POSTGRAD. MED. J. (1963), 39, 401

PROGRESSIVE PATIENT CARE IN THEGERIATRIC UNIT

R. E. IRVINE, M.D., M.R.C.P.Physician, Hastings Geriatric UnitFrom St. Helen's Hospital, Hastings

IT is not many years since the old-fashionedchronic wards of a hospital' were thought to havean entirely custodial function. They existed toprovide care and attention for elderly patientswhen nothing further could usefully be done.With a rapidly ageing population this custodial

approach proved inadequate, and since it was notpossible to provide and staff an ever increasingnumber of chronic sick beds a new approachbecame necessary.

This was provided by the pioneers of geriatrics,Marjory Warren, Brooke, Olbrich and others whodemonstrated that given proper treatment in aproper setting old people were capable of re-habilitation. They found that the majority oftheir patients could return to the community andthus escape the human scrap heap of the old-fashioned chronic sick ward. These pioneers andtheir successors have in a few years transformedgeriatrics from the cinderella of the hospital serviceinto a most active and exciting branch of medicinewhich has seen the development of many new ideasconcerning the function of the hospital and themanagement of patients. One of these new ideasis progressive patient care.

The Concept of Progressive Patient CareThe idea behind progressive patient care is the

classification of patients according to their medicaland nursing needs. It is also a recognition of thefact that these needs change during the course of apatient's stay in hospital. In one sense the ideagoes back as far as Florence Nightingale, whosepractice it was to nurse the most ill patients nearthe entrance to the ward close to the sister's office,and to move the convalescent or least ill patientsto the further end of the ward.

In geriatrics the idea really began 20 years agowhen Marjory Warren (I943) made a plea thatno patient should be admitted to a chronic sickward without prior investigation in a generalhospital. Following this the British MedicalAssociation (1947) recommended the establish-ment of geriatric units in general hospitals. Thesewere to be wards under consultant physicians

where elderly patients could receive investigation,treatment, and rehabilitation, so that in due coursethey might return to the community. If theyfailed to respond to treatment they could be trans-ferred later to long-stay nursing annexes. Thuswas born the idea of a patient moving from onetype of ward to another at the appropriate point inhis illness. Later the pattern was enlarged toinclude the conception of a recovery home orhalf-way house to provide a more domestic en-vironment away from the hospital where thepatient could prepare for return to the community(Adams, 1954; King Edward's Fund, I954).The idea was developed further by Cosin (1956,I957) who described a scheme in which thepatient was admitted to an initial treatment ward,was later transferred to a rehabilitation ward,or to an 'independent unit' for a period of self-care if this was necessary to prepare him fordischarge. A particular feature of this schemewas the conception of several long-stay annexesfor different grades of patient, and the economicdeployment of nursing staff was emphasized.More recently Exton-Smith (I962) has describedone of the most fully developed schemes of pro-gressive patient care so far reported from ageriatric unit. His scheme has gone further thanany other in identifying and classifying patientsvarying needs for nursing care. Porter (1962)stressed the economic advantage of progressivepatient care and claims that under this system itwould be possible to build a unit of 240 beds forthe same cost as I80 beds in conventional wards.

Meanwhile, in the United States, where, in-cidentally, the name originated, the idea of pro-gressive patient care was evolving along a differentroute. Soon after the war some Americanhospitals introduced recovery rooms where post-operative patients could be grouped together underconcentrated nursing surveillance until they re-gained consciousness (Leon, 1952). An extensionof this idea led to the establishment of intensivecare units to include acutely ill as well as post-operative patients (Haldeman and Abdellah,1959). In American military hospitals there has

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POSTGRADUATE MEDICAL JOURNAL

been a long tradition of grouping critically illpatients and those capable of self-care in separateunits (Claussen, 1955).

