ICU Stepdown workload

[rotteufel]

Who else works on a stepdown unit? What is your workload like? Do you have your own charge? Do you have a CNAs?

I just started on an ICU stepdown unit, with the hopes of going to ICU and I am having a hard time accepting the workload on this floor. We have 3 patients who are total care, including vents and titrating drips. We are expected to do hourly rounds with that scripting that I have seen on other discussions. We have no CNAs, no charge nurse and we don't even have our own nurses station. We have to go down the hall and around the corner and use the med/surg units nurses' station. When it comes time for breaks, we relieve each other. I was scolded the other day for having a drug book on my med cart and I was told that if I want to look up drugs, I need to go to the nurses' station. There is no team work on the floor and I have a hard time finding anyone to help me turn a patient, let alone give them a bath. I will admit, my patients aren't getting the care they deserve and my assumption is that the other nurses are in the same predicament.

Are all stepdown units like this? I feel my license is at risk and I am counting down my six months until I can put in for a transfer.

[netglow, ASN, RN]

Geez, seems ridiculous. That whole nurses station 5 miles away from the patient rooms is ridiculous. You know what? Nobody gets to tell me I can't use reference material. Tough s***! Here's what you do though. Buy an itouch and download Davis Drug Guide. It has all the drugs and all you can possibly need to know about them and admin as well as teaching. That one costs some money. But you can download Medscape, and the student version of Epocrates for free. Those two are also good references. I keep all three. Pop that iTouch in your pocket and use it when you need to.

[rotteufel]

My coworker told me she got in trouble for using her smart phone to look up a drug. I am not making that up. They said that we have to use the reference materials that are on our laptops. I complained that the internet isn't always working on the computers but they said to walk to the nurses' station and use the drug book there.

[April, RN, BSN, RN]

No, not all step-down units are like this. The step-down units at my hospital typically have a patient load of 3 patients (2 if on vents or titrated gtts), there are CNAs, there are charge nurses, and there is a nurses station! I think you are right to be looking for a new position as soon as you can...

[noregrets]

I am a nurse manager from an ICU step down unit. Ratio 3:1 for day shift 4:1 for night shift. Charge nurse without patients. No CNA's. We have 30 beds and the nurses station is in the center of the Unit. We have the Pyxis machine in the med room so plenty of possibilities to look up medications. Do you have a manager just for your unit? A Unit Counci? Shared Governance. If you do, these are your resource for change. Do not give up, there will never be change if everybody leaves.

[nminodob]

I work in a stepdown unit and we always have a charge nurse and a tele nurse, except times when we're short-staffed and the tele nurse might have to admit a pt. We require sitters (CNAs) since we have a lot of ETOH w/d and TBI pts - lately sitters are in short supply. This is a concern, for sure! We typically have 3 pts, but often start out with 2 and admit/transfer.

However, we work as a cohesive unit - great teamwork all around. When an unstable pt comes from the ED (which is often), you should see the crowd of nurses that pile in the room to start IVs, get labs, etc. We are a teaching hospital, so often the residents also crowd into the room. That doesn't mean we are not pulling a huge load - often we take ICU pts when there are no ICU beds, and 1-2 hrs after arriving, these unstable pts get pushed to the ICU before the receiving nurse on our unit has even had a chance to do an iota of documentation! Unfortunately, we still have to do the paperwork even if we have had them a short time.

I don't see how a stepdown unit with unstable pts can operate without teamwork. If the culture at your workplace can't be changed to make it more friendly, I think you should look for another place to work.

[shiccy]

We have 4:1 on our stepdown w/ vents and gtts. If we have high acuity (>= 6 totals / 20 pts and/or a good number of vents) our numbers go to 3:1. We have 3 NA's (or we SHOULD have) for 20 patients, do q4 vitals on everybody.

The only thing I see wrong with your unit is your complete lack of NA's. I'd fight long and hard for help with additional staff, or find another unit to work on if possible b/c that's not fair staffing.

FWIW we had to fight and fight HARD for 3:1 and 3 NA's ... all stepdowns at our hospital are to be 4:1 and 2 NA's per 20 pts, but we got it upped b/c we couldn't provide good care.

