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The distinctions between the intensive care unit (ICU) and progressive care unit (PCU) extend beyond patient acuity levels to critical aspects like nurse-to-patient ratios and billing classifications, all of which influence patient outcomes and healthcare costs.
As a nurse, it's important for you to understand these differences, which will influence how you care for patients in these settings.
Each level of care is meticulously designed so healthcare professionals like nurses can address specific patient needs and provide targeted and effective treatment, which optimizes the recovery process and improves the patient’s treatment experiences.
To start, let’s review the care levels in acute care hospitals. Acute care hospitals’ levels of care include:
- Critical care: This is considered the highest level of care, dedicated to patients who typically suffer from severe illnesses or injuries that require constant monitoring and advanced interventions.
- Intermediate care: A step below critical care, patients in this level require constant monitoring.
- Acute care: This care level is designed for stable patients needing periodic monitoring, treatments, or procedures.
- Observation: This level is intended for short-term monitoring or treatment while assessing the need for admission or discharge.
PCU vs. ICU: Defining levels of care
The intensive care unit (ICU) is classified as critical care. According to the Centers for Medicare and Medicaid Services (CMS), ICU care involves “the direct delivery of medical treatment by a physician for critically ill or injured patients.” These patients have conditions that severely impair one or more of their vital organ systems, with a high likelihood of imminent or life-threatening deterioration.
In contrast, the progressive care unit (PCU), also known as intermediate care, represents an intermediate level of care. PCUs typically care for patients who are hemodynamically unstable or at risk of becoming unstable but do not require the full scope of ICU services. These patients typically need assessment or intervention every one to two hours.
Telemetry is a technology, not a care level
A common misconception is that telemetry defines a level of care. Telemetry refers to the continuous electronic monitoring of a patient’s heart rhythm and other vital signs. It can be used across various levels of care depending on patient needs.
Telemetry services are typically included in the room-and-board charge. Many private insurance companies don’t allow cardiac monitoring to be billed separately, as the technology is seen as a fixed asset of the facility and is used multiple times by multiple patients.
Differences in billing to consider
When looking at the differences between the ICU and PCU, it’s important to note the differences in billing at each level of care. To bill for the different levels of services, called a utilization review, nurses evaluate the physician's clinical documentation to determine which level of care the patient needs. However, reviewing and documenting should be completed daily.
Only physician documentation counts in determining the level of care and billing for the inpatient stay. However, nursing and ancillary documentation, such as the use of a dietitian and various therapies, can be used. The provider needs to incorporate ancillary documentation into their own documentation to demonstrate the medical complexity of a patient.
The interesting part about having levels of care, particularly documenting the intermediate level, is it usually doesn't make that much difference in payment. Medicare, most Medicaid payers, and most private payers pay based on a diagnosis-related group methodology.
Diagnosis-related groups are categories of diagnoses and procedures in which patients demonstrate similar resource consumption and length of stay patterns, which is why hospitals benchmark length of stays.
A payment rate is then set for each diagnosis-related group, and the hospital's reimbursement for inpatient stays is based on that.
Why staffing levels matter so much
Critical care is critical care, and progressive care is progressive care regardless of facility type and ability. But what does the difference between intensive care and progressive care have to do with staffing levels?
When you think about staffing, it’s important to consider how geographic location impacts staffing at both levels of care. An ICU in a 900-bed inner-city hospital will admit very different patients and has a different capacity for critical care than an ICU in a 100-bed community hospital in a rural area.
Yet the same definition above is applied to determine the level of care. Payment-wise, your organization is not getting paid much, if anything, for that intermediate level of care because of the diagnosis-related group payment system.
If you’re looking for data that equates higher hospital payment in progressive care unit settings to higher staffing levels, you won't find the needed supporting documentation. What this means for staffing intermediate, acute, critical, or observation level of care is that there is not just one answer for you to take and run with.
In the ICU setting, it’s generally required to have a ratio of 1:2. However, in the example of the 900- vs. 100-bed hospital, that is the reason you need an acuity system in place. While the patients may be equally complex in both hospitals, the larger hospital has access to greater resources, including physician specialists, equipment, and so on, to care for critically ill or injured patients.
The role of patient acuity and nursing intensity
Nursing intensity is defined as the amount of nursing care (time and effort) required to care for a patient. It considers the various tasks, interventions, and patient needs that nurses must address during their shifts. However, nursing intensity is closely tied to patient acuity.
Patient acuity refers to the severity of a patient's condition and their need for medical and nursing care. Higher patient acuity indicates more complex and critical conditions that require intensive monitoring, specialized interventions, and a higher level of nursing expertise, which occur at both intensive and progressive care levels. As patient acuity increases, so does the nursing intensity required to provide adequate care.
A well-designed acuity system helps categorize patients based on their acuity levels and align nursing resources accordingly. This ensures that patients receive the appropriate level of care, aren’t overburdened, and hospitals can maintain high standards of patient care.
It is an absolute must to arrive at the right staffing levels to document the nursing intensity required to take care of an intermediate patient. As noted in the two different sized hospitals, this will be different in each organization. Nurse staffing needs to be determined locally within each hospital and unit based on a variety of factors.
A staffing committee for each unit should be comprised largely of bedside nurses with unit managers. Unit-level outcomes should be monitored monthly in relation to staffing levels and should be adjusted to meet patient outcome goals.
Ultimately, this drives all decisions, patient care, and staffing levels. It is imperative to know the difference in levels of care and to help ensure patients obtain the outcomes they deserve with the appropriate RN staffing regardless of level of care.