There has also been an economic motive. Whenevery patient in a hospital is provided with allthe facilities for the treatment of acute illnesswhether he needs them or not, the costs of hospitalcare go up with every advance in treatment, andthe whole process is wasteful of equipment andexpensively trained nurses. Accordingly in 1956the question of how to give the patient better valuefor money in hospital was taken up by the UnitedStates government (Golin, 1958). The resultsof six years research have recently been publishedin America and progressive patient care is nowaptly described as 'the tailoring of hospital servicesto meet the patients' needs' and 'the right patientin the right bed with the right services at the righttime' (U.S. Dept. of Health, I962).The American classification of medical and

nursing needs in progressive patient care assignsthem into four groups as follows:

Intensive care. This is needed for acute and severeillness with disturbances of consciousness, respiratoryfailure, severe metabolic upsets, major haemorrhage,etc. For these patients the deployment of all the mostelaborate life-saving equipment, including respiratorsand suction, is a necessity. Specially trained nursesare needed and the ratio of nurses to patients needs tobe very high. A patient suitable for intensive careprobably corresponds to the kind of patient who wouldbe 'specialled' in this country.

Intermediate care. This is required for the majorityof patients ill enough to be taken into hospital fortreatment. It corresponds to the ordinary nursingcare given to the 'average' hospital patient in thiscountry. Many patients in terminal illness are alsoconsidered suitable for this grade of care.

Self-care. This is appropriate to the patient who isfully ambulant. Such patients may either be conva-lescent or undergoing investigation and treatment.Some patients receiving radiotherapy are suitable forthis type of care.

Long-term care. This is needed for those whosestay in hospital is likely to be prolonged, either becauseof a need for extensive rehabilitation, or becauserehabilitation is only possible to a very limited degree.

Changing NeedsAny survey of patients in a geriatric unit reveals

a number of groups each requiring different typesof care, not only from the point of view of theirown needs, but also from the point of view of thedeployment of nurses. Indeed one can hardly dobetter than to apply the American categoriesdirectly to geriatric patients. Only a very littlemodification is needed.

First there are the new patients. Most of theseare acutely ill, and require the same kind of treat-ment as is given in any hospital to the acutely illpatient, the only difference being that they arelikely to be out of bed sooner. Many will require

intensive care because ill old people are oftenunable to make their needs known, and many areconfused or have other severe disturbances ofconsciousness. The nurse has therefore to observethem carefully and to be prepared to think forthem. Moreover at the beginning of a typicalgeriatric emergency such as a severe stroke theremay well be a need for oxygen, suction, intravenousfluids, catheterization, gastric intubation, and theuse of electrical equipment such as the Ripplemattress. Other new patients will not be acutelyill, but will have been admitted for investigationand assessment, usually on account of some severedefect of locomotion. All such new patients willneed to be in a ward where there is a high ratio ofnurses to patients.

After a period devoted to assessment and thetreatment of acute illness the patient's needchanges. He is then likely to need intensiverehabilitation to get him on his feet again, or elsehe may need prolonged continued nursing carefor what may prove to be a terminal illness. Forthis he needs treatment of an intermediate type ina continuation ward, where a slightly lower ratioof staff to patients will be appropriate.

If the patient's rehabilitation is started promptlyhe will probably find his feet again within a week ortwo, though with some patients it may takemonths before this stage is reached. Once it isreached however, the patient will be better caredfor in a ward organized around the needs of theambulant patient. Many such patients will stillneed a good deal of help with dressing and toilet,and a lot of sympathetic encouragement, but a few,usually those with no mental impairment, will beready for a period of full self-care to prepare themfor discharge. The ambulant ward and the self-care unit fulfil one of the functions of the con-valescent home used by younger patients, andcan be correspondingly staffed.A few patients will never graduate to the

ambulant ward, and because of a severe residualhandicap, physical or mental, but usually both, willrequire continued care, probably for the rest oftheir lives, in a long-stay nursing annexe. Ideallystaff ratios here should be about the same as in theintermediate ward, but in practice are likely tobe less.

Identification of Needs.In theory it would perhaps be desirable to have

wards specifically devoted to patients requiringeach grade of care. In practice this cannot befully achieved in a geriatric unit, because it isnecessary to use a fixed number of beds in differenttypes of wards to cope with a changing populationof patients, and patients' needs even within a singleward may change from day to day.

