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?

[PMFB-RN, 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.

Sure but I don't consider a dilt gtt to be a step down level drip. In most of the places I have worked dilt was a regular med-surg floor drip and certainly no reason to transfer a patient to step down. Our step down units run levo, dopamine, NTG, nicaripine and other drips. hence the monitors at bedside.

[ChristineN, BSN, RN]

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

Nope. Although not done often, my facility allows A-lines in step down.

[ChristineN, BSN, RN]

Sure but I don't consider a dilt gtt to be a step down level drip. In most of the places I have worked dilt was a regular med-surg floor drip and certainly no reason to transfer a patient to step down. Our step down units run levo, dopamine, NTG, nicaripine and other drips. hence the monitors at bedside.

My facility doesn't allow any drips except for Heparin or Insulin to be given outside of stepdown or ICU. Not all of our Med-Surg floors do tele, and it would be very unsafe to have someone on a dilt gtt without tele. I wonder what the Med-Surg ratio is at these facilities you reference

[MunoRN, RN]

My facility doesn't allow any drips except for Heparin or Insulin to be given outside of stepdown or ICU. Not all of our Med-Surg floors do tele, and it would be very unsafe to have someone on a dilt gtt without tele. I wonder what the Med-Surg ratio is at these facilities you reference

I would think that referred to what's called "medical tele" at facilities I've worked at, it's regular medical floor ratios but with patients on cardiac telemetry. At my facility diltiazem and amiodarone can be done on these floors.

My facility doesn't allow insulin drips outside of ICU, we used to allow them on stepdown and on the progressive care floor but only for open hearts, now all open hearts must transition off their insulin gtt on post -op day one prior to transferring to progressive care, unless they are going to have to stay on ICU for some reason.

Some of AACN's staffing recommendations are a bit unrealistic, but the recommendation to only use art-lines in patients with a 2:1 ratio is a pretty reasonable standard and I've never worked at a facility that allowed them outside of those ratios.

[ChristineN, BSN, RN]

I would think that referred to what's called "medical tele" at facilities I've worked at, it's regular medical floor ratios but with patients on cardiac telemetry. At my facility diltiazem and amiodarone can be done on these floors.

My facility doesn't allow insulin drips outside of ICU, we used to allow them on stepdown and on the progressive care floor but only for open hearts, now all open hearts must transition off their insulin gtt on post -op day one prior to transferring to progressive care, unless they are going to have to stay on ICU for some reason.

Some of AACN's staffing recommendations are a bit unrealistic, but the recommendation to only use art-lines in patients with a 2:1 ratio is a pretty reasonable standard and I've never worked at a facility that allowed them outside of those ratios.

Our stepdown units are 1:4, with med-surg 1:5 and ICU 1:2. It is a newer change, we have only been doing A-lines in stepdown for maybe 2 years. Majority of pts with A-lines are too unstable to be stepdown, but this is referring to the occasional pt who is stable-ish with an A-line

[PMFB-RN, RN]

My facility doesn't allow any drips except for Heparin or Insulin to be given outside of stepdown or ICU. Not all of our Med-Surg floors do tele, and it would be very unsafe to have someone on a dilt gtt without tele. I wonder what the Med-Surg ratio is at these facilities you reference

I don't recognize med-surg and tele being different units. All of our med-surg wards are tele wards. Our step down is either 1:2 or 1:3 depending on the type of patients. At any one time about half of our ICU patients are 1:1 and the rest 1:2 with the occasional 2:1 ICU patient.

Med-surg / tele would be 1:4-5 on days and up to 6 on nights.

[calivianya, BSN, RN]

Hearing about how different hospitals define their floors is interesting. It makes me think that mandating nurse-patient ratios will be pointless until there is also standardization of what kinds of technology/patients certain floors will accept. Food for thought, for sure.

[BlueEyedGuy]

I work at a mid-sized hospital on a 32-bed 'Telemetry' unit, but we are THE step-down unit. We titrate NTG, dopamine, dobutamine, diltiazem, and a few other drips (not levo or epi). We have monitors at bedside that we can wirelessly sync to the Tele box at our own discretion. While sync'd we can import vitals from the monitor to the chart also.The only time I've seen a-lines is when the cardiologist leave the stent in from a Cath and we can hook up a transducer to that, but that's usually only for a few hours until we pull the stent.

The only thing we don't really see much is trauma, they're either in the ICU or end up on surgical(ortho or neuro).