Cardiac Stepdown unit 5:1 patient ratio...is this normal???

[jaznia15]

I had an interview for a position on a cardiac stepdown unit. The unit receives patients who have undergone cardiac procedures such as open heart, cath lab, and etc. She said a lot of patients come down with drips and what have you and I was quite shocked when she said the patient ratio was 5 patients to 1 nurse. I graduate in May with my BSN and am currently precepting in an ICU in a small rural hospital where the patient ratio is about 1 to 2 maybe 3 sometimes. But usually nurses who receive a drip pt only have two patients to care for that day. I guess things are different at a bigger hospital but I just wanted to ask to be sure. The interviewer did mention they had the highest turnover rate in the hospital for patients with many of them being discharged everyday. I didn't think to ask if these were discharges home or to the floor.

[traumalover, RN]

Can you ask to shadow a day to see exactly how the patients are assigned? Acuity in our hospital depends a lot on whether drips are titrated or not...stable amio/cardizem gtts and low dose Dopmaine/Dobutamine are on our stepdown units. All our open hearts are extubated, lines pulled, and have been up to the chair prior to transferring from our ICU. I think the stepdown's patient ratio is 4:1. They take all post cath lab patients as well unless they are really sick.

[Carrig RN]

In my limited experience, I have never had more than 3 step-down patients at a time. Step-down patients are often very time consuming and are just below critical. Five step-down patients would make me terribly nervous.

[FancypantsRN]

I worked on 2 CV step-downs. We would get POD 1 open hearts with chest tubes, drips, etc. Ours was 4:1 days (M-F) and 5:1 nights and dayshift weekends.

Is it doable? Yes, if you are well organized. Does it suck? Absolutely.

It taught me time management for sure. Burn out rate is high though, it's a tough floor. Pt turnover is very high, it was nothing for us to discharge 3/4 of our pt's in a day. You are the receiving floor for CVICU and the cath lab - they need to move their pt's on so you have to make sure you have open beds for them. Good part about this, less ER admits than other floors and it's generally a cleaner floor (less isolation pt's).

[jaznia15]

@FancyPantsRN would your recommend a new grad nurse attempting to work on such a floor and their first job???

[MunoRN, RN]

Not ideal but common. Our tele/Cardiac step down takes Post OHS often just a few hours post-extubation and still on drips, although they are supposed to be "stable" drips. On the other end of the spectrum we also have post PCI's which are usually pretty easy, so you'll usually have a mix of post OHS, postitve pre-cath MI's, negative rule outs, CHF'rs, and post PCI's. We do titrated insulin, NTG, and cardizem gtt's. Dopamine, lidocaine, and other gtt's are supposed be at a fairly set rate or a very narrow range. The staffing during the day is 4 without an Aide, 5 with, and up to 6 at night. If you want to work critical care someday then it is a great unit to start on.

[FancypantsRN]

Like munorn said - it is common. I have seen new grads on the floor. I will be honest, some do very well and some ask to transfer (and some should ask to transfer).

Depends on the person. I would def ask to shadow if you are a new grad. It can be an excellent learning opp if you want to go critical care. It can also overwhelm ng's. It's very fast paced and at times, the acuity can be higher than what it should be - post open hearts (like anyone else) can go bad and you have to know how to manage them.

If it were me, I would find out if they have a training program (basic critical care, 12 leak ekg, etc). How long is orientation - it should be at least 3 months. I would also do days to start (not many resources on nights).

Hope I didn't scare you - it is a great floor and you learn ALOT. No floor is easy when you are a new grad. I went to it with 2 years of PCU experience - and I loved it.

[APRN., DNP, RN, APRN, NP]

If it helps; In California, the mandatory ratio of RN to Stepdown patient is 1:3. In the past, I've worked in an ICU stepdown unit with post cardiac, level II trauma, and your obligatory sepsis, DKA and ETOH'rs that were supposed to be more "stable" vents and what-have-you.

A vented patient's alarms cannot be put off like a call light for the bathroom. If you add hourly blood sugar checks and insulin drip titration, a delicate drip titration on a gorked-out ETOH'r, a need to address a CVP of 1 in a septic patient, a sheath-pull on a post-op heart cath and the vent alarming in the other room...... Things can get hairy very quickly.

The trick is to know what management expects of the nursing staff. If you find out that they make every attempt possible to prevent the scenario that I gave above, then 5:1 can be do-able. If they cannot state what their parameters are for acuity purposes, then do not put yourself in that environment.

It is so critical to be able to see....then understand....then act with increasingly quicker response times as a new grad. If you are constantly drowning, you're really not cementing the lesson for further use like you could otherwise.

[aCRNAhopeful]

I think a 5:1 assignment is ridiculous and unsafe. I work at a small cvicu and occasionally I take 3:1 assignment of step down acuity pts. Just the other day I had 1 pt on heparin gtt who was constantly on his call light, a confused pod1 cabg who's pressure was tanking and while I'm waiting on the doc to call me about that pts bp I check my post cath pts groin to find a huge hematoma with blood everywhere. Ur telling me some places do 5:1?? Unsafe.

[songgirl]

I agree, 5-1 can be done if everything is perfect. But so much can go wrong. CBG patients often go into Afib post op, confussed patients can tie up your time when something serious is happening out there on the monitors...is there a monitor tech or are you going to be watching monitors yourself? You are responsible and the one who has to take care of the problems that come up.

As a former travel nurse I saw 5-1 and it made me retire! As a staff nurse I felt safe with 3-1. Good Luck to you!

[JonM_RN]

Seems common to me, although with post-op open heart patients, I think it's a bit much. Where I work on my step down unit, we have post-op cath's (cardiac caths, carotids, peripherals, etc. with angio and stents), post-op pacemakers, ICU step down, drip patients (cardizem, dopamine/dobutamine, lido, amio, etc.), and neuro/cva patients. The only thing we don't have is open heart because our hospital doesn't have a cardio-thoracic OR. On day shift we go up to 5:1 (although realistically its more like 3/4:1) and on night shift we can do 6:1. We're a 29 bed unit, and we also get patient's from the med-surg units that flip into AFIB or SVT and need to go on drips.

Also, we have some staffing guidelines like no more than 2 drips in an assignment, if a nurse has a vented patient they have no more than 3 patients including the vent, and no more than 2 fresh post op cath's per nurse.

[KeepItRealRN, BSN, RN]

If this ratio bothers you then don't ever work at any hospital in South Florida. LOL