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.

[rotteufel]

Ok, I am glad to know that this floor is a little on the ridiculous side. We don't have our own manager. Our manager is the ICU manager and she is rarely seen. About the only time I see her is when she comes over to tell one of us that we did something wrong or that there is some new policy. I wouldn't say I got yelled at for looking something up, but I was told that I would be written up if I was found with those items on my cart again. We have a union and I think they are currently fighting to get us at least a nurses' aid. The lack of team work astounds me. I got a patient from the ER today and NO ONE came in the room to help me. I think I have made my decision to move when the opportunity arises.

[DeLana_RN, BSN, RN]

I recently worked on a stepdown unit. Lots of pts on BiPAP, but no vents; we did titrate drips. Ratio 3:1 (rarely 4:1), 2 aides (sometimes 1, rarely none) for up to 21 pts. One hallway with a nurses' station. Charge took pts. It was a crazy nuthouse.

Why? Not only did teamwork (or breaks, or lunches) not happen, it was actively discouraged by the charge nurse. She actually stated that asking other nurses for help or advice would inconvenience the other nurses (Drug guides, BTW, were frowned upon - I haven't the slightest clue why, except that looking up a med might slow a nurse down - pt safety, who cares? - but not forbidden. At least something...)

Good riddance to a he||hole.

Years ago, on the other hand, I worked on a stepdown/tele unit where the ratio was 8:1 with one aide per nurse. That was a different kind of nightmare... although we did not have to sign off the orders, the charges did that. But it was a just-as-impossible workload as that on my most recent stepdown unit, although for slightly different reasons.

* * *

Run, don't walk out of there (after you have secured a new position, of course). Your unit is unsafe - for you and the pts. The manager doesn't seem to care, no teamwork, no aides, ridiculous rules - need I say more?

Best of luck to you!

DeLana

[rotteufel]

DeLana, it sounds like you were in the same nightmare I am in. I feel foolish because my acquaintance tole me not to go to work on that floor before I took the job, but when I asked why she told me, "Because they take vents" or "The patients are really sick." Well, I want to go to ICU, so I was open to those challenges. Why didn't she tell me what was really wrong with that floor?

When I worked yesterday, I was walking by a room where a vent alarm was going off. I watched two other nurses walk past the room, ignoring the alarm. When I went in, the patient was disconnected from the vent!!! My countdown is on until I can transfer.

[DeLana_RN, BSN, RN]

DeLana, it sounds like you were in the same nightmare I am in. I feel foolish because my acquaintance tole me not to go to work on that floor before I took the job, but when I asked why she told me, "Because they take vents" or "The patients are really sick." Well, I want to go to ICU, so I was open to those challenges. Why didn't she tell me what was really wrong with that floor?

When I worked yesterday, I was walking by a room where a vent alarm was going off. I watched two other nurses walk past the room, ignoring the alarm. When I went in, the patient was disconnected from the vent!!! My countdown is on until I can transfer.

It's funny, I had a bad feeling when I accepted this last stepdown position, in part because I was hired on the spot (as I know now, they have a ridiculously high turnover... surprise), but a trusted friend had told me that this unit, which has a very bad rep in the hospital, had somehow changed due to a new manager and was now a "really good unit". NOT. And the manager was just replaced... again.

In your case, I'm surprised you have to deal with vents in stepdown; that's another reason why your unit is dangerous for a nurse's license (and of course, the poor pts!) But you realize all of that, and the one good thing in your situation is that you are now well qualifed to work in any ICU (where you will get more training, of course).

I hope you don't have to wait too long until you can transfer and wish you the very best!

DeLana

[rotteufel]

I, too, was hired on the spot. I just find this floor frightening and I was worried that I was just underestimating what I had gotten myself into.

I have about 4 months left before I can transfer. They gave me an 8 hours training class on vents, during which I never touched a real patient. Luckily, I had a short stint at an acute rehab place that did vent patients, so I knew a little about them. I worry for the people who come to this unit with no vent experience.

[jlbic]

Wow, that really sucks. I worked step-down for a couple years, started off in PHX on a cardiac step-down that was awesome. I miss that job. Then moved to Colorado to work in another cardiac step-down that was awful! As soon as I fulfilled my year contract I was out of there. Sounds like you are in the same predicament. I would get out ASAP and find a better place to work where you don't feel your license is at risk everyday you walk into work.

[netglow, ASN, RN]

Yeah OP, this hiring on the spot garbage... "Oh we don't usually hire NGs" (makes you feel special) so, you have to take the job right now...

My friend had the above situ and she said last week they hired more NGs.... she said she guesses maybe all that was not true. LOL. She's hanging in tho, she tells me it's a scary place but she does get help.

[April, RN, BSN, RN]

The situations that have been mentioned here are so scary to me. It's just not fair or safe for the nurses or the poor patients. Step-down units really need good support and teamwork because the patients are not stable enough for the floor, yet they aren't as closely monitored as ICU patients. Things can turn really bad at any time...

[umichjenks]

I have a question for everyone on this thread. I currently work on a telemetry step-down. Our ratio is usually 1:5-6. We always start off with at least 4 and then get one or two admits a night. To give you an idea of the types of patients we get: vented, new trachs, chest tubes, etoh/drug withdrawal, bipap/cpap, NSTEMI, PE, etc. We titrate heparin, nitro, cardizem gtts. We also have other gtts: Lasix, argatroban, amiodarone, dopamine, dobutamine, esmolol, etc.

We have one charge nurse who rarely ever takes an assignment. We usually have 3 techs for 44 pts. The nurses who work on the floor are what you would expect on any floor, some are really good and some are not worth the weight of their stethoscope. I guess I'm just frustrated b/c I've been on the floor for one year and I feel as though I'm not learning as much as I should b/c the high acuity level and the ratio we have to work with.

Does this seem like it's too many patients? It seems unsafe to me and I'm looking to move to an ICU after dealing with this floor for one year.

[Nurse SMS, MSN, RN]

I work ICU stepdown. No vents but we do have titrating gtts, bipaps, fresh trachs, chest tubes done at bedside, STEMI, withdrawals, neuro, trauma, etc etc etc. Day ratio of 4:1, nights 5:1 or 6:1. Three techs during the day plus a charge nurse, unit secretary and tele tech. Charge and tele tech at night with one or two PCTs. Charge does not have room assignments but does help out. I am a new grad interning on this floor and so far the patient to nurse ratios seem pretty acceptable and for the most part it is a happy team with people who enjoy teaching and helping one another. Night shift is unhappy when it goes to 6:1 but do okay at 5:1. We have our own manager as well and she is well liked. I feel very lucky to be where I am.