Step-Down Nursing Unit (SDU) Overview, Differences to ICU

A growing number of people with multiple co-morbidities and longer life expectancies are driving the need for more critical care beds. Developed in the 1960s, SDUs were designed to alleviate congestion in the ICU.

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Step-Down Nursing Unit (SDU) Overview, Differences to ICU

What is a Step-Down Unit (SDU)?

SDUs fill a gap between ICU and the MedSurg/Tele units by providing a:

  • lower level of care than resource-intensive ICUs and a 
  • higher level of care than MedSurge/Tele units

SDUs provide care to stable but critically ill patients of varying acuity.  SDUs have been found to significantly improve patient outcomes, especially in high-risk patients2. 

SDUs are known by a variety of names. Hospitals may call SDUs transitional care units (TCUs), progressive care units (PCUs), or specialty care units such as surgical, medical, neuro, coronary care units, or other names, depending on their population.

Table of Contents

Step-Down Unit vs. ICU

ICU nurses manage more technical equipment and more unstable patients than SDU nurses. Many procedures reserved for ICU settings include

  • Continuous renal replacement therapy (CRRT) 
  • Invasive and non-invasive hemodynamic monitoring
  • Titratable vasoactive drips such as norepinephrine, dopamine, and dobutamine
  • Intra-aortic balloon pump therapy (IABP)
  • Mechanical ventilation with propofol sedation
  • Temporary cardiac pacing
  • Ventricular drain management
  • