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Mary Carol-Ambrose, RN, BSN, didn’t work
much with elderly patients during her 20-year
stint in the Army Nurse Corps. But it was still
a surprise when the open-heart critical care nurse,
now at Sutter Medical Center of Santa Rosa, Calif.,
learned that a surgeon there performed a bypass
on a 102-year-old patient.
“Ten years ago, I don’t think any
80-year-old would have had open-heart surgery,”
Carol-Ambrose said.
Medina said critical care nurses are caring for
more elderly patients with multiple ailments who
require more monitoring and complex treatments,
resulting in a demand for more acuity skills in
the critical care nursing ranks.
“We have a greater percentage of patients
who are at the most frail ages of their lives,
with the most complex illnesses,” she said.
Although medical improvements increase the median
age of critical care patients, managed care is
putting pressure on the ICU by changing the acuity
threshold of hospitalization.
“If somebody was having some sort of abdominal
pains in the past, they would do all the tests
in the hospital,” said veteran ICU nurse
Bobbie Wiles, RN, BSN, CCRN, of Mesa, Ariz. “Now
they are sent to [the] outpatient [unit].”
Managed care companies keep the lid on costly
hospital stays, but the patients who are admitted
are placing a greater burden on critical care
departments and nurses. Hospitals have to adjust
staffing and organization to handle more gravely
ill and injured patients, and the expertise of
nurses must increase accordingly. In 2001, the
AACN convened a task force that looked at ways
of delineating some critical care functions into
more specialized, intermediate care proficiency
— what the AACN has dubbed progressive care.
Progressive care
The crunch on ICUs has forced hospitals to consider
creating services for various step-down or telemetry
units, where patients recover for eventual transfer
to a standard care room. Frequently, hospitals
have had no choice but to keep stabilized ICU
patients in the unit, such as cardiac patients
being weaned from ventilators or whose anti-arrhythmic
drug infusions had to be closely monitored.
For reasons of cost and patient safety goals,
hospitals have started to introduce these progressive
care programs.
“Progressive care is the fastest-growing
area of alternative care management,” said
Ray Quintero, RN, MSN, CCRN, nurse manager of
the progressive care unit at Virginia Commonwealth
University Health System. Patients who were admitted
to critical care units five years ago are now
“routinely” admitted to progressive
care units, according to the AACN.
Quintero cites studies where hospitals see the
potential cost savings of 50% by treating progressive
care patients outside the ICU. In addition, the
1-to-1 or 1-to-2 nurse-patient ratios followed
by hospitals in critical care areas can be expanded
to 1-to-4 with progressive units.
For hospitals that created more step-down units,
the need for more ICU-level nurses in those areas
became acute. “I don’t want to say
there was anything lacking [in patient care],”
said Deborah Barnes, RN, MSN, CCRN, AACN’s
clinical practice specialist and a member of the
2001 progressive care task force. “But it
had never been brought together in a general umbrella
to really identify what those [progressive care]
nurses needed” in education and support.
Nurses working in progressive care conduct less
invasive monitoring of patients who are at less
risk of a life-threatening event, Barnes said,
but still need the vigilance and the skill should
trouble occur. “They certainly needed more
education above the med/surg level,” Barnes
said.
The AACN this month will hold the first exam
for progressive care certification, based on the
task force recommendation of core competency requirements.
About 450 to 500 nurses signed up to test for
the new certification.
Family issues
Of the several criteria for progressive care
certification, a major distinction with ICU credentialing
is being able to enhance patient involvement in
the hospital-to-home care transition. Patients
in the progressive care status are sometimes able
to start participating in their own care, and
must be taught how to properly sustain their treatment
and recovery outside the hospital.
Family involvement is also a major component
of progressive care and a growing factor in standard
ICU care.
An April 2000 study published in The American
Journal of Nursing noted that 97% of family members
studied believed they had a right to be present
in the ICU, even during the dire circumstances
of a code. A majority of parents surveyed in 1999
wanted to be present during invasive procedures
performed on their children, according to the
Annals of Emergency Medicine. Organizations such
as the Emergency Nurses Association and the American
Heart Association support facilities providing
the family presence option during resuscitation.
“I think we’ve all educated ourselves
with shows like ER 85 and there are more and more
people who say they want to be there when you
do the resuscitation,” Medina said. “I
think our structures and our processes haven’t
allowed us to be as nimble with what we’re
being [asked] to do.”
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