Step Forward
Progressive care units allow nurses to provide more specialized care and help improve patient satisfaction

By Lorraine Steefel, RN, MSN, CTN
October 18, 2004

They’re neither med/surg nor ICU/CCU nurses. Like the misperceived middle children, progressive care nurses often feel like they're in a no-man's land. They bristle at the buzz--that they work in patient holding areas and provide lesser care.

So who are these progressive care nurses? What is their unique contribution to patient care?

Maggie White, RN, BSN, remembers 1982 as the year that surgeons at Methodist Dallas Medical Center requested a separate area staffed with skilled surgical nurses to monitor patients with cardiac arrhythmias. She and another nurse, Peggy Miller, “recruited nurses from wherever we could, educated them, and got the group up to speed,’’ White says. So began the hospital's surgical telemetry unit, where White is nurse manager.

‘’The way our unit developed parallels the birth of progressive care units (PCUs) and nursing in the early ‘70s across the country,’’ she says.

With critical care beds at a premium, step-down units embraced patients as they migrated outside the traditional walls of the ICU. ‘’Patients’ need for a new level of care pushed open progressive care doors,’’ says Juan (Ray) Quintero, RN, CCRN, a staff nurse in the neuroscience unit at the VCU Medical Center in Richmond, Va. ‘’Today, any new ICU is almost never considered without a PCU,’’ he says.

Today’s venue

Typically, hospital organizational charts place progressive care with medical/surgical nursing, but the care environment is different, says Karen Harvey, RN, MSN, a certification specialist with the AACN Certification Corp. in Aliso Viejo, Calif.

Progressive care units can be extremely specialized, with patient care focused on a specific system, such as cardiac, or broader based, such as in a medical intermediate care unit. ‘’A high turnover of patients and a faster pace than med/surg are the facts of life in PCUs,’’ says Kathleen Dooney, RN, MSN, director of nursing education at Winthrop-University Hospital in Minneola, N.Y.

Some potential PCU patients include those with low-probability MI, hemodynamically stable MI, dysrhythmia or pacemaker, mild to moderate heart failure, and hypertensive urgency with no evidence of end organ damage.¹ ‘’In our telemetry unit, we care for cardiac patients, some with comorbidities, who can be up and about connected to monitors,’’ Dooney says. ‘’These patients can participate in their care more than those in ICU.’’

PCU care is more high tech and includes treatments that require more intense care and monitoring than those on med/surg units. ‘’What makes the difference in our telemetry patients is their need for high-frequency monitoring for cardiac changes and interventions often the result of medications not administered on medical/surgical floors,’’ says Leslie Hampton, RN, BSN, nurse manager on the telemetry unit at the University of Washington Medical Center in Seattle.

PCU nurses perform vital signs, blood gases, and patient assessments more frequently than on med/surg floors but less often than in the ICU, a reflection of the patient's condition, says Diane Salipante, APRN, MS, CCRN, nurse practitioner, Pulmonary Critical Care (on the pulmonary critical care unit at), University of Rochester (N.Y.)-Strong Memorial Hospital.

‘’Though PCU patients are stable, they are also acutely and critically ill and at risk for rapid status change,’’ Salipante says. ‘’Patients have one foot in progressive care and one foot in critical care. There’s a revolving door for patients whose degree of need for vigilance escalates from intermittent to continuous.’’

Defining parameters

Four years ago, the American Association of Critical-Care Nurses created the Progressive Care Task Force to discuss the impact of this expanding patient care management component. ‘’We agreed to set the direction of progressive care and its vision to give progressive care nurses a sense of who they are and the required skills they use when caring for high-acuity patients outside ICUs,’’ says Quintero, an AACN task force member.

Today, the AACN recognizes progressive care as part of the continuum of critical care. According to the AACN-developed Synergy Model, a framework for practice, patient needs drive nurse competencies, and when characteristics and competencies synergize, outcomes for the patient, the nurse, and the system are optimal.² Progressive care nurses practice the same standard of nursing as critical care nurses and require the same level of education as nurses who work in the ICU, except with respect to invasive technologies.

What’s in a name?