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July 1963 IRVINE: Progressive Patient Care in the Geriatric Unit 403

Norton, Mclaren, and Exton-Smith (I962) gotover this difficulty by suggesting that patientsrequiring different grades of care could be identi-fied by a colour code attached to their beds. Theysuggested three grades, full nursing, coloured red,partial nursing, coloured yellow, and rehabilitation,coloured blue. In the Hastings Geriatric Unitwe have found this colour coding extremelyvaluable, but we have preferred to group thepatients into four groups according to their needfor care as follows:

Intensive Nursing Care (Colour Blue)Patient to be fed and washed, and confined to bed.Patient to be turned two-hourly day and night.Patient to use bed-pan unless otherwise ordered.Temperature, pulse, respiration (T.P.R.) and blood

pressure to be charted as ordered.

Normal Nursing Care (Colour Yellow)Patient to feed himself, and wash own hands and face.Patient to use commode unless otherwise ordered.Patient to sit out of bed as orderd by the doctor.T.P.R. to be charted twice daily unless otherwise

requested.Convalescent Nursing Care (Colour Green)

Patient to be encouraged to help himself.Patient to walk to toilet with assistance if necessary.Patient should be up for at least one meal a day, and

should be dressed for part of the day if possible.Evening T.P.R. only, unless otherwise ordered.

Self-Care (Colour Orange)No nursing attention given normally.T.P.R. not taken unless requested.

Dangerously IIIAn additional red label is attached to the bed ends of

those who are considered dangerously ill.

Progressive Patient Care in a Geriatric UnitThe Hastings Geriatric Unit serves a population

of 130,000 of whom 24%, about twice the nationalaverage, are of pensionable age. A special featureof the area, which is a popular one for retirement,is the large number of old peoples' homes andnursing homes. There are at least I,ooo beds inprivate and charitable homes in addition to goodwelfare accommodation provided by the localauthorities.

The Geriatric Unit has 238 beds, 138 in the maingeneral hospital of the area, St. Helen's Hospital, ando00 away from the main hospital in three long-stay

annexes. Before progressive patient care was intro-duced the number of patients treated per year neverexceeded 600, but after it was introduced in 1959 theadmissions more than doubled and in the years I960,1961 and 1962 have been between I,350 to 1,400annually. The annual turnover is 5.9 per bed. Themortality is 35%/0 The average age of new patientsis 80. As in every geriatric unit there is a preponderanceof female beds in a proportion of five females to threemale. The distribution of beds and the allocation of

TABLE I

BED AND NURSE ALLOCATION FOR PROGRESSIVEPATIENT CARE

M. F. 2

Admission unit .. 32 23 55 23 40 1/1.4Intermediate unit.. 10 36 46 19 29 I i.6Ambulant unit .. 5 22 37 i6 I6 1/2.3Total in main hos-

pital . .. 57 8 136 58 85 i/i.6Long-stay annexes 32 68 Ioo 42 50 1/2.0Total . .. 89 149 238 10o 135

staff at each stage of progressive patient care is givenin Table i.The figures include all grades of nurses between

ward sister and nursing auxiliary. They excludedomestic assistants.The figures include night nurses, but do not make

allowances for holidays and sickness. To maintain fullstaffing the total number required would need to beincreased by 15%.

Types of PatientThe types of patient are probably typical of

those accepted by any active geriatric unit.About 70% are medical emergencies, mostly

patients with heart disease, respiratory infections,urinary infections, or strokes. As there is usuallyno waiting list these patients are admitted im-mediately upon request to the geriatric housephysician. Hastings has an emergency bedbureau and the Geriatric Unit takes a third of themedical emergencies referred by it.

Just under Io% are patients who are notacutely ill, but have medical and social problemsthat can only be dealt with in hospital. Suchpatients have often been seen before admission on adomiciliary visit. A few are taken in fromoutpatients.

Transfers from other hospital departments,mainly orthopaedic, urological, and radiotherapymake up the next biggest group and comprisesome 8% of admissions.

Another 7% are patients who come in as'social admissions', either in an emergency be-cause the person on whom they depended at homehas become suddenly ill and there is no availablesubstitute, or else for a planned period of holidayrelief.About 5% are patients with malignant disease

deliberately admitted for terminal care.At least a third of all admissions, in whichever

category they come, are confused for part of theirillness. Four-fifths are patients coming to theGeriatric Unit for the first time. The remainderare old patients being re-admitted.

Ci

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404 POSTGRADUATE MEDICAL JOURNAL July 1963

The Initial-Treatment WardsAll patients are admitted to the initial-treatment

wards for assessment, which must be social aswell as medical, and for treatment of their acuteillness.

