Elective Report Regarding the
Preliminary Care Unit
1. Introduction:-
It is the common practice that, patient who comes to a hospital for medication, to be treated as in patients and out patients. Minor ailments and episodic illnesses i.e. cough are treated in the out patient department (OPD) whereas conditions which require further evaluation and intense monitoring require ward admission.
Needless it is to emphasize the inconvenience most patients have to undergo when they are admitted to a ward in current setup. They might have to stay for an indefinite period, until the hospital staff sort out the ailment, treat it and follow up. All depends on the human and material resources available which are not up to the expectations in most hospitals in the country, especially the government hospitals.
On top of it, it is an open secret that many inpatients do not in patient management. The consequence are many including over crowding of wards which inevitably lead to dump patients to the floor and more stress on staff which ultimately leads to substandard patient care.
Therefore it is imperative to reorganize the out patient services in government hospitals to filter patients who really need ward admission from those who do not.
The
Preliminary Care Unit (PCU) is focused on fulfilling the above requirement. It
is a concept of Dr. Dhanapala Rodrigo MD, a
2. Learning Objectives:-
1. To gain basic knowledge regarding PCU, its objectives, how it functions and health care services it provides to patients.
2. To assess how patients are benefited by the presence of a PCU.
3. To identify the deficiencies in the service and underlying reasons related to material, manpower and money.
4. To make recommendations to further improve the services of PCU.
3. Description of the activities undertaken:-
First of all, I took permission from the medical superintendent of the District General Hospital Gampaha, regarding the elective. Then I went through the PCU circulars and guidelines and talked with medical officers to get a basic knowledge regarding the PCU. After that, I observed the activities of the staff, available facilities and the function of the PCU. I had the opportunity to participate in a study undertaken by the authorities of the hospital regarding patient’s perception on PCU as an interviewer, where I had the opportunity to talk with patients.
4. (a) Evaluation of the event and the
extend to which personal learning objectives have been met:-
Objective
1:-
In general terms, the PCU is a casualty unit of all specialties (medicine, surgery, paediatrics, psychiatry, obstetrics and gyneacology) which functions 24 hours of the day through out the year.
Important
aspects of PCU:-
- Material:-
It should have an emergency medical procedure area, emergency surgical procedure area and an emergency treatment unit (ETU). There should be an observational area to monitor patients until they are stabilized either to admit to a ward or to an operation theatre for further management. A minor surgical procedure area, bedside investigation area and a vaccination room is necessary to manage less emergency cases.
It should also have a reception, visitor waiting area and toilets for the comfort of the patients and their bystanders.
- Staff:-
The medical staff comprises of experience medical officers designated to the PCU (MO-PCU) lead by the medical officer in charge (MOIC-PCU) and the ‘consultant nominees’ in each discipline. The nursing staff is spearheaded by the sister. The minor staff and the ancillary staff represent the non medical staff.
- Function:-
All the patients seek medical treatment should go through the PCU. The MO-PCU has the authority to admit and discharge patients from the PCU. He cannot admit a patient directly to a ward without consulting the ‘consultant nominee’ to the PCU, except in following situations;
(a) Consultant referrals i.e. from private sector.
(b) Clinic and ex-ward cases referred by the ward clinical staff.
(c) Transfer from other institutions with prior arrangements.
(d) Normal labour and delivery, after initial evaluation by the MO-PCU.
Consultants in each discipline should allocate an experience staff member i.e. senior house officer (SHO) or a registrar to admit patients in the PCU to his ward, who is known as the ‘consultant nominee’. He should go routine rounds in the PCU to admit patients who need ward admission. In spite of that, he should be available at the PCU whenever a critical patient presents to it, needing emergency ward admission. He cannot manage patients in the PCU but can help the MO-PCU on decision making regarding the patient’s management.
