Proposition for the Implementation of

a Progressive Care Unit

at WRNMMC

Cadet Aquino, Cadet Dayton, Cadet Kennedy, Cadet Zou

Outline
• Observation of the hospital
• Defining a Progressive Care Unit (PCU)
• Disadvantages without PCU
• Advantages to having PCU
• Proposed course of action
• Works cited
Observation of the Hospital
• Walter Reed doesn’t have a designated progressive care
unit

• Most civilian hospitals and other Army hospitals have

stepdown units (i.e. BAMC in San Antonio)

• Some dysfunction in flow of care

Defining a Progressive Care Unit
An intermediate level of care...

Intensive Care Unit: Progressive Care Unit: Medical Surgical Unit:

• high acuity patients • lower acuity than • lowest acuity patients
• can be ventilated, ICU, higher than • cannot be ventilated
comatose, unstable regular floor
• nurse-patient ratio
• nurse-patient ratio • can be ventilated but 1:5 or 1:6
1:1 or 1:2 stable, telemetry
• requires less frequent
• require continuous • nurse-patient ratio 1:3 monitoring and
monitoring or 1:4 focuses on discharge
• requires more
frequent monitoring
than floor
Disadvantages
• “It is well recognized that, although numbers of ICU beds
are limited, many patients are admitted to the ICU who do
not really need full ‘intensive care’” (Vincent and Rubenfieid 2015)
• Prolonged ICU stay (Needham, 2014)
•Psychological reactions
•Functional deterioration
•hospital acquired infections
• Prolonged ICU cost (McLaughlin, 2005)
•Daily cost - ventilated $10,794
•Daily cost - non-ventilated $6,667
Disadvantages cont.

• Patients are sent to the floor prematurely

&
• Med-surg floor nurses overloaded with patients who require
higher level care

• Potentially decrease patient safety and staff satisfaction

Disadvantages cont.

• Increased readmission to the ICU

• 3,169 patients admitted to ICU
• 2,852 transferred to the floor
• Readmission rate was 13.4% (Kaben et al., 2008)
•once - 82.4%
•twice - 10.2%
•more than twice - 7.3%

• Correlation with increased morbidity and mortality of

patients (Vincent and Rubenfield, 2015)
Advantages
• Reduce the amount of time a patient spends in the ICU and
reduce the cost of maintaining an individual in the ICU

• ICU average cost $8,730

• PCU average cost $2,625

• May improve critical care cost effectiveness $6,105
Advantages cont.

• 33% of PCU admissions from ED and wards were “step up”

patients (Prin and Wunsch, 2014)

• 80% of PCU admissions from ED and wards were “step up”

(Prin and Wunsch, 2014)

• Reducing the work overload on floor nurses

• May improve patient flow without compromising quality
of care
• Decrease in med-surg floor mortalities with the
establishment of a PCU
Proposed Course of Action
• Integration of a PCU into an existing ICU
• Use of Ebola unit in the MICU as additional rooms for the PCU.
• “Flexible” beds
• Preferred ICU staffing
• train willing Med Surg nurses to float when needed
• Different experience for nurses in the ICU to experience
• Patients are in extremely close proximity to ICU care if a
complication was to arise
• Equipment that is expensive can be shared between the units
• Increased nurse to patient ratio
• Sick patients can receive needed 1:1 or 1:2 care
Proposed Course of Action Cont.
• Easier to transfer patients from ICU to PCU due to close proximity
• Nurses in the PCU have the ICU nurses to fall back on in case if
questions arise about equipment and care. This fosters a team effort.
• Staffing: ( Lewis and Latney 2016)
• 1:3 or 1:4
• Average hours per patient day: 8.75 to 9.5
• Monitor HPPD and cost of each patient per day to ensure staffing is
adequate and that the budget is respected.
• Minimum staffing needs dependent on patient census
• ICU staff to staff the PCU
Proposed Course of Action Cont.
• Utilize skills of LPNs, Tech, Corpsman, and other medical personnel on
the floor
• Ensure all staff are aware of their scope of practice and are provided
opportunities to be educated on skills staff feel they are lacking on.
Work Cited
Dirksen, C., Merode, G., Nieman, F., Poeze, M., Ramsay, G., & Solberg, B. (2008). Changes in hospital
costs after introducing an intermediate care unit; a comparative observational study. BioMed Central.
https://www.ncbi.nlm.gov/pmc/articles/PMC2481456/
Prin, M., & Wunsch, H. (2014). The role of stepdown beds in hospital care. American Journal of
Respiratory and Critical Care Medicine, 190(11), 1210–1216. http://doi.org/10.1164/rccm.201406-
1117PP
Rappleye, E. (2015). Average cost per inpatient day across 50 states. ASC COMMUNICATIONS.
http://www.beckershospitalreview.com/finance/average-cost-per-inpatient-day-across-50-states.html
Rubenfeld, G., & Vincent, J. (2015). Does intermediate care improve patient outcomes or reduce costs?
BioMed Central. https://ccforum.biomedcentral.com/articles/10.1186/s13054-015-0813-0
Stacy, K. (2011). Progressive care units: different but the same. Critical Care Nurse, vol 31, no. 3.
http://ccn.aacnjournals.org/
Needham, D. (2014). Longer stay in hospital ICU has lasting impact on quality of life. John Hopkins
Medicine.
http://www.hopkinsmedicine.org/news/media/releases/longer_stay_in_hospital_icu_has_lasting_impact
_on_quality_of_life
Dasta, J, F., McLaughlin, T, P., Mody, S, H. & Piech, C, T. (2005). Daily cost of an intensive care unit day:
the contribution of mechanical ventilation. U.S. National Library of Medicine, 33(6):1266-71.
https://www.ncbi.nlm.nih.gov/pubmed/15942342