This arrangement enables a high concentrationof medical and nursing attention, one nurse toI.4 patients, to be deployed where it is mostneeded. Because all new patients come to thesewards the medical staff are inevitably in and outof them all day, the consultant and registrar areable to do two full rounds a week, and the Almonerpays frequent visits. These wards are centrallyplaced in the main hospital with easy access tothe X-ray department, the Almoner's office, themedical staff office and the physiotherapy depart-ment. Every new patient has a number of routineinvestigations including haemoglobin and bloodurea estimations, a chest X-ray, and an ECG, andthe ward staff become expert at ensuring thatthese important investigations are promptlycarried out.Each admission ward has a very high turnover,

the highest in fact in the whole hospital, and theamount of paper work is therefore considerable.To cope with this a nursing auxiliary over andabove the normal establishment has been appointedto each ward to deal exclusively with the clericalwork.

These 'ward clerks' have proved themselves invalu-able. They do all the documentation of new patients,and they prepare the routine pathological and X-rayrequest forms. They answer the telephone, and areresponsible for seeing that the patients' old notes areobtained promptly from the records department. Theybook the property of new patients and of patients beingtransferred to other wards, and they send out letters toinform relatives that patients are being moved. Theyissue dangerously ill notices, and do the necessary docu-mentation in case of death. They keep the case notesin order and file reports as they come in. They alsoobtain from the laboratory and X-ray departmentadvance information over the telephone. These ser-vices cut out many delays, and lead to earlier dischargefor some patients, and thus to a more efficient use ofhospital beds.

The wards are equipped on the same scale asthe acute medical wards, and an attempt is made,with the assistance of colour coding, to group thepatients in such a way that the most ill ones areat the near end of the ward close to the sister'soffice. The male wards are fortunate to havemale charge nurses and staff nurses, who areexpert at handling the numerous urologicalnursing problems which arise there.Even in these wards for acutely ill patients

there is a need for plenty of chairs, since at leastfour patients out of five are fit to be up in a chairfor part of the day before they leave this ward.

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FIG. i.-Equipment used in initial treatment ward.Note cantilever bed cradle, Ripple mattress,geriatric chair, walking aid, and bedside locker tohold the patient's clothes.

For the same reason the ward should be equippedwith adjustable height beds and plentiful walkingaids. In order to prevent sore heels and pressuresores every bed needs a modern type of bedcradle, and bed tables should be of the adjustablecantilever type which can be used over the bed orover an arm-chair. Because many patients willneed their clothes before they leave the ward alocker suitable for this purpose is invaluable.These features are shown grouped togetherin Fig. I. Full use is also made in the admissionwards of mechanical nursing aids such as hoists.At present these are mostly manually operated,but doubtless the future will see more extensiveuse made of electrically operated hoists, of whichwe already have one in use.The average stay in the initial-treatment ward

is about ten days on the female side and abouttwice this on the male side. This is becausecircumstances dictate that there should beproportionately more initial-treatment beds andproportionately fewer continuation type beds onthe male side. Although it is usual for the femalepatients to be ready to move on to the continuationward in the course of their second week inhospital, they may be retained in the initial-treatment ward for as long as it is necessaryshould they continue to need intensive treatmentand nursing care. A few make such rapid progressin the initial-treatment ward that they are able togo straight home from there.

Transfer ProcedureIt is important to prepare the patient psycho-

logically for the move to the intermediate wardor ambulant ward, so that it is felt to be a plannedstep forward in treatment and not merely a pieceof gratuitous interference. The procedure is

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Yuly 1963 IRVINE: Progressive Patient Care in the Geriatric Unit 405

:(:·:·:C iI~~~~~~~~.....

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FIG. 2.-A group in the intermediate ward. Noteinformal arrangement of day spaces and cantileverdual purpose tables.

explained to every patient on admission to theward (if they appear capable of understanding),and as old people are liable to be forgetful everyopportunity is taken, on the doctors rounds forexample, to remind them of the moves that maybe in store for them.The relatives must be informed as soon as

possible what is likely to happen to the patient.A standard letter is sent to the next of kin whenevera patient is moved. We have found that contactwith relatives has become easier and more informalsince the introduction of open visiting in theGeriatric Unit (Irvine and Smith, I963).