AS FAR AS THE MED LOOKUPS, many if not all institutions have instituted a NO CELL PHONE zone. That being said, if you want to tell them to **** you can buy a palm pilot and put epocrates on it. If the MD's can use it, then so can you. If they want to try to tell you "no drug books that aren't on the computer", then you response should be a courteous and non-confrontational question to them: "Is there a policy and procedure that prevents me from using this device for a medically necessary inquiry?"

If they say that there is a P&P, (Which, if it's a Palm Pilot that is NOT a cell phone, is DOUBTFUL) your response should be something along the lines of, "This is a tool just like a stethoscope, pen light, etc. It assists me in making decisions on whether or not to hold a medication, and gives me conscise information that may be useful for my patient care. I will continue using this device until you can print me off a copy of the P&P booklet forbidding my use of this device. It is NOT a cell phone, and has no connection to the outside world other than using the hospital provided wifi network. It also does NOT have a camera, so there is NO HIPAA violations that are occurring."

Some places are funny about some things being on carts that shouldn't be there. For instance, our hospital is funky about putting ANYTHING but 1)gloves 2)saniwipes on an isolation cart. ANYTHING else is not allowed (we put a "clean" water pitcher on the carts that stayed out of the room so we could fill it, and dump into the 'dirty' one ... they said, "NOPE NOT ALLOWED!") It may be in there somewhere about not having anything but meds, MARS, etc on the med cart. This one MIGHT be 'for pt safety'.

FINALLY I would like to say that I have epocrates on my cell, and I very regularly take my phone out of my pocket and look up things for patients that have questions and I don't have a good answer for them re: meds. My phone is very typically on "airplane" mode and is DEFNITELY never off of silent. My patients have never said anything against it, although we DO have a P&P against cell phone 'use' at our institution. I've actually SHOWN patients my cell phone with it on there b/c epocrates also has a 'pill ID' function. When the patients say, "Um I take a purple and white pill not an orange and red one!" I can look up the different pill strengths and show them "Oh they just make a few different colors in your dose they're all the same thing, though, just different manufacturers"

[PostOpPrincess, BSN, RN]

This is not the type of stepdown I would want to stay in.

[ObtundedRN, BSN, RN]

Stepdown at my hospital is typically only 2:1. We have the capability of taking vents and titrated drips, but the unit manager prefers all of those pts to only go to the ICU. We have CNA's, but only a few. The unit is 2 hallways, and each hallway has a nurses station with tele monitors and medication room.

I can't imagine why they wouldn't let you have a drug guide with you. If it belongs to the unit, I can see them wanted it to stay near the nurses station for others to find easily, but there is no reason why you can't have your own.

Have you tried picking up one of those small drug guides? Like tarascon pharmacopoeia, or something similar? They are very small and lightweight. They give alot of the vital information, and fit in your pocket well.

[RNperdiem, RN]

No wonder the OP sounds overwhelmed.

My hospital's stepdown unit has a 3:1 ratio, a free charge nurse, and 1 or 2 CNA's to help.

Vents are unusual unless they are chronic vents with a trach. Drips are allowed, but not ones that require frequent titration.

Lack of teamwork is the hardest obstacle since there is no quick fix. I like to use the reciprocity approach. I will help you turn your patients and then we can go turn mine.

[shoegalRN, RN]

Our hospital stepdown unit is 3:1 at all times, unless short staffed then it's 4:1.

It's total care. No CNA's or techs unless they are sitting on a 1:1 which is often.

They don't take vents, only trachs. They do drips, but not titratable ones. They take DKA's with open gaps. They will titrate insulin gtt's. I work ER and have transported several pts to the stepdown unit.

There is a charge nurse who do not take a pt load. There is also a team lead who does take a pt load, but who is responsible for assignments for the next shift.

There is a nursing station and a med room on the unit.

[blondy2061h, MSN, RN]

My unit is sort of considered step down critical care (though we only take BMT patients). We can do any drip, titrated or otherwise. We do not take vents. We do take bipap. We do CVP monitoring (though very rarely), but no art lines. We're typically staffed 3:1 with a dedicated charge and 1 aid. I can't imagine being yelled at for looking something up.