Friday, 1 August 2014

PROGRESSIVE PATIENT CARE



     
Nursing supervision is deliberately maximized in critical care unit, where the patient is very ill and need for privacy is reduced. When the patient is getting better, observability can be reduced. Gradually , the recovering patient is transferred to a medically less sophisticated unit. Different kinds of unit that offer varying degrees of patient care are replacing standard units. . Ford,
Hunter and Clevelan, Jeffers, and De Vries describe intermediate care patients as requiring          
"less intensive," "a lesser degree," or "less critical" nursing care. Walker, however, describes the same requirements for minimal care patients. Ford and Griffith and co-authors use theself-care unit for patients hospitalized for diagnostic tests, whereas Walker and Hunter and Cleveland
place such patients in the minimal care unit. Gordon and associates distinguish between ambulatory and non-ambulatory patients requiring diagnostic tests by placing those who are ambulatory in minimal care and those who are non ambulatory in intermediate care. in the past 15 years the concept of PPC has evolved from a purely hospital organizational model to
a system of health care incorporating many types of health facilities. Although there are exceptions, it seems that the elements of PPC are no longer considered to be services such as intensive care, intermediate care, or self-care. Instead, the components of PPC are institutions-
hospitals, health centers, limited care facilities, and extended care facilities-and home care.
Although the "PPC hospital" may have limited applicability today, the concept of PPC personifies the goal of health care delivery: the right services, for the right patient, at the right time and at the right care.

                             PROGRESSIVE PATIENT CARE
PPC is defined as the care through the organization of hospital facility services and staff around the changing and nursing needs of the patient.

           Progressive patient care,a system of care in which patients are placed in units on the basis of their needs for care as determined by the degree of illness rather than on the basis of a medical specialty. The usual levels or stages of progressive patient care are intensive care, intermediate care, and minimal care.
                                                                                                   Mosby's Medical Dictionary (2009)
                                                                                                                                                                                                                                                                                                                                                     




THE CONCEPT
Two phrases are commonly used to describe progressive patient care;
“The tailoring of hospital services to meet the patient’s needs.”
And
“the right patient, in right bed, with the right services, at the right time”
These two statements express the salient features of progressive patient care.
The principal objective of this growing concept:
To provide better treatment and care by organizing hospital services around the individual patient’s medical and nursing needs. Specially planned and organized units are set up to which patients are assigned in accordance with their degree of illness and need for care to increase efficiency.
HISTORY OF PROGRESSIVE PATIENT CARE
The classification of  patients according to their needs has been carried out by the Japanese for centuries, and more than 100 years ago in England.
Miss Florance Nightingale, in a sense, practiced progressive patient care in her operation of open wards. It was her plan to place the sickest patients at the head of the ward nearest nurses desk, while the convalescent or least ill patients were placed in rear beds.
In the United States the concentration of critically   ill and self-care patients in separate areas has been the practice of armed service hospitals, tuberculosis hospitals, psychiatric institutions, and some private hospitals since early in this century.
The exact date that progressive patient care emerged into its present form is open to question.
In 1950, the concept began to take shape in several hospitals.
In 1956, it was given the name of progressive patient care and the Department of Health, Education and Welfare began to place special emphasis on the need to study and develop methods of adapting hospital facilities and more closely to the varying needs of patients.
In September 1956, A Government advisory committee was appointed to survey the problem areas and make recommendations applicable for new hospitals as well as existing facilities.
In 1957, a Public Health Service team was assigned by the Division of Hoospital and Medical Facilities to observing in some detail the transition of Manchester Memorial Hospital from a facility with traditionally organized services to on which had adopted progressive patient care.Since that time many additional studies covering various phases of the concept have been underway at that hospital as well as other such institutions around the nation.