Continuity of nursing information is providedby the use of the Kardex system of nursing noteswhich accompany the patient wherever she goes,a most valuable innovation introduced by Exton-Smith (I962).Intermediate or Continuation WardsThe intermediate or continuation wards have

two functions, rehabilitation and continued nursingcare. The primary task is to get the patients ontheir feet again. This task is sometimes prolongedand difficult, especially in female patients but itgives the nurses confidence to know that thepatient has been fully assessed medically beforetransfer. They can then concentrate on theirspecial task, to get the patient walking. Such award requires slightly less staff than the initialtreatment ward. An establishment of one nurseto 1.6 patients proves adequate in practice.

Physiotherapy takes place on the ward sincenothing does more to give a feeling of interest andlife to the patients and staff.

While an attempt must be made to rehabilitateevery patient it becomes obvious in some casesthat this is not possible and a more traditional andless strenuous type of nursing care is then appro-

priate. It is convenient to have these two types ofpatient, the rehabilitation patient and the con-tinued nursing patient in one ward since there isalways a good deal of interchange between thetwo groups and a patient who was doing well inthe rehabilitation section one week may havebecome a candidate for terminal care the next andvice versa. By a fortunate quirk of Victorianarchitecture our female intermediate ward issub-divided into six small sub-units, so patientscan readily be grouped in different sections of theward as well as being identified by the colour code.

In the intermediate ward there is no day roombut the beds are arranged so as to leave a numberof day spaces where the patients can gather theirchairs in little groups for conversation, occu-pational therapy and physiotherapy (Fig. 2).The equipment needed in the intermediate

ward gives greater emphasis on rehabilitation.Handrails, Guthrie Smith frames, walking aidsand tripods must be plentiful and there must bea good number of adjustable height beds. Everypatient must have a geriatric chair, and these mustbe of a variety of types, for no one chair can suitevery patient. In general, geriatric chairs shouldhave a seat higher than the average arm-chair(about i8 in.) and a high back with a good lumbarsupport. Chairs for frailer patients are the betterfor having built-in adjustable trays. (The wholesubject of chair design has been discussed byNorton, McLaren, and Exton-Smith I962). Theremust also be a good supply of commodes. Thetypes that take a bed pan are probably the bestsince most wards already have bed pan washersinstalled. Lockers to hold the patients clothesbecome increasingly important in an intermediateward, since it is of the essence of rehabilitation thatthe patient should be dressed for a good part of theday. For many patients, especially those withstiff hips, a raised toilet seat is an advantage.The average stay in the intermediate ward is

three weeks, but if the patient is doing well aweek or ten days may be all that is necessary toprepare for the ambulant ward. In other casesthe period may be much more prolonged. Patientswho make exceptional progress in the initial-treatment ward may be able to bypass the inter-mediate stage altogether and proceed straight tothe ambulant ward. Some patients who do wellin the intermediate ward are able to be dischargedfrom there, if home circumstances are suitable.

The Ambulant WardsOnce the patients have graduated to the

ambulant wards they are expected to be up anddressed all day, and to spend their time in theday room. The ward is thinly staffed, with onlyone nurse to 2.3 patients. (In practice this means

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that only two or three nurses are on duty at anyone time, and only one at night.) It is equippedwith low beds, so that patients can get in and outwithout assistance. If patients become ill, how-ever, and require bedside nursing they must beremoved straightaway, since the ambulant wardis neither staffed nor equipped to cope with suchproblems.When all the patients must be up and dressed it is

essential to provide facilities for their day clothes. Theordinary hospital bedside locker is not suited to thispurpose and after some enquiry and experiment asatisfactory solution has been found in the form of aspecially designed 'twin set'. This is based on a designoriginally made for Amberstone, a unit of HellinglyMental Hospital, and has been modified for use ingeriatric wards. The St. Helen's-Amberstone locker isonly 2 feet wide, yet it contains a wardrobe, a chest ofdrawers and a mirror. The top of the chest of drawersis at a convenient height to serve as a bedside table.