In a recent NURSING SPECTRUM survey, 70% of nurses reported that their facilities did not use the term ‘’progressive care’’ to refer to telemetry, step-down, or intermediate care units. PCUs vary in name, management, and patient population, and their size typically ranges from two beds to 80 or more.

Although facilities like Eisenhower Medical Center in Rancho Mirage, Calif., don't identify units or nurses as progressive care, Chief Nursing Officer Louise White, RN, says, ‘’The work the nurses do fits in with AACN's description of progressive care.’’At Eisenhower, progressive care nurses work in the telemetry, vascular, and the postinterventional units. ‘’They care for patients formerly admitted to ICU, but who now go to a step-down unit to receive highly trained nursing care according to patients' needs,’’ she says.

According to the AACN, patients' care needs and required interventions define progressive care, rather than the location and name of the hospital unit in which they receive that care.³ ‘’The AACN Task Force struggled with the name 'progressive care,'’’ says Salipante, a task force member. ‘’We see the term as positive. Our patients are on the critical care continuum and [make] progress through it.’’

The bottom line

Progressive care makes financial sense. ‘’Hospitals are cost constrained,’’ Quintero says. ‘’Since costs drop by about 50% with each decrease in a level of patient care, progressive care offers a significant savings over critical care.’’ Quintero maintains that patient outcomes are improved when a patient is cared for at the most appropriate level of care. Discharging patients from the ICU to the PCU instead of to a general floor lower mortality rates because patients receive the appropriate care level for their acuity.⁴

Moving patients to PCUs offers a morale boost for patients, says Maggie White of Methodist Dallas. ‘’Patients who progress to a step-down unit see themselves as getting better, a real boon psychologically,’’ she says. ‘’Next step is discharge home.’’ And because rules for visitation are less restrictive than in ICUs, families have more opportunities to be with patients and participate in their care.

‘’Because of progressive care, patients get home quicker,’’ Dooney says. ‘’Within patients’ short stay, nurses educate them as they focus on health and wellness. Nurses connect patients with rehabilitation and home care visits that will keep them healthy and at home.’’

Progressive care also might enhance permanence among staff in telemetry units, Eisenhower Medical Center's Louise White says. ‘’Typically, mobile units are considered places to gain knowledge, stepping-stones to work in critical care,’’ she says.

Moving toward the mainstream

‘’The story of progressive care is one of inclusion into the mainstream, recognition, and acceptance,’’ says Quintero, who encourages progressive care nurses to be active spokespeople about the care they provide. ‘’Read the latest articles about progressive care and share them with your administration. Invite the local AACN chapter leaders to present at your facility. Acquire a voice at your hospital. We need to champion progressive care to help it grow,’’ Quintero says. And that will make all the difference.

New credential for progressive care

The American Association of Critical-Care Nurses in May launched the first certification exam designed for progressive care nurses. Requirements for the PCCN exam include:

Passing the 125-question, 2½-hour exam

Meeting the eligibility requirements for hours of clinical practice: 1,750 hours in direct bedside care of the acutely ill during the previous two years, with 875 of those hours accrued in the most recent year preceding application.

“Progressive care is relatively new terminology,” says Karen Harvey, RN, MSN, a certification specialist with the AACN Certification Corp. in Aliso Viejo, Calif. “The new credential helps define progressive care practice and gives recognition to the practice area, skills, and knowledge nurses need to work in the area.”

For more information on the PCCN exam, contact the AACN Certification Corp. at (800) 899-2226 or visit www.certcorp.org

Lorraine Steefel

Lorraine Steefel, RN, MSN, CTN, is a senior staff writer for Nursing Spectrum. To comment on this story, send e-mail to editorsc@nurseweek.com.

References

1. Edwards DF. The synergy model: linking patient needs to nurse competencies. Crit Care Nurse. 1999;19:88-97.

2. AACN. Progressive Care Fact Sheet. 2002. Available at https://www.aacn.org/AACN/ pubpolcy.nsf/0/d887e5cacc4d972488256d7a007bfba5?OpenDocument. Accessed August 11, 2004.

3. Berke W, Ecklund M. Keep pace with step-down care. Nurs Manage. 2002;33(2):26-29.

4. Meyer MN. Avoid PCU bottlenecks with proper admission and discharge. Nurs Manage. 2002;33:31-35.