It is the duty of the MO-PCU to keep the unit as empty as possible. Every patient should be reviewed after treatment to determine the fitness for discharge. A patient cannot be kept for more than six hours in the PCU. It is recommended to admit the patient if a decision cannot be taken even after monitoring for six hours. Patients who are fit to be discharged should not be kept in the unit until the results of the investigations are available. If any abnormality is detected in the investigations, they should be asked to be re-admitted via a phone call.
MO-PCU doesn’t have the authority to transfer patients to other institutions directly except in special occasions where patient’s life in extreme danger. Still he should inform the relevant consultant nominee over the phone.
Services provided by the nursing staff, minor staff do not differ significantly from routine ward practices.
-Monitoring
and evaluation:-
A board constitutes of all the consultants in the hospital, the MOIC-PCU, MO-PCUs and the nursing sister in charge should evaluate and make recommendations on care delivered by the PCU, monthly. PCUs can be established in tertiary, general and base hospitals. A national steering committee should be appointed to co-ordinate, maintain and implement activities of the PCU program, in national level.
-PCU at
Adherence to above mentioned guidelines depends on the resources available and the support provide by the hospital authority for effective implementation. The national steering committee is yet to be established. As a result, short comings are ubiquitous in functioning PCUs.
The conventional OPD still functions with the PCU. All the patients who come for treatment other than for minor episodic illnesses i.e. cough are diverted to the PCU by the reception. One bystander is allowed to accompany the patient inside the PCU to minimize congestion. A doctor who receives the patient directs to one of the four rooms in the PCU for further evaluation, after initial evaluation. Meanwhile, the bystander should go to the OPD to register the patient and come back to accompany the patient.
Room 8 is allocated for females and children which has nine beds. There is a table for three doctors to clerk patients. The Drug store of the room has a refrigerator containing drugs and equipment. Facilities for investigations i.e. draw blood, surgical equipment i.e. cannulae, needles and intravenous fluid are also available. Nebulisation is also carried out.
The ETU is situated in the room 9, which continues with room 8. It has two beds for acute management with wall oxygen supply. A fully fledged emergency trolley is by the side of the defibrillator with cardiac monitoring and pulse oxymeter. Two doctors clerk patients there and whenever an emergency situation arises, they attend to the bad patients with other doctors.
Room 10 which communicates with room 9 is allocated for wound dressing. It has necessary equipment for it.
Room 12 is for men who are reviewed for sub acute ailments. There are 9 beds. A separate section inside room 12 is to clerk male patients which includes a drug trolley and a cupboard.
The mobile X ray machine is out of order. Simple investigations like Full blood count (FBC), Blood sugar, Urine full report (UFR), Electro cardiogram (ECG) are carried out. Drugs which are available in a ward are available in the PCU but Thrombolytic drugs i.e. Streptokinase are not available.
The MO-PCU has the authority to admit patients directly to any ward except Paediatric cases, after informing the SHO via telephone. This is because of inability of them to be present at the PCU as required, due to various commitments. This has lead to unnecessary admissions to wards which have lead to friction between SHOs and MO-PCUs.
Objective 2:-
The PCU treats patients ‘on demand’, to minimize unnecessary admissions to the ward. The patients who are fit to be discharged after treatment are sent home immediately.
For an example, a school boy who comes with a laceration on the leg after a fall won’t be admitted to a surgical ward. He will be discharged soon after his wound is sutured and Tetanus vaccine is given.
In a normal hospital setting, a patient who needs ward admission has to wait for a long time before he gets admitted. This delay can be fatal in patients who need urgent management. Delay management costs more and leads to poor outcome. It inevitably causes patient dissatisfaction, lack of confidence on staff and the hospital. Presence of PCU helps them immensely.
For an example, a middle aged man presented with severe chest pain with shortness of breath suggestive of a myocardial infarction, will be attended promptly and treated to stabilize his vital signs before he get admitted to a ward for proper management.
A
survey [1] was carried out at the PCU for 10 days from 1st
of October 2008 to assess patient’s point of view regarding PCU. Data was
collected using an interviewer based questionnaire from randomly selected
patients between
According to it 45.6% (n=57) patients were satisfied with the service provided. 14 of them told they get medicine pretty quickly. Two patients told they don’t need to stay in the queue. Majority of the patients thought that the staff is hard working and attentive.
