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PROGRESSIVE PATIENT CARE
223 PROGRESSIVE PATIENT CARE
THE concept of Progressive Patient Care-doubtless soon to be known as P.p.c.-seems to be advancing in the United States like a prairie fire. In operation in at least one hospital, it already has its own research unit in the U.S. Public Health Service2 and a four-page
bibliography. It seems to have started as an extension of the recovery-unit idea, now almost universal in America: after immediate recovery from their operation those patients who still needed close attention were placed in
Progressive Patient Care based on the experience of the Manchester Memorial Hospital7 are that it helps to solve the problem of scarcity of trained staff, and that it improves the service to patients without increasing its cost. Neither of these two claims is yet proved. In the first place, it is not certain that the total number of nurses, doctors, and other professional staff needed is less for the same number of patients and for the same standards of care. Clearly, the American system of single-bed or small wards makes admission of surgical, medical, pxdiatric, and psychiatric cases to the same unit easier than it would be in the larger open wards to
Intensive Care Unit, and the same unit took other patients who were critically ill but had not necessarily been operated on. On this plan the remaining patients.in which-almost alone in the Western world-we still the hospital were divided between an Intermediate Care cling: but the Americans already recognise the difficulty of foreseeing the demands on the Intensive Care Unit for were those who and a Self Care Unit, largely bedfast, Unit for those who were ambulant and, apart from and thus making full but not excessive use of the staff, investigations and therapy, could mostly look after and the cloven hoof of heresy may be seen in the sugthemselves. gestion of providing " a number of beds on the unit for Some of what has been written in this context about patients who are less critically ill than those in the care room What is called in the jargon "organising the services and staff around the medical intensive " patient satisfaction is said to be improved, but " the and nursing needs of the patient " has been a primary patients at hospital objective since least the days of Miss Nightin- never really move around ", and a doctor is quoted as knowing where his patients will be when he gale (though she set her face firmly against dayrooms arrives-which conjures up a somewhat alarming prospect and convalescent wards within civilian hospitals, largely for and patient. But basically, this seems doctor, nurse, because she insisted that " no patient should be kept in to a nursing problem, and the decision will turn on be hospital a day longer than is absolutely essential " 3; but the essence of the new concept is that hospitals should whether division into levels or areas of intensive, intermediate, and minimal care, or our present system of be divided into areas where facilities and staff are prounits in which all three levels of need may be portional to the quantity and quality of the patients’ need, hospital in found adjoining beds, is the best for the nursing of irrespective of diagnosis. It is essentially an internal the patient. reorganisation of the hospital’s accommodation and based on the of the rather than illness services, Certainly, the rigid classification of beds and units by severity its type. For example, cases which might go to the specialty is already being relaxed, to the increased Intensive Care Unit would include multiple injuries or efficiency of the hospital, if also to the confusion of its burns, internal hxmorrhages, some pneumonias and statistics; and one lesson may be that, since a hospital is coronaries, and some acute psychiatric disorders, as well said to be out of date by the time it is opened, the utmost as cases following major operations. The Intermediate flexibility in planning and construction should be a Care Unit-which will have the greatest proportion of cardinal principle. It has long been apparent that the patients-will cater for the moderately ill, such as provision of all the facilities of an acute hospital for all hospital must be wasteful, patients admitted for palliative treatment and those with the patients who go to that the less acute medical and surgical conditions. The Self Care and that some zoning by " need " should be economical Unit will include those who need some form of investiga- (not only in money) provided the patient does not suffer. The greater interest now being shown in hostel-type tion or treatment which they cannot get as outpatients, and also convalescents.4 The complete picture is filled in beds is evidence of this concern. by adding Long Term Units for the chronic sick, and Though much work has already been done in the Home Care Programmes run from the hospital; but these States on model plans and schedules of accommodation raise wider issues. and equipment, it would clearly be unjustifiable to These arrangements recall the proposals of Professor spend public money here in building a new hospital based on a on lines which would allow it to be used only on a McKeown,5 survey of Birmingham inpatients. those who McKeown, however, divided the patients into plan not yet shown to be effective. Yet we must hope full needed hospital facilities (54%), limited hospital that funds may be found for trials of this new facilities (9%), limited hospital with mental concept of hospital organisation, which may prove supervision (31%) and no hospital facilities (6%); and practicable in a hospital designed on more orthodox his plea was more for integration of the chronic and lines. mentally sick into a " balanced hospital community " than for a new classification of the acute sick. In an
facilities
principle such integration is already being widely accepted, though its achievement will inevitably take time. The main claims made for the American type of 1. Manchester Memorial Hospital, Manchester, Connecticut. 2. Haldeman, J. C. Elements of Progressive Patient Care. U.S. Dept. of Health, Education and Welfare: Public Health Service. February, 1959 3. Nightingale, F. Notes on Hospitals; p. 114. London, 1863. 4. Haldeman, J. C., Abdellah, F. G. Hospitals, 1959, May 16 and June 1. 5. McKeown, T. Lancet, 1958, i, 701; see also Garratt, F. N., Lowe, C. R., McKeown, T. ibid. p. 682. 6. McKeown, T. The Hospital, July, 1959, p. 58.
Sir ROBERT YourlG, consulting physician to the Middlesex Hospital and the Brompton Hospital, died in London on Aug. 22 at the age of 87. We also have to announce the death on Aug. 22 of Sir FRANCIS TEALE, lecturer in bacteriology and in immunotherapy at University College Hospital Medical School. Dr. RICHARD TRAIL has been elected of Apothecaries of London. 7.
