Progressive Care FACT SHEET

Background

In the early 1970s, advertisements were placed in Heart and Lung by major medical center recruiters for both critical care and progressive care nurses. Initially, progressive care units were used to house post myocardial infarction patients who needed cardiac monitoring but who did not require intensive care and observation. As the health care environment began to change, the acuity of patients admitted to the hospital steadily increased and with it the demand for critical care beds also increased. With an increased demand for and decreased availability of critical care beds, patients were often transferred from critical care units while still requiring an increased level of nursing care and vigilance. Patients who were admitted to critical care units five years ago are now routinely admitted to progressive care.

Progressive care is the term the American Association of Critical-Care Nurses (AACN) uses to collectively describe areas that are also referred to as Intermediate Care Units, Direct Observation Units, Step-down Units, Telemetry Units, or Transitional Care Units as well as to define a specific level of patient care. AACN recognizes the need to define and identify the special needs of progressive care nurses. In 2001, a task force and advisory panel were created to define the progressive care environment and patient populations served, as well as the core competencies and basic knowledge and skill requirements of progressive care nurses.

Definition

The American Association of Critical-Care Nurses recognizes progressive care as part of the continuum of critical care. AACN's vision is dedicated to creating a healthcare system driven by the needs of patients and families where critical care nurses make their optimal contribution. The AACN Synergy Model for Patient Care is the conceptual framework that actualizes the vision. It defines nursing practice based on the needs of the patient and the characteristics of the nurse to attain optimal patient outcomes.

Progressive care defines the care that is delivered to patients whose needs fall along the less acute end of that continuum. Progressive care patients are moderately stable with less complexity, require moderate resources and require intermittent nursing vigilance or are stable with a high potential for becoming unstable and require increased intensity of care and vigilance. Characteristics of progressive care patients include: a decreased risk of a life-threatening event, a decreased need for invasive monitoring, increased stability, and an increased ability to participate in their care.

Progressive Care Patient Location

Using AACN's Synergy Model will assist in defining the progressive care patient. The Synergy Model identifies patients based on the characteristics and needs that they present and not on the location of the bed they occupy. As in critical care, the geographic domain of progressive care is expanding. Care provided to progressive care patients is not limited by geography but is based on the needs and required interventions of the patient. While specific progressive care units can be identified, patients requiring progressive care nursing can be located throughout the hospital.

Progressive care can be very specialized, with care focused on a specific system such as cardiac, or more generalized, as in the care of patients with multi-system problems.

Educational Requirements

Progressive care nursing has expanded beyond the basic cardiac telemetry that marked its beginning and now encompasses many of the same technologies and therapies that were once limited to critical care units. To meet the changing needs of the patient, nurses caring for progressive care patients must demonstrate competencies that are influenced by ever changing technology. Progressive care nurses must demonstrate the following core competencies:

  • Dysrhythmia monitoring techniques
  • Basic & advanced life support
  • Basic dysrhythmia interpretation and treatment
  • Drug dosage calculation, continuous medication infusion administration, and patient monitoring for medication effects (i.e., non-titrated vasoactive agents, platelet inhibitors, anti-arrhythmic agents, and insulin)
  • Patient monitoring using standardized procedures for pre, intra, and post procedures (i.e.; cardioversion, TEE, cardiac catheterization with PCI, bronchoscopy, EGD, PEG placement, chest tube insertion)
  • Hemodynamic monitoring including equipment setup and troubleshooting, monitoring and recognition of signs and symptoms of patient instability
  • Recognition of the signs and symptoms of cardiopulmonary emergencies and initiation of standardized interventions to stabilize the patient awaiting transfer to critical care
  • Interpretation of ABGs and communication of findings
  • Recognition of indications for and management of patients requiring non-invasive O2 delivery systems including oral airways, bipap, and nasal CPAP
  • Assessment of the ventilated patient to assure delivery of the prescribed treatment and patient response
  • Assessment and understanding of long term mechanical ventilation and weaning
  • Recognition of the indications for and complications of enteral and parental nutrition
  • Assessment, monitoring and management of patients requiring renal therapeutic interventions; For example hemodialysis, peritoneal dialysis, stents, continuous bladder irrigation, and urostomies
  • Recognition of and evaluation of the family's need for enhanced involvement in care to facilitate the transition from hospital to home

According to the Synergy Model, stability, complexity, vulnerability, resiliency, predictability, resource availability, participation in care and participation in decision making are the patient characteristics that describe patient function. The nurse characteristics that typically represent comprehensive nursing practice include clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry and learning facilitator. The framework therefore takes into account the unpredictability of the progressive care patient, and based on the patient and family's needs the competencies of the progressive care nurse.

Reference List

American Association of Critical-Care Nurses: Standards for Acute and Critical Care Nursing Practice. AACN. Aliso Viejo, CA. 1-7, 2000.

American College of Critical Care Medicine of the Society of Critical Care Medicine: Guidelines on admission and discharge for adult intermediate care units, 1997.

Burke, W., Eckland, M. "Keep Pace with Step-down Care" Nursing Management: 33(2): 26-29, 2002

Edwards DF. The Synergy Model: linking patient needs to nurse competencies. Crit Care Nurse, 1999;19:88-97

Pelczarski, K. Continuum of Care Monitoring: Its time has come. ECRI (Emergency Care Research Institute). 1998.

Quintero, J.R. Achieve cost benefits with innovative care management CCN: 23(2) April 2003 109-113.

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