Is this dangerous?

[Nurse Beth, MSN]

Dear Nurse Beth,

The new PCU at my place of work will NOT have Bedside monitors.

I don't believe the RN's who work there or the Unit should be called Critical Care.

We will have BiPap, post-op open hearts, s/p VATs, RATs, non-titratable drips.

Ratio 4:1. Sounds dangerous to me. What do you think?

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Dear Sounds Dangerous,

Progressive Care Units (PCU) are also called Step Down Units (SDU). They are for patients who need extra nursing care, but not the intensity of ICU. Patients are typically heavy workload wise, but stable, and require more intensive care than provided on MedSurg.

According to the AACN, "Progressive care defines the care that is delivered to patients whose needs fall along the less acute end of that continuum. Progressive care patients are moderately stable with less complexity, require moderate resources and require intermittent nursing vigilance or are stable with a high potential for becoming unstable and require an increased intensity of care. Characteristics of progressive care patients include: a decreased risk of a life-threatening event, a decreased need for invasive monitoring, increased stability, and an increased ability to participate in their care".

The core competencies of a PCU nurse can include managing vasoactive drips, hemodynamic monitoring, ventilator care. Regardless what the unit is called, clear admission criteria is important. It sounds like your facility has defined the patient population.

What you are describing sounds closer to a Telemetry unit, in my experience. Post-op open hearts and non-titratable drips are appropriate for Tele level of care.

A ratio of 4:1 is good for Tele, but high for PCU/SDU. Of course, ratios and nomenclature of units vary across the United States, with no universal standard, except in California, where nurse-patient ratios are mandated.

As far as not having bedside monitors, unfortunately, most Tele level units do not. A true SDU is more likely to have bedside monitors, and especially if you have art lines and hemodynamic drips. If you are accustomed to caring for patients with bedside monitors, as in ICU, it is initially very uncomfortable to work without them.

This sounds like an issue of semantics with the unit you describe called a PCU but functioning more as a Tele unit.

Best wishes,

Nurse Beth

Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!

[Nurse SMS, MSN, RN]

I worked Stepdown when I first began my nursing career. We took cardiac drips, heparin and insulin drips. Our rations were 4-5:1 on day shift, 5-6:1 on nights. It was indeed considered a critical care floor, given that the only thing we did not take in terms of patients were those requiring intubation. Pretty much anything else, we did. We pulled sheaths. Titrated drips. Did peritoneal dialysis. We took patients in active alcohol withdrawal. We had trauma patients with head injuries, stroke patients, cranial bleeds. Etc. The patients we cared for were unstable, 100% of them were on telemetry monitoring and it was a stressful, active job.

I am unsure why this would not be considered critical care.

After this job, I moved into a PCCU (Progressive Critical Cardiac Unit) where our ratios were 3:1 and our patient population consisted of fresh postop CABG patients who were exactly 24 hours post surgery, fresh thoracotomies, lots of chest tubes, lots of endarterectomies and other heart/lung patients. This too was very much considered part of the critical care spectrum and these patients required closer monitoring than a regular telemetry floor with frequent call for rapid intervention and escalation. Obviously these patients too were 100% on telemetry monitoring. We did a lot of drips, lots of titrations, lots of rapid intervention.

Neither of these floors had bedside monitors on a regular basis. Some patients we did move portables into the room with them. Both of them were high acuity with highly unstable patients that would be inappropriate on a regular med-surg or even regular telemetry unit. I definitely consider both of these floors critical care. The presence of a bedside monitor isn't what determines that. Ratios on these floors continue to grow unfortunately. It was stressful. It felt dangerous sometimes. Not every day. I loved it and yet had to leave it. It was hard, hard, HARD work. The kind that goes home with you at night.