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.slideshare.net/nc/das/progressive patient care.14/12/11.
www.hospiad.blogspot.com21/12/11.
www.assistinghands.comprogressive patient care.11/12/11.
Patients are not the only participants within the system who must maintain several lines of communication.
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