no longer require intensive monitoring. If a patient requires or will likely require active life support, he should be transferred to the ICU.13
Objective Parameter Model
In December 1992, a midwestern hospital developed PCU admission and discharge standards to meet its needs based on the objective outlined in the Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Subsequently revised, the facility is evaluating its standards against the SCCM’s guidelines. The philosophy of admitting hemodynamically unstable patients to the PCU is under review. (See "Objective Parameter Model: PCU admission and discharge criteria.")
Prioritization Model
The Prioritization Model categorizes patients according to three priority levels for monitoring with Priority 1 patients needing the most monitoring. For example, a Priority 1 patient receives vital signs monitoring every 1 to 2 hours or temporary frequent monitoring of vital signs after a procedure, and is first to be assigned to the PCU. Priority 2 patients receive vital signs monitoring every 2 to 4 hours and may receive care in a cardiac telemetry unit, not the PCU. Priority 3 patients have the lowest care needs and least potentially critical conditions, so they may receive care on units with remote telemetry.14 (See "Prioritization Model: PCU admission criteria.")
Bedside nurses can offer a unique perspective on the type and amount of nursing care each patient needs.15 Discharge from a critical care area is typically a medical decision; however, more nursing input related to discharge may result in better patient outcomes.
References
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