THE ELEMENT
Progressive patient care is a dynamic concept with application to the hospitals of all sizes and types. Although certain fundamental principles should be observed by all hospitals contemplating the adoption of such program, individual variations can be expected among different hospitals.
SIX ELEMENTS OF PPC.
Intensive care
Intermediate care
Self-care
Longterm care
Home care
Outpatient care
INTENSIVE CARE
For critically and seriously ill patients who are unable to communicate their needs or who require extensive nursing care and observation. These patients are under close observation of nurses who have been selected because of their special skills, training, and experience .All necessary lifesaving emergency equipment ,drugs and supplies are immediately available.
INTERMEDIATE CARE
For patients requiring a moderate amount of nursing care. Some of these patients may be ambulatory for short periods of time. Emergency care and frequent observation are rarely needed. Included in this group are those patients who are beginning to participate in caring for themselves. In addition, the terminally ill may be cared for here.
SELF CARE
For ambulatory and physically self-sufficient patients requiring therapeutic or diagnostic services, or who may be convalescing. In this home like atmosphere, provision is made for relaxation and recreation.Here the patient is instructed in self-care within the limits of his illness.
LONGTERM CARE
For patients requiring skilled prolonged medical and nursing care.Rehabilitation, occupational therapy and physical therapy services may be needed for these patients.
In addition,emphasis is placed on instructing  those patients who must learn to adjust to their illness and disability.


HOME CARE
For patients who can be adequately cared for in the home through the extension of certain hospital services.A hospital based home care program provides personnel and equipment from the hospital or through community agencies.
OUTPATIENT CARE.
For ambulatory patients requiring diagnostic, curative, preventive and rehabilitative services.

ELEMENT TYPE
INTENSIVE CARE
INTERMEDIATE CARE
SELF CARE
LONGTERM CARE
HOME CARE
Selection of patients
Critically ill patient
E.g.:Major Surgery
·         -acute coronary occlusion
·         Critical/RTA patient

·         Moderately ill ambulatory
·         Uncomplicated cases
·         Can helping planning and implementing care
·         Convalescing
·         Ambulatory
·         Patient needs
-Rehabilitation
-Teaching
-Diagnosis
·         Chronic ill patients
E.g.;Disabled
·         Terminally ill patients
E.g.;Last stage of cancers
Carefully select patient who can care for in the home
Services required
·         Specialised skills
·         Life saving extensive nursing care
·         Close frequent observation
·         Moderate care
·         Teaching self care with limitation of illness
·         Educational and supervising services
·         Less technical care
·         Skilled supervision
·         Palliative and restrictive treatment
·         Physiotherapy
·         Rehabilitation
·         Emotional support
·         Basic medical, nursing, social services
·         Supportive care
Nursing Personnel
·         Specially trained
·         Technically efficient Computer staff
·         Nurse patient ratio[1:1/shift]
·         Ability in general ward care
·         Special skill in health teaching
Nurse patient ratio1:5 day shift
1:7 evening shift
1:11 night shift
·         Skilled in human relation
·         -counselling
·         -emotional support
·         Knowledge in public health service
Nurse patient ratio 1:26 with nurse aid+1 clerk
·         Skill in educating assisting and motivating
·         Team nursing best approach
·         Nurse patient ratio 1:3 day shift
1:4 evening shift
1:5 night shift
Hospital services
Extend through community health agencies

APPLICATION TO COMMUNITY WIDE PLANNING
Progressive patient care is not only has important implications for individual hospitals but in its broadest sense, encourage the development of a co-ordinated pattern of services and facilities on a community wide basis.
The Establishment  on a common site of a regional medical center which would offer a wide spectrum of services and facilities for both the in-patient as well as outpatient.
In many respects the emphasis of the regional medical center would differ from that of today’s conventional general hospital.
    As interested in caring for the ambulatory patient as it is now with caring for the bed patient;
    As concerned with caring for the long-term patient as it is now with caring for the short-term patient.
      As readily available for assisting the physician with caring for the patient at home, as it is now with assisting him in caring for the patient in the hospital;
     As interested in providing continuity care for patients in paramedical institutions as it is now with providing continuity care for patients within the walls of its own buildings;
And
      As dedicated to providing preventive services and teaching health care.
BENEFITS OF PPC
Hospitals which are successfully practicing progressive patient care report that the benefits are manifold.
Some of the primary advantages are;
1)PATIENT receives the specialised attention he needs when he needs it. Moreover,he is assisted in making his adjustment first to the hospital atmosphere and later to his return to the home and community.
Some of the hospital’s objectives are to provide the following: lifesaving care within seconds;constant nursing care when needed the most;high quality care regardless of economic status;total physical teaching, emotional, rehabilitative services when needed; and nursing care which is planned around progress towards recovery.
The need to prepare the patient to adjust from the hospital to the home or community is an important consideratrion. The transfer of the patient to the self-care unit prior to discharge minimizes the problem as the patient has the opportunity to adjust gradually from complete dependency to self sufficiency.
2)PHYSICIAN is given greater assurance that his patient is receiving a high quality of nursing care, and that the special drugs ,medications and equipment necessary for diagnosis and treatment are in the immediate vicinity of the patient .Moreover, there is greater likelyhood that a bed will be available and that trained personal will be on duty who will contact the physician immediately in emergencies and carryout procedures as required.Emergency orders may be carried out with out upsetting the entire routine as the personnel are geared mentally and physically to cope with this problem.
Since early involvement of the physician in setting up PPC is essential, is made more aware of the hospital’s problem and policies.This creates better understanding and promotes better clinical services, team action and administration.
The physician also figures prominently in the hospital’s in service training program.He is called upon to express opinions on his particular speciality,On general policies or on some innervations in patient care which he feels would be helpful to hospital personnel.
In addition, he will have an opportunity to further develop his own knowledge by participating in discussion with other staff members.
3)NURSE makes effective use of her special capability and nursing department is less harassed by problems of providing coverage, for critically ill patients in widely separated area. PPC permits “the assignment of nurses to the area where there individual skills can best meet the needs of the patient.”
Nurses have more time to spend with patients on nursing and, as contributing members of a health team, are able to help patients and families to solve their health problems.
Conventional nursing unit usually separates patient by type of service, age or sex and the patient often remains on the same unit during the various stages of his illness. His likelihood of receiving complete physical care when he needs it the most is decreased. When he makes sonic progress and is ready for instruction, emotional support and rehabilitation, the demands of other critically ill patients must be given priority. The patient often is left with feeling of being neglected and his progress towards full recovery may be retarded.
4)HOSPITAL
Effective use of hospital bed is increased. Increased number of beds in ICU needs increased manpower.
DEMERITS
There may be discomfort to who are moved often.
Continuity care is difficult even though possible.
Longterm nurse-client relationship is difficult to arrange.
Great emphasis on comprehensive written care plan.
There is often times difficulty in meeting administrative need of the organization, staffing evaluation and accreditation.
THE FUNDAMENTALS
A guide for hospital planning to introduced progressive patient care? What are the pitfalls? How may be avoided?
          From the studies and experience over the past several years, ten fundamentals in carrying out progressive patient care program have evolved.
          Although the manner in which these principles are adapted may vary among hospital, each principle should be carefully considered during the early planning stages.


THE TEN FUNDAMENTAL PRINCIPLES ARE:
Study concept
Developed team work
Evaluate needs
Orient staff
Estimate cost
Establish policies
Provide flexibility
Staff adequately
Instruct patients
Inform public
STUDY CONCEPT
Become thoroughly familiar with the PPC concept
       A major organizational change should not be attempted overnight. In fact, several months or even a year may be the necessary frame work. Representatives of all disciplines should become familiar with the program during this period. This can be accomplished by reviewing available literature, conferring with experienced persons in the field, and visiting hospital practicing progressive patient care. The patient care studies and in providing assistance to hospital interested in initiating the program. In addition , valuable information concerning PPC has appeared in various medical and hospital journals as well as in popular publication during the past few years.

DEVELOP TEAM WORK
Involve key presentation of various disciplines
If planning is to proceed smoothly , endorsement is needed by the key members of the board of trustees and the medical and nursing staff,as well as by the key hospital administrator. These persons may be among those to form the nucleus of an overall committee to work out the details for setting up and implementing the program.Subcommittees are sometimes needed to carry out specific facet of the program.
       The success or failure of the progressive patient care program often revolves about teamwork. It is therefore important that all people involved in administering the program become part of the team.
EVALUATE NEEDS
Analyse your own hospital and determine needed innovations
        No two hospitals are identical in every respect. There may be variation in many areas such as patterns of medical practice, operational procedures, patient load, staff requirements and type of patient treated, architectural arrangement, dietary services and housekeeping facilities.
          Many other areas of hospital operations are also affected and should be considered. These include purchasing, business, central supply, admitting and medical record departments. It is therefore become obvious that any how to do it guide must be considered in light of the conditions prevailing in a hospital.
ORIENT STAFF
Conduct orientation program for staff
The medical and nursing staff, the hospital administrator and other involved in the operation of the program should be included in this operation, serve a 3 fold purpose.
         It is here that the staff becomes an acquainted with the various aspect of PPC.
         The meeting serves as an ideal setting for arising opinions regarding the innovation.
         They help to stimulate the staff’s interest and enthusiasm in initiating the program.

ESTIMATE COST 
Determine estimated operating costs and make special arrangements with third party prayers regarding insurance coverage.
   Hospital shows a considerable range in their cost of operating the different patient care unit. This is primarily due to the wide variation between units from the standpoint of nurse stalling patterns and the use of special equipment.
     Policies governing charges for services are established by each hospital. There are some charge difference on each unit, relating the charges to actual costs; other operate on the spread of risk principle and make no special charge for intensive care.
The local variations in Blue Cross and other insurance coverage may have an important influence on how hospitals set their charges. Insurance practices may also affect the willingness of hospitals to establish long-term care and self-care units, Insurance plans which do not ordinarily cover admission for diagnosis only make no exception for patient admitted to the self-care area for this sole purpose. Special attention must be given to hospital cost accounting if charges on each unit are to be based on actual cost of unit. Regardless of the type of charging pattern planned, arrangement should be made with third party payment plans before the program is initiated.

PROVIDE FLEXIBILITY
Establish flexible zones between patient care units
The classification study of patient described above should indicate minimum and maximum number of beds needed for each care unit.To build or provide for maximum number would result in some empty beds most of the time. To offset this, some beds in the unit should be flexible; i.e., may be used as required by two areas. Flexible zones, because of their interchangeable features and their ability to accommodate the overflow from the different care areas,help stabilize the use of hospital bed.They are readily available to accommodate emergency patients. Such zones should be established between the intensive and intermediate care units. They may also be useful between the self-care and intermediate care units. Other condition will also be needed, depending upon the patient and his condition.Those assigned to the self-care unit must be advised of the extent to which they are expected to take care of their own needs.
STAFF ADEQUANCY
Provide adequate nurse staffing of units
      A careful evaluation of requirements for each patient care unit is prerequisite o the development of workable plans. The establishment of an adequate nursing staff in the intensive care area precludes the need for special duty nurses.In fact, most PPC hospitals permit only their own specially trained staff nurses as per the speciality.
The physician’s job has been eased considerably since the nursing staff in each area has become more stable and has been trained to care for the special types of cases. Because of this specialized training, the physician is called upon less frequently to give instruction to nursing personnel.
INSTRUCT PATIENTS
Instruct   patients prior to their transfer, concerning their new care unit
Since the patient care units have their difference, particularly in regard to starling, the patient should be advised of the reasons for the changes he will be experiencing in his new surroundings. The greatest transition occurs between the intensive care unit and wards. Therefore a patient making such a transfer should be given a careful explanation regarding the difference in the arrangement of services for those two units.
INFORM PUBLIC
The public informed of the patient care concept
         Patients, their relatives and the general public should be advised of many advantages of progressive patient care as a means to ensuring patient acceptance program.
         Early PPC studies reveal that attitude of patients reflect those of their physicians.If the patient’s doctor favoured progressive patient care, then the chances where excellent that the patient would also. In view of these findings, the role of keeping the public and particularly his patients, informed become extremely important.
A number of hospitals have found it advantageous to prepare brochures to explain the program in layman’s terms. These brochures are made available to patients and their families both in the hospitals as well as the physician’s offices.
The conventional means of communication newspaper and magazine articles , press, radio, television, lectures, exhibits may also be used to keep the public abreast of the latest development of the program.

