And this is why I hate floating to stepdown...

[calivianya]

I floated to stepdown last week and I am still irritated about how things went. Our stepdown unit has patients on a tele box. There is no monitor in the room, so unless I stop by the nurses' station and intentionally find and watch my patient's rhythm, I don't see it. I got report that this patient was in normal sinus rhythm and had been his whole admission. At the times I was auscultating his heart sounds and feeling his pulses, all were regular. No murmurs, no irregularities, equal pulse strength in all four extremities, etc. I assumed the report I got was correct, and I assumed the monitor tech would let me know if something funny started happening with my patient. I have since learned that what they say about assuming is pretty darned accurate...

Four AM rolls around and I was hanging out at the nurse's station and watched the monitor for the tech while she went to use the restroom. I noticed my patient was having pretty frequent PVCs, and I dug back through the alarm review to discover he had been having frequent PVCs all night long, often going into bigeminy, and had even had a 20 beat run of V-tach once!

When the monitor tech came back, I asked her very calmly if it was normal for this floor to totally ignore a patient going into a potentially lethal rhythm. She stated the charge nurse had been watching the monitor when that happened, so I turned to her and asked her why I was the last person to know my patient was having runs of V-tach. She apologized that she silenced the alarm and didn't tell me. I asked if she at least printed a strip to put in the chart so someone could be aware this was happening, and she had not. I printed one and dug through the chart, only to find the patient had in fact been going into runs of V-tach his whole admission and yet I had gotten report that he was in perfect normal sinus rhythm.

The patient also didn't have labs ordered for the morning at all, and hadn't had labs for a couple of days despite his obvious rhythm irregularities (!!!), so I called the hospitalist to notify her of the patient's abnormal rhythm and got orders for a CMP. All of his labs came back normal, but still.

Obviously I should have been stopping by the nurses' station and watching the monitor myself more often, and I will in the future now that I have learned this lesson, but what is the point of even having a monitor tech if I have to watch my patient's rhythm myself because I won't get told if things look funny? I really can't stand having patients that aren't on monitors in the room. It's almost as bad as having patients who aren't on telemetry at all.

Am I expecting too much out of our stepdown unit, or is it common for things like abnormal heart rhythms to be ignored if a patient is not in an ICU? Everyone I have talked to on my unit states that they also hate floating to stepdown for this reason, it just seems to be the culture down there to sweep things under the rug. What are your experiences with floating to floors where you cannot see the patient's heart rhythm in the room?

[Nalon1 RN/EMT-P, BSN, RN]

Stepdown units need to have monitors at least at the bedside, ideally at the nurss station.

My IMU does and we have caught quite a few things with patients because of it.

[mo16]

Forgive me I don't know adult tele. What is the purpose of a tech if the nurse can't trust him/her and needs to be watching the pt's strip themself? Why does the "only trust yourself when it concerns your pt" nurse's mindset apply?

At the end of the day if something happens to that patient, the RN is still accountable. RNs delegate but they are responsible for the work they delegate because they are overseeing care for that patient. At least that's how I see it.

[MunoRN, RN]

Sorry to be odd man out, but I don't get the hub-bub. I only expect the tele tech to notify me of something that is new, or that is recurrent but more urgent than just increased V-ectopy while asleep. I don't need to know that a patient who has increased V-ectopy while sleeping (which isn't uncommon) every night is doing it again tonight. If I noticed that a patient is having frequent V-ectopy, and I was told this wasn't the case during the day, the first question should be "did they do that last night?", "do they do that every night", which takes a pretty quick and simple investigation on my part.

[PMFB-RN, RN]

Stepdown units need to have monitors at least at the bedside, ideally at the nurss station.

My IMU does and we have caught quite a few things with patients because of it.

Stepdown needs monitors at the bedside. How else can they possibly tranduce the art lines, monitor CVP, and titrate drips like dopamine and dilt?

If they aren't doing any of those things how can it be labeled a step down?

[MunoRN, RN]

Stepdown needs monitors at the bedside. How else can they possibly tranduce the art lines, monitor CVP, and titrate drips like dopamine and dilt?

If they aren't doing any of those things how can it be labeled a step down?

