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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.”