Objective
3:-
According
to the study, every one patient out of four is new to PCU. Therefore, patient
information is invaluable to increase patient satisfaction on the unit. But often,
poor guidance by the reception has lead to confusion.
Registration for admission is a hassle, as the bystander or the patient himself ought to go back to the OPD. The study further says that, 10.4% (n=13) patients felt it is under staffed, particularly the nursing and minor staff. This was more prominent at nights. Many times the bystanders and doctors have to handle patients to get on to the couch and back to the wheel chair. There was only one member in the cleaning staff to clean two toilets, the floor and to remove the waste away.
Often there is overcrowding mainly due to lack of resources like beds and chairs. MO-PCUs often encounter dilemmas when admitting and reviewing patients. They are not provided with proper criteria to decide on patient’s destiny. Because of too many people to be looked after, the staff often tends to loose their temper, leading to poor doctor patient relationship. As a result, the staff members may develop negative attitudes regarding their job.
The facilities for investigations are limited as many patients have to get them done in the private sector. There is a shortage of glucose strips making it difficult to measure random blood glucose level. There is a considerable shortage of the drugs like Ranitidine. All contribute not only for overcrowding but also needless expenditure for the patient. Essential surgical equipment such as eyeless needles, suture material are sparse.
There is no facility to measure arterial blood gas and serum electrolytes, which are mandatory for an ETU. But, authorities have invested a lot of money to buy an ECG recorder even though, 3 functional ECG machines are available. As clean gloves are unavailable, doctors are compelled to use sterile gloves to adhere with universal precautions.
The beds are not covered by curtains making it difficult to maintain the privacy, of the female patients in particular. The cover sheets and pillow cases are not changed routinely, which looks dirty.
Objective
4:-
By looking at the deficiencies of the services, it is evident that the hospital administration has a major part to play in rectifying them. The meeting regarding the PCU with the participation of the hospital authorities should be held routinely. Effective methods should be devised to get patient and staff feedback regarding the PCU. Frequent clinical auditing is required to monitor the implementation of the decisions taken.
The reception should be upgraded to register all patients who come to the hospital. It will enhance the service of the reception as they are entitled to a responsible purpose. The authority should analyze which time of the day they receive the highest number of patients. The duty rosters should be modified to mobilize more staff on that critical time period to
minimize congestion. Because there is a genuine shortage of the nursing staff, the authorities should try to recruit more.
A consultant, who is competent in emergency medicine, should lead the medical team to minimize dilemmas and upgrade the confidence of MO-PCU in decision making regarding the patient. They will not be found fault of referring ‘trivial’ cases to SHOs which make them angry and undue friction.
Money donated by the donors to the hospital development committee can be used to buy more linen, curtains, fans and chairs to increase patient’s confidentiality and comfort. Medical equipment like blood pressure apparatus ect can be purchased as well.
When prioritizing the needs of the hospital, the authority should not undermine the PCU because it plays a pivotal role. There should be a continuous and adequate supply of drugs, staff and other equipment i.e. needles, gauze, plasters, gloves ect to the unit.
Members of the nursing staff should be allocated different tasks to sustain smooth function of the unit. For example, a nurse should be held responsible for the function of the defibrillator or continuous supply of stationary. They should be advised to see whether the equipment is in working condition, in the beginning of their shift. If not, they should inform the relevant authorities to sort it out. Because this mechanism is not in place, the X ray machine is still out of order.
Routine workshops, clinical meetings should be held to impart latest knowledge. Their ability in effective communication in difficult times should be addressed. Those steps will help the PCU to provide a better out patient service without much effort and cost.
4 (b) Limitations in achieving
objectives:-
As the PCU was often crowded, it was not easy to find a time to communicate with doctors. The study was used to get the patient’s feed back regarding the unit.
5. References
[1] Unpublished data.
End