This locker has proved as serviceable in the initialtreatment wards as it has done in those devoted torehabilitation, and it is proposed to introduce it bydegrees as a general purpose locker throughout thegeriatric unit (Fig. i).The ambulant ward gives the patients good

practice in the use of their legs, and in the moreelementary activities of daily living. Groupexercises are held in the ward daily, and specialimportance is attached to practice in climbingstairs.

The Self-Care UnitA section of four beds in the female ambulant

ward has been set aside as a self-care unit. Thisunit has its own small dormitory, day room,bathroom, toilet and kitchen. In the kitchen themidday meal is prepared each day by the patientsunder the supervision of an occupational therapist.The kitchen provides a sense of pleasure andusefulness to those who work in it and theoccupational therapist finds it a convenientmeans of assessment for those who will have tocook for themselves after discharge. In theself-care unit the patients are expected to maketheir own beds and to help with the cleaning,washing up and table-laying. No nursing attentionis provided at night. Commodes are not allowed,and the patient must be able to attend to her owntoilet needs. It has proved a useful means ofpreparation for discharge, especially for thosewho after they go home will be living on theirown, and it is as reassuring to the relatives as it isto the patients.The male patients also have an ambulant

ward but in an effort to make their life moreinteresting it has been arranged for them to taketheir midday meal in the same dining room as thewomen patients. Once a week a party and danceis held by the occupational therapists in the

ambulant wards. All this social activity helps tomake the patient more alert mentally and physi-cally, and is designed to give him a greater senseof his own value and usefulness as a person.The general improvement in morale which followsis of unquestionable value in preparing the wayfor the patient's discharge and for his return tothe community.Long-Stay AnnexesThe longer-stay patients are cared for in three

nursing annexes, totalling Ioo beds. The nursingestablishments in these various units vary alittle, but on paper are not less than one nurse totwo patients. In practice the staffs are usuallysomewhat below strength.One annexe, of eight beds, is in a ward in the infec-

tious diseases hospital. This is kept for patients over 90who need a very gentle type of care.

Another, of 26 beds, is in an old private home forinvalids. This serves a dual purpose. It is principallya unit for frail ambulant patients whom it tries to bringup to the standard required for life in an old people'shome which it somewhat resembles. It also under-takes some long-stay nursing care.The main long-stay annexe, of 64 beds, is situated

8 miles away from the centre, at Battle. This is usefulfor those whose homes are in that area of East Sussex,but it is less convenient for those whose homes are inHastings.

Although the long-stay annexes comprise 40%of the beds in the geriatric unit it is important toemphasize that they take less than Io% of thepatients originally admitted to the Unit. Ananalysis of a typical years work shows that only3% of those who come to the Geriatric Unit arestill in hospital a year later, and 92% are dis-charged within three months.

It is important not to regard the occupants of along-stay annexe as the poor relations of thegeriatric population, and they should be keptunder constant review since their medical orsocial circumstances may change and so allow adischarge that at one time appeared impossible.Occupational therapy is particularly importantsince nothing does so much, even in the feeblestpatients, to preserve their morale and their senseof uniqueness as human beings. It is alsoimportant to try and arrange the admission ofpatients to a long-stay annexe in such a way thata trickle of discharges can take place from time totime. An occasional discharge from such a unitdoes a lot to improve the atmosphere.DiscussionThe pattern of progressive patient care which

has evolved in Hastings is very similar to thatdescribed by Cosin (1956) and by Exton-Smith(1962), and their contention that this is a good

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July 1963 IRVINE: Progressive Patient Care in the Geriatric Unit 407

way to organize a geriatric unit can certainly beconfirmed. There is no doubt that progressivepatient care does, as the Americans claim, enablethe nursing and medical attention offered to thepatient to be varied according to his changingneeds, and it has doubled the geriatric turnover.One might think that so many moves would be

upsetting to an old person, and so indeed they areat times, but only for a short while. It is notuncommon for patients to be a little confused fora day or two after a move, but thereafter theyflourish in their new and more appropriateenvironment. They sense that each move has apurpose, and it is not difficult to help them tofeel it as a step forward in treatment.

Progressive patient care is helpful to the nurses,because the frequent changes of patients fromward to ward prevent any sense of stagnationwhich might beset a geriatric ward. It is also agood thing to prevent a patient with a prospect ofdischarge from lingering too long in any oneward; for it is possible for the nurses to becometoo attached to such a patient, and this leads theminto unconscious opposition to the idea of hisdischarge.

Progressive patient care is certainly helpful tothe medical staff. It leads to a concentration ofmedical energy where it is most needed, and italso enables the doctor to change his way oflooking at patients as they progress. In theadmission ward the important thing is medicalassessment in the traditional academic sense, butas the patient progresses further down the linefunctional and psychological assessment become ofgreater importance, and under a system ofprogressive patient care it is easier for the doctorto be thinking in the right terms at the rightmoment.The pattern of progressive patient care that has

been described is not the only one possible for ageriatric unit, and its form is largely determinedby local circumstances. As compared with

Exton-Smith's (1962) scheme Hastings has aconsiderably larger admission section, a smallerintermediate section, and a large proportion ofbeds in peripheral long-stay annexes, wherenursing recruitment is always difficult.We seem to have about the right number of beds

for each of the four categories of progressivepatient care, but they are not ideally sited, sincetoo many are away from the general hospital.Exton-Smith (1962) claims that two-thirds of thebeds in a geriatric unit should be within thegeneral hospital, but there is much to be said forhaving an even greater proportion than this at thecentre, at least in urban districts. McKeown's(1958) plan for a balanced hospital communityincorporating amongst other things the entiregeriatric unit within the curtilage of the generalhospital is probably the ideal. Nurse recruitmentwould be easier because of the greater variety ofwork, and, as the Lancet (1961) pointed out, itwould break down the artificial distinction betweenacute and chronic illness, and it would raise thestandard of the care of the aged to a level com-mensurate with their needs. It would also providethe ideal setting for the practice of progressivepatient care.

SummaryThe concept of progressive patient care and its

application to a geriatric unit is described.Progressive patient care provides a satisfactory

method of meeting the varying needs of thepatient at various stages of his illness, and it leadsto a more efficient use of hospital beds, medicalstaff, and nursing resources.

It is a pleasure to acknowledge my indebtedness tothe Matron of St. Helen's Hospital, Miss B. J. Smith,the Administrator, Mr. H. Hoyle, the Head Almoner,Miss M. K. Bagnall, and to all my colleagues-medical,ancillary, nursing and clerical-in the Hastings GeriatricUnit, who have made the scheme work.The photographs are reproduced by courtesy of Mr.D. E. Valentine.

REFERENCESADAMS, G. F. (I954): Betwixt and Between, Lancet, ii, 486.BRITISH MEDICAL ASSOCIATION (1947): 'The Care and Treatment of the Elderly and Infirm'. London.CLAUSSEN, E. (1955): Categorization of Patients According to Nursing Care Needs, Milit. Mled., II6, 209.COSIN, L. Z. (1956): A New Approach to the Problem of Geriatric Care, Kaiser Fdn. med. Bull., 4, 321.

(I957): 'Progress in Psychotherapy', p. IIo. New York: Grune and Stratton.EDITORIAL (1961): The Birmingham Venture, Lancet, i, I212.EXTON-SMITH, A. N. (1962): Progressive Patient Care in Geriatrics, Lancet, i, 260.GOLIN, M. (1958): At Last a Hospital to Fit Doctor-Patient Needs, J. Amer. med. Ass., 166, 2180.HALDEMAN, J. C., and ABDELLAH, F. G. (1959): Concepts of Progressive Patient Care, Hospitals, 33, 38.IRVINE, R. E., and SMITH, B. J. (1963): Patterns of Visiting, Lancet, i, 597.KING EDWARD'S HOSPITAL FUND (I954): 'Recovery Homes'. London.LEON, A. (I952): Post-anaesthetic and Post-operative Recovery Units, Amer. J. Nurs., 52, 430.MCKEOWN, T. (1958): A Balanced Hospital Community, Lancet, i, 701.NORTON, D., MCLAREN, R., and EXTON-SMITH, A. N. (1962): 'Geriatric Nursing Problems in Hospital'. London:

The National Corporation for the Care of Old People.PORTER, K. R. D. (1962): Ward Design, Lancet, ii, 35.U.S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE (I962): 'Elements of Progressive Patient Care'. Washington.WARREN, M. (1943): Care of Chronic Sick, Brit. med. J., ii, 822.

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