Report p. 73.
on
Progressive Care—it works.
master
Modern
of the
Society
Hospital, May, 1958,
THE concept of Progressive Patient Care-doubtless soon to be known as P.p.c.-seems to be advancing in the United States like a prairie fire. In operation in at least one hospital, it already has its own research unit in the U.S. Public Health Service2 and a four-page
bibliography. It seems to have started as an extension of the recovery-unit idea, now almost universal in America: after immediate recovery from their operation those patients who still needed close attention were placed in
Progressive Patient Care based on the experience of the Manchester Memorial Hospital7 are that it helps to solve the problem of scarcity of trained staff, and that it improves the service to patients without increasing its cost. Neither of these two claims is yet proved. In the first place, it is not certain that the total number of nurses, doctors, and other professional staff needed is less for the same number of patients and for the same standards of care. Clearly, the American system of single-bed or small wards makes admission of surgical, medical, pxdiatric, and psychiatric cases to the same unit easier than it would be in the larger open wards to
Intensive Care Unit, and the same unit took other patients who were critically ill but had not necessarily been operated on. On this plan the remaining patients.in which-almost alone in the Western world-we still the hospital were divided between an Intermediate Care cling: but the Americans already recognise the difficulty of foreseeing the demands on the Intensive Care Unit for were those who and a Self Care Unit, largely bedfast, Unit for those who were ambulant and, apart from and thus making full but not excessive use of the staff, investigations and therapy, could mostly look after and the cloven hoof of heresy may be seen in the sugthemselves. gestion of providing " a number of beds on the unit for Some of what has been written in this context about patients who are less critically ill than those in the care room What is called in the jargon "organising the services and staff around the medical intensive " patient satisfaction is said to be improved, but " the and nursing needs of the patient " has been a primary patients at hospital objective since least the days of Miss Nightin- never really move around ", and a doctor is quoted as knowing where his patients will be when he gale (though she set her face firmly against dayrooms arrives-which conjures up a somewhat alarming prospect and convalescent wards within civilian hospitals, largely for and patient. But basically, this seems doctor, nurse, because she insisted that " no patient should be kept in to a nursing problem, and the decision will turn on be hospital a day longer than is absolutely essential " 3; but the essence of the new concept is that hospitals should whether division into levels or areas of intensive, intermediate, and minimal care, or our present system of be divided into areas where facilities and staff are prounits in which all three levels of need may be portional to the quantity and quality of the patients’ need, hospital in found adjoining beds, is the best for the nursing of irrespective of diagnosis. It is essentially an internal the patient. reorganisation of the hospital’s accommodation and based on the of the rather than illness services, Certainly, the rigid classification of beds and units by severity its type. For example, cases which might go to the specialty is already being relaxed, to the increased Intensive Care Unit would include multiple injuries or efficiency of the hospital, if also to the confusion of its burns, internal hxmorrhages, some pneumonias and statistics; and one lesson may be that, since a hospital is coronaries, and some acute psychiatric disorders, as well said to be out of date by the time it is opened, the utmost as cases following major operations. The Intermediate flexibility in planning and construction should be a Care Unit-which will have the greatest proportion of cardinal principle. It has long been apparent that the patients-will cater for the moderately ill, such as provision of all the facilities of an acute hospital for all hospital must be wasteful, patients admitted for palliative treatment and those with the patients who go to that the less acute medical and surgical conditions. The Self Care and that some zoning by " need " should be economical Unit will include those who need some form of investiga- (not only in money) provided the patient does not suffer. The greater interest now being shown in hostel-type tion or treatment which they cannot get as outpatients, and also convalescents.4 The complete picture is filled in beds is evidence of this concern. by adding Long Term Units for the chronic sick, and Though much work has already been done in the Home Care Programmes run from the hospital; but these States on model plans and schedules of accommodation raise wider issues. and equipment, it would clearly be unjustifiable to These arrangements recall the proposals of Professor spend public money here in building a new hospital based on a on lines which would allow it to be used only on a McKeown,5 survey of Birmingham inpatients. those who McKeown, however, divided the patients into plan not yet shown to be effective. Yet we must hope full needed hospital facilities (54%), limited hospital that funds may be found for trials of this new facilities (9%), limited hospital with mental concept of hospital organisation, which may prove supervision (31%) and no hospital facilities (6%); and practicable in a hospital designed on more orthodox his plea was more for integration of the chronic and lines. mentally sick into a " balanced hospital community " than for a new classification of the acute sick. In an
facilities
principle such integration is already being widely accepted, though its achievement will inevitably take time. The main claims made for the American type of 1. Manchester Memorial Hospital, Manchester, Connecticut. 2. Haldeman, J. C. Elements of Progressive Patient Care. U.S. Dept. of Health, Education and Welfare: Public Health Service. February, 1959 3. Nightingale, F. Notes on Hospitals; p. 114. London, 1863. 4. Haldeman, J. C., Abdellah, F. G. Hospitals, 1959, May 16 and June 1. 5. McKeown, T. Lancet, 1958, i, 701; see also Garratt, F. N., Lowe, C. R., McKeown, T. ibid. p. 682. 6. McKeown, T. The Hospital, July, 1959, p. 58.
Sir ROBERT YourlG, consulting physician to the Middlesex Hospital and the Brompton Hospital, died in London on Aug. 22 at the age of 87. We also have to announce the death on Aug. 22 of Sir FRANCIS TEALE, lecturer in bacteriology and in immunotherapy at University College Hospital Medical School. Dr. RICHARD TRAIL has been elected of Apothecaries of London. 7.
Report p. 73.
on
Progressive Care—it works.
master
Modern
of the
Society
Hospital, May, 1958,