HOSPITAL DESIGN
The impact of progressive patient care concept on the design of the general hospital is felt mainly in the arrangement and location of patient care units.
The perspective sketch and diagrammatic plans presented in this section indicate a way of arranging and relating departments in a hospital of approximately 280 beds so as to permit the grouping of functions for effective control , and the distribution of the many and diverse items and services required in a hospital.

LAYOUT OF HOSPITAL BASED ON PPC CONCEPT
GROUND FLOOR
Supporting services are concentrated here so that all material entering and being distributed throughout the hospitals can be received and processed and controlled in a Central Service Department, under one responsibility.

FIRST FLOOR
Adjunct facilities such as X-ray, laboratory and physical therapy, as well as administrations are located here to make these facilities convenient to the emergency and outpatient department.Surgery is placed here so that X-ray and laboratory are closed by.The supply room and soiled holding room service all departments on the floor.
SECOND FLOOR
The dietary department is placed here, thus making it possible to locate food tray conveyors close to the supply conveyors on the inpatient floor.The self care unit is also located here so that the patient can walk to the meals and be convenient by elevator or stairs to entrance admitting office, and the adjunct facilities on the first floor.
THIRD FLOOR
The delivery suite and the maternity unit could be on any floor.They are arranged so that the patient and visitor traffic are separated. Three double on this floor may be used either by maternity or by the adjacent intermediate care unit.The doors at each end of this block of room permit to be cut off from either unit. The supply room and soiled-holding room serve the entire home. Food tray services for the floor is handled by the mechanical conveyors and dumbwaiter in the central nourished room.
FOURTH FLOOR
The three patient care units on the floor, long term and two intermediate care, are served by the centrally located supply room and soil-holding room. Food tray service for all units is handled in the central nourishment room.
FIFTH FLOOR
Intensive and intermediate care units are related so that either can overflow into the flexible zone between the two units when patient census requires. The entire floor is serviced by the centrally located supply, soiled-holding and nourishment rooms.
SIXTH FLOOR
In the psychiatric unit, patient-staff and visitor elevator traffic is separated. The addition of other patient care units to this floor is interfere with these separation.



VENTILATION AND AIR CONDITIONING
Interior rooms
Interior rooms will be served by a conventional duct system, with recirculation of air of all areas with the exception of toilet, soiled holding and treatment rooms.The following ventilation rates are recommended.
Treatment room, soiled holding room and day room
The equivalent of four room volumes of air per hour with a negative air pressure relative to the air pressure of the corridor.
Conference room and Doctor’s charting room
The equivalent of the three room volumes of air per hour with a negative air pressure relative to the air pressure of the corridor.

Corridors
The equivalent of 2 room volumes of air per hour with a positive air pressure relative to the air pressure of adjoining rooms of the central core.


BIBILIOGRAPHY
BOOKS
1.Basavanthappa BT, ‘Nursing Administration’.2nd ed.New Delhi:Jaypee Brothers Publisheres;2005.
2.Sakharkar BM, ‘Principles of Hospital Administration And Planning’. New Delhi:Jaypee Publishers.

INTERNET.
www.ncbi.nlm.gov>postgradmed j>v.39(453);july1963.14/12/11.
www.assistinghands.comprogressive patient care.11/12/11.



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