"stepdown" is a surprisingly inexact term. I've never worked anywhere that allowed A-lines as a stepdown patient. I've worked in a couple places where stepdown only referred to nursing acuity, not medical acuity, these were all patients that required a significant amount of nursing attention but relatively minimally intensive monitoring. At one facility the levels went ICU, stepdown, tele, and while all tele patient were on continuous EKG monitoring, only about 3/4 of stepdown patients were at any given time. Certainly no CVP's, no art lines, no dopamine drips, not even dilt drips.

[calivianya, BSN, RN]

"stepdown" is a surprisingly inexact term. I've never worked anywhere that allowed A-lines as a stepdown patient. I've worked in a couple places where stepdown only referred to nursing acuity, not medical acuity, these were all patients that required a significant amount of nursing attention but relatively minimally intensive monitoring. At one facility the levels went ICU, stepdown, tele, and while all tele patient were on continuous EKG monitoring, only about 3/4 of stepdown patients were at any given time. Certainly no CVP's, no art lines, no dopamine drips, not even dilt drips.

I had a cardizem drip at a different time I floated there, one that I was titrating. The hassle was ridiculous. Using a rolling vitals machine to take q15 vitals, manually keeping an eye on the patient and the machine, writing the vitals down, and then manually plugging them into the computer instead of importing them, while I was watching three other patients, one with explosive c. diff and all of the CNAs were doing magic disappearing acts every time that one hit the call bell... It was one of my most aggravating nights.

Nothing about my facility makes a ton of sense.

[ChristineN, BSN, RN]

"stepdown" is a surprisingly inexact term. I've never worked anywhere that allowed A-lines as a stepdown patient. I've worked in a couple places where stepdown only referred to nursing acuity, not medical acuity, these were all patients that required a significant amount of nursing attention but relatively minimally intensive monitoring. At one facility the levels went ICU, stepdown, tele, and while all tele patient were on continuous EKG monitoring, only about 3/4 of stepdown patients were at any given time. Certainly no CVP's, no art lines, no dopamine drips, not even dilt drips.

At my facility A-lines can be step down as well as Dilt gtts (non titratable) we do not allow CVP monitoring out of ICU, so no IV medication that would be titrated by blood pressure. We also make initial bi-pap or c-pap go to ICU ( other hospitals in the area see them as step down pts).

[PMFB-RN, RN]

"stepdown" is a surprisingly inexact term. I've never worked anywhere that allowed A-lines as a stepdown patient. I've worked in a couple places where stepdown only referred to nursing acuity, not medical acuity, these were all patients that required a significant amount of nursing attention but relatively minimally intensive monitoring. At one facility the levels went ICU, stepdown, tele, and while all tele patient were on continuous EKG monitoring, only about 3/4 of stepdown patients were at any given time. Certainly no CVP's, no art lines, no dopamine drips, not even dilt drips.

I would consider any "stepdown" that lacked monitors and the ability to transduce pressure lines or handle drips to be incorrectly named.

[Nalon1 RN/EMT-P, BSN, RN]

I would consider any "stepdown" that lacked monitors and the ability to transduce pressure lines or handle drips to be incorrectly named.

Depends on you facility.

Larger hospitals (teaching facilities, Level 1/2 Trauma centers, etc), sure, but in smaller local facilities, pressure lines, titrated drips, vents and such are usually ICU only, but they should have monitors in the room and ideally at the nurses station.

[PMFB-RN, RN]

Depends on you facility.

Larger hospitals (teaching facilities, Level 1/2 Trauma centers, etc), sure, but in smaller local facilities, pressure lines, titrated drips, vents and such are usually ICU only, but they should have monitors in the room and ideally at the nurses station.

Maybe a regional thing. I am not accustomed to those smaller local facilities even having a step down.

[MunoRN, RN]

At my facility A-lines can be step down as well as Dilt gtts (non titratable) we do not allow CVP monitoring out of ICU, so no IV medication that would be titrated by blood pressure. We also make initial bi-pap or c-pap go to ICU ( other hospitals in the area see them as step down pts).

Did you mean that the other way around; No A-lines outside of ICU and CVP's on ICU and stepdown?

[MunoRN, RN]

I've worked at one facility where the 'order' went ICU-stepdown-progressive care-medical tele, and another where it went ICU-progressive care-stepdown-medical tele, so I don't think it's all that well defined or standardized. Depending on how things are organized and defined, not having an in-room monitor might be totally outrageous or it may be no big deal. Personally I don't really need a permanent in room monitor to manage a dilt drip, I check mostly through the monitor at the nursing station or core.