What is the big difference?

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    Currently I work in a step down MICU, we are 3:1 and its a crazy floor! High turnover of patients, we get most of the Rapid Responses, we are the CVA and also DKA unit. Its a busy floor, but I have learned so much. We use 80% of all of the ICU protocols when it comes to vasoactive/ionotrope drips, plus heparin, insulin. We have vents as well.

    I have an opportunity to go to the MICU, which is a 2:1. My floor is very busy as mentioned, high turnover, just pretty crazy with transfers in and out.

    You guys that work in ICU and are familiar with stepdowns, do you usually notice that step down ICUs are usually this crazy/busy? How do such floors compare to ICUs?

    Some people have told me that although icu can be busy as well, you have more time to become more familiar with the patient, more attentive and of course, less chaotic than step downs. I might be attending a Critical Care internship, which is a great opportunity since my goal has always been to do MICU.

    Pros vs Cons of ICU vs Step Down ICUs?

    Thanks in advance!!
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  3. 6 Comments so far...

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    I worked in a stepdown very similar to yours and now work in a level 1 trauma SICU. They're both very, very busy. You have more patients that are talking to you in stepdown. Did your stepdown take vents? Vents, sedation, paralytics, and iv narcotic drips were relatively new to me in the ICU vs. stepdown. Then obviously, I have a lot more surgical patients now and less medical. Sometimes you'll have a patient in the ICU who is literally so close to death... for days. These are the ones you can't make judgements on of whether they'll pull through or not. Whereas, in Stepdown, if the patient is getting too sick, you send them to the ICU.

    I think you'll like the change. It's a different world though. My verdict is still out on which I like better, but that is for more reasons than just the patients...
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    Wow our step down does not take even the stablest of vented patients and definitely no vasoactive gtts. Most are glorified floor patients that need closer monitoring. There's a very high turnover rate, though, so it's hard to keep your head from spinning. I float there once a month and it can either be a really nice break from the ICU or an absolute nightmare.
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    Our stepdown units are off the hook usually. I'm in the MICU and when we're in a bed crunch, we play "who's the least sick in the house?" When I was on the floor I'd send my RRTs to stepdown and feel awful about it because I believed they needed to be in the unit!

    I think the ratios for stepdown are a little higher than in your facility but they don't take drips that require titration. And only the ICU can take a DKA.

    Go for the ICU! You already have a great information base and know how to organize, prioritize and manage your time!
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    We just opened a stepdown ICU at our hospital, and now our M/SICU acuity went up. We still take all the vents (even home vents), super-resistant ETOHers, and vasoactive gtts. Even with the increase in acuity, I really like being able to go more "in depth" into my knowledge and understanding of the patient and the pathophys... and I won't lie, the adrenaline rush of the code or finding the one thing that keeps the patient from coding is my drug.

    On the other side, I have heard that the 3:1 pt ratio of the stepdown patients (AKA "soft ICU" patients) is far more frustrating. When I am the admit bed in my unit and have only one semi-stable patient, I make it a priority to have someone watch my patient for a few so I can go visit the stepdown unit and offer a second pair of hands. I could not sanely do what they do!
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    Ours is a combined ICU/Stepdown. I's are 1-2, 1-1, or 2-1 for some. Stepdown is 4-1 and we take vents and drips as well as DKA's. MY previous unit was a high acuity med surg that functioned as a SD but no vents and we could get anywhere from 6-11. I have never had a non-busy nursing job.

    Some nights in the ICU I am bored out of my mind and looking for things to do,most times a coworker will have a super sick patient and I can jump in and help them. Other times I am running like a chicken with my head cut off with one patient. It is all relative and depends on acuity. When you are real busy in the ICU it means someone is not doing well and for me that is the most chaotic time of all.

    There seems to be this wide-spread belief that ICU nurses don't run like other nurses do. That we have all this time to sit and read our charts and know every little detail about our patients. While this can be true, often times it is not. When you get a fresh admit from ER who is coding/crumping, hypothermia, bleeding out, etc. you hit the ground running and do not stop all shift. If another of my med-surg friends tells me how lucky I am that I can sit and really read my chart and know what is going on with my patients because I only have two, I am going to invite them for a shadow so they can see how much chart reading I am doing when I am on 8 drips and running the rapid infuser lol.

    Step down is certainly challenging. Especially when it is a team of 4 teetering on the brink and you are actively trying to prevent them from becoming ICU patients. Other nights I feel like I am babysitting floor patients, running and fetching pain meds, helping to the bathroom, fetching water etc. Its all relative.

    I get more satisfaction working on ICU. Especially when I have a super sickie who keeps me hopping all night. I leave work feeling like I really made a difference. That being said I also love watching the SD and occasionally when I do floor, the floor patients get better and go HOME. I truly did not realize before coming to the ICU how many people I would be d/cing to hospice or to LTAC. I wish I got to see more go home intact like I do on SD.

    In my opinion it sounds like your current floor has given you excellent preparation for a move to the ICU. A busy SD unit requires the same from a nurse as an ICU does. You have to prioritize in much the same way, titrate and assess the response to some potentially dangerous meds, trouble-shoot the vent, etc.
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    I work in a M/SICU stepdown (some have described it as MICU overflow because our acuity has been higher recently) and our ratio is 3:1. It can go up to 4:1 if staffing is short overnight, but the patient turnover is insane. I get an admission pretty much every time I work, sometimes two. The most concerning thing about this is the unknown: patients can be pretty easy ("hypertensive crisis" 220/105 who was just noncompliant with their meds) or critical who were placed in stepdown because there's no ICU bed (asp. pna/sepsis with SpO2 90% on 100% NRB and BP 80s/40s post 4x liter boluses). We handle DKAs, heparin gtts, cardizem gtts, levophed gtts for some conditions (sepsis with refractory HOTN goes to the unit after we start levophed), stable vents (pretty much PSV only), any variety of sarcoid/emphysema/COPD exacerbation - lots of RRTs, and recently codes too. We do our own IVs and phlebotomy, and since there's one PCA for the floor, AM care too oftentimes.

    I want to make a move to the ICU too, but maybe after I finish my year on stepdown. I've gained so much knowledge since starting on my floor and there's so much more experience to be gained, but for every learning experience there's 3x a hassle. It's physically demanding and very stressful to balance 3 borderline patients sometimes, especially with the admissions. Coworkers who are experienced nurses are also run down and overwhelmed, that I observe, and it only serves to discourage me. I just feel like I'd rather be using my brain in ICU than my body in stepdown. I'd rather be titrating pressors or changing vent settings to affect real change in the patients clinical status than having an alert patient chew me out and belittle me because I can't give them 1mg IV dilaudid q.freakin' minute. How rewarding an experience to wean a recovering critical patient off of a pressor or ventilator and to see their mental status improve? I don't find it rewarding when my patient rings on the call bell all night to have me move their leg 2 inches to the left or rearrange their bedside table or to complain about the hospitals food, only to have forgetten my name when I come back 12 hours later.


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