Thoughts on differences in admission criteria/acuity of urban vs rural stepdowns?

  1. Hello all,

    I tried searching for a similar thread - I had no luck, but if I'm missing something obvious, I'd love someone to point it out. This was kind of a difficult term to query for.

    I'm a new grad who went to school in a large city and recently moved for my first job in a general, mixed medical/surgical "stepdown ICU" (called an SCU, Special Care Unit) in a small, rural hospital. It's been a great change and I'm loving the fresh air. Having spoken to some friends who've started working back in stepdown units in the city, I wondered if some better-travelled critical care nurses could offer some insight on this subject.

    I'm basically wondering if any of you believe the admission criteria and general acuity in a rural stepdown unit is different than that of urban. For example, might patients considered 'stepdown' in my small rural hospital just be general med/surg in a large, urban, academic medical center? And conversely, might patients considered stepdown in a large urban facility be admitted to the ICU of a small rural one?

    I ask because I'm just wondering how my workload compares to that of urban new grads. Doing clinical in NYC, I was on what were considered med/surg floors with the odd tele-rooms with 4/1 ratios. However, working at my new job, I get a bit of the feeling that some of these stepdown patients in my unit would just be thrown into a general med/surg unit in the city. I know this is not the case with DKA, day 1 post PCI/cath, carotid endoarterectomy, and r/o MI, but we rarely even get drips, and vents are strictly prohibited. The most compromised airway we would see is a BiPAP, and the only drip we titrate is insulin. Other vasoactives like dobu, cardizem, and nitro are allowed but no titration - and these seem rare, a bit to my dismay. The ratio is never more than 4/1, even on nights, which is wonderful for learning but seems atypical.

    Could anyone comment on differing experiences having worked in urban and rural critical care? I just ask because I'm young and inexperienced, and would love to hear from some nurses who have worked in ICUs or stepdowns in varying settings who could just shed some light on this - curious for your thoughts.

    Thank you so much for your time and patience!

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    Joined: Apr '12; Posts: 7; Likes: 3


  3. by   Bec7074
    I'm glad you asked this! I used to have the same questions and now I feel like I may have some insight. This is my experience:

    I worked in a small, rural hospital that had about a 15 bed ICU, a 30-ish bed PCU, and 3 medical floors. I worked in the PCU (Progressive Care aka ICU-Stepdown/Telemetry) and we had ratios of anywhere between 2:1 and 4:1 depending on staffing/acuity. I loved it. Fantastic experience and preparation for my current career in ICU. We had 2 cardiothoracic surgeons at the hospital though and once their patients left the ICU, they only came to our unit and were D/C'd from there. The surgeons refused to let their patients go to the medical floors. They were complex patients with high acuity. We also did vasoactive medications, but we were allowed to titrate only to a point (cardizem max of 10, nitro max of 30, and dopamine max of 5). And I can remember multiple times where our patients were intubated and sent to ICU after Bi-Pap therapy didn't work for them. I also remember seeing a patient in asymptomatic VT. All kinds of good experiences....

    This rural hospital was part of a larger hospital network that included many many rural hospitals and several large hospitals in the largest city in my state. I remember Resource Nurses who traveled the entire system would float to our unit and say "Well in the city, the patients are way sicker and blah blah blah." I remember thinking I was glad I didn't work in the big, urban hospitals. As life may have it, I ended up moving to that city and working in the ICU of a Level One Trauma Center of a very large urban teaching hospital within the same health system. I was scared because I thought the patients were going to be super duper sick and scary.

    Some of them are. But to be honest, my experience in the PCU at the smaller hospital was GREAT experience. At that rural hospital, they take sicker patients on the PCU because their ICU is much smaller. They only have so many beds to put actual ICU patients in so anyone who doesn't necessarily have a vent or drugs, may get downgraded. At the large hospital I work at now, we have a cardiac medical ICU, cardiac surgical ICU, neuro ICU, medical ICU, and a trauma/surgical ICU (mine). I've floated to cardiac surgery multiple times and have thought "wow, we admitted these type of patients into the PCU at my last job!"

    The last thing I think (sorry I realize I'm writing a book!), is that in smaller hospitals, you get a variety of patients (neuro, cardiac, surgical, etc), because they don't have the designated floors like large hospitals do. On the PCU, I took care of multiple acute strokes, and now, if we get even a small head trauma, everyone is like "Oh, no they need to go to the neuro ICU!"

    That's just my experience. It could be entirely different in another health system.
  4. by   EMTtoRNinVA
    I'm starting next week in a 16 bed stepdown unit at a Level 2 trauma center with a 48 bed (MedSurg/CCU/CVICU) ICU. Our Surgical Tele unit is 40 bed and Medical Tele is 40 beds. I'd say my hospital is rural, though on the upper edge of the spectrum. It's the flagship hospital in a medium sized health system. I've wondered the same things that you have posted. Thanks for posting! The outlying (read: more rural) hospitals have ICUs of 6-8 beds or no ICU at all! Everything gets transferred to the flagship hospital, a Level 1 center, or a specialty hospital.
  5. by   NurseRiv
    I work in a hospital 20 minutes outside of a large city in the stepdown unit. I wouldn't describe it as 'rural' per se, but maybe 'suburban'. The acuity of patients, med drips, etc. sounds very similar. I do enjoy the variety of patients we treat because, as said before, we do not have separate floors for different specialities.
  6. by   petraarkanian
    Thank you so much for all of your replies! I'm glad a few others were wondering the same thing. Thanks for all the insight.