Med-Surg v. Telemetry/Step-down

[Guest1033582]

Just a curious soon-to-be nursing student...

What is the difference between med-surg and telemetry/step-down units in terms of pt load, acuity, etc.? I've seen the two used interchangeably but I've also seen them be listed as completely different.

[marienm, RN, CCRN]

It depends on your hospital... at mine, we have med-surg floors where patients may or may not be on telemetry. The nurses are expected to pay attention to the central telemetry (cardiac & oxygen saturation) monitor and respond to alarms, but these patients aren't on any cardiac drips (continuous medications to control rate, rhythm, or blood pressure). Some of the floors at my hospital don't have any telemetry capability, and their patient:nurse ratios are typically a little higher (each nurse has more patients, but presumably they are believed to be stable from a cardiac standpoint).

All of our step-down units have more-advanced monitoring capabilities, such as a full bedside monitor that can measure blood pressure and other parameters. These patients are less stable and/or require more frequent interventions (multiple dressing changes, lots of antibiotics or blood), or are on certain drips for cardiac rate/rhythm that require titration and can lower or raise blood pressure so the BP is checked every 15 minutes. The nurses on these floors usually have 3 to 4 patients at my institution.

Does that help? Good luck with your studies!

[AlwaysLearning247, BSN]

Many hospitals have different definitions of this. The stepdown floor at my hospital has extremely sick patients requiring vents, continuous bipap, cardiac drips, insulin drips, etc. All of the patients on this floor have bedside monitors, the ratios is 3:1, this is where I work now. Med surg/tele floors can differ. At one of the hospitals I was at we had a "hard" tele floor, all patients were monitored and you could give cardiac drips, the ratio there was 4-5:1 with high turnover. Other floors consists of med/surg patients with some tele beds, from what I've seen the cardiac meds you can give on those floors are limited, the patient ratios are still 4-5, sometimes 6 from what I've seen.

[aksti1018]

The med/surg floor I work on has a lot lower acuity patients than the tele/step down units (those are like the above posts have described). Our patients are basically "obs" but may require longer stays because they need IV abx, blood transfusions, TPN, chemo (it's an oncology floor), or are pending placement to a SNF/rehab, etc. They aren't connected to any monitors (only continuous pulse ox if they have a PCA), we do v/s q6hrs and I haven't seen a code yet *knock on wood*, we do see a lot of DNR/hospice pt's that do pass away on the unit but it's expected. Med/surg is great if you don't like very stressful situations- although it does get stressful but I'm sure nothing compared to the step down units.

[joyla163]

I am going to answer this question, give some advice, and vent a little...

My answer:

By definition med/surg should consist of patients that are stable but require IV antibiotics, IVP pain meds, continuous pulse ox monitoring, dressing changes post procedure, and general nursing care. Telemetry floors have patients that require cardiac monitoring and more frequent vitals/assessment than a med/surg patient. You can also push different IV drugs if the patient is on the monitor. Some places have techs that watch the rhythms and others place that responsibility on the nurses. Step down units have more critical patients that are on cardiac monitoring and may even be on a ventilator, but they do not meet the criteria for a critical care bed (or the micu is full and bed placement and administration is playing who can we kick out to open beds). They may require gtts to maintain normal pressures or heart rates. These patients require much more frequent assessment and have greater care needs than a med/surg patient.

My advice:

When you interview for a position, ask the nurse manager to define the unit and explain the types of care the patients require. Also ask about ratios. The more complex care each patient needs, the less patients each nurse should have.

My vent:

I work on a "med/surg" unit. We have a 1:6 ratio on a good day and a 1:7 ratio typically. I call it a med/surg unit because that is what my facility calls it. We have no step-down/progressive-care unit in the hospital. We do have two other units that that have tele monitors. Every bed in my unit has bedside cardiac monitoring (that also shows up on a central monitor at the desk, although there is no tech to watch them). Every bed is also vent ready. And we are the only unit outside of the micu/sicu/cvicu that has this. Out of 40 beds about 25-30 require tele and we have anywhere from 4-12 ventilators at a time depending on admissions. So out of my 6-7 patients, at least 5 are tele monitored and you get a vent patient (who always have a ton of care needs besides the vent care). We push lots of IV cardiac drugs that other units can't. However, we cannot titrate cardiac drips because there is no way to assess a patient frequently enough to titrate when you have 6 other patients. It is unsafe. We end up having a lot of rapids, falls, and even codes because of this arrangement. I have been in a vent room doing dressings and had another nurse come in to tell me that my CIWA patient down in the other hall was found on the floor with a systolic BP I the 200's. Sometimes a patient in fluid over load with giant pleural effusions that desperately needs a chest tube placed goes south and takes up your time and you can hear a vent alarm ringing and have to wonder if it is your vent and hope a team member jumps in a suctions them while you work on getting your CHFers sats up. We are told by administration that it is all about time management, but it is completely unsafe. Time managing tasks in med/surg (real med/surg) is one thing, but when your patients are very sick time goes out the window, you need to keep them alive!

I'm thinking of applying to ICU's and step down units in other hospitals at this point. I have learned a lot at my current job but I would like to take excellent care of a few very sick people without having to basically ignore the 4 or 5 patients that appear to be more stable (the guilt is getting to me, they are admitted to the hospital because they are sick but are neglected because they are placed on a unit that has patients MUCH sicker than they are).

[Elaken]

Your unit sounds terrifying. At my hospitals all med/surg have the ability to be remote tele, where a monitor tech watches all the hospital (including the patients on tele unit). Too often patients are put on tele unit because doctors think they get "better care" which is insulting. Our tele can do drips but no titrating. I have never heard of a vent patient outside of ICU. Continuous bipap is about the worst it gets. Or trach patients but with regular O2 and not a vent. And 4-5 ratios. I am not shocked you have so many rapids and codes. It seems like things keep getting more dangerous and I am afraid my hospital system will start going that way.

[caffeinatednurse, BSN, RN]

Our med-surg unit has remote tele. We take basically anything and everything - those awaiting SNF placement, pts needing IV ABX, insulin drips, heparin drips, PCA pumps, BIPAP, CPAP, traches, central lines, chest tubes, feeding tubes, etc. We're also dual-dx and take pts who are too physically ill to be admitted to our psych/detox unit (in other words, they're detoxing with complications and require close nursing supervision). We also take ambulatory patients - basically, your retina detached, you come in for repair of it and will go home in 3-4 hours as long as there's no complications. We also administer chemo, IVIG, etc. Our ratio is 1:5 to 1:6.

The criteria for admission or transfer to our PCU/tele unit is the presence of a cardiac arrhythmia (such as new onset A. fib w/RVR with no prior hx or current anticoagulation) or requiring cardiac drips. Some of our providers will go ahead and transfer a pt to PCU when their respiratory requirements are increasing and they suspect they may be headed for an ICU transfer. The ratio is 1:5 on our PCU unit.

[StevieRay BSN RN]

I work on a med-surg/tele unit. Our ratio is 4:1 and seldom we get 5:1 but we try to do our best to coordinate this so the RN with the sickest patient doesn't have a 5 patient assignment. All of our patient's are monitored & we do have remote telemetry technicians (although a majority of the time we catch a dysrhythmia first anyway). Many of our patient's are 1st day post-op transfers from the ICU after open-heart surgery. We get TAVR's, VAT's, permanent pacers, new onset A fib w/ RVR. It's a lot of pre and post cardiothoracic surgery patients. We have heparin drips, tridil (only for chest pain since we don't have continuous BP monitoring), PCA pumps, epidurals, cardizem and Amiodarone drips that need to be titrated, blood administration, IVIG. A ton of cardiac caths.

However we don't do insulin drips, venous sheaths or titrate cardiac drips for BP.

Hope this helps!

[Elaken]

As someone above said when interviewing get specific on what a unit takes and ratios.

At my hospital every unit takes insulin drips (I know at some this is considered ICU because of the hourly checks but not us nor does it cause a decrease in your patient load). Essentially our med/surg and tele only really differ by drips and procedures. Nitro/amio/diltz drips all have to be tele. But have to call doctor to get an order for rate adjustments. Obvs CABG, Tavrs, caths, pacemakers etc all go on tele.

Any unit can get continuous bipap, cpap, trachs, etc. but vents are only in ICU. Every unit can remote monitor a patient and there are monitor techs watching every monitored patient including the tele patients. A few units have monitors so you can look at the rhythms in real time.

In general we do 1:4 in days. Occasionally 1:5. I have never gone 1:6. Tele is less likely to go up to 5 than the other units.

I literally do not know how some of you do your jobs with the patient numbers and acuities that you all get.

All our hospitals are Magnet so I think that is one reason we don’t get overloaded with patients.

[EveP]

I work in a Tele unit and our ratio is mostly 1:6, some times 1:7 when we are short staffed. It's scary but true. Sometime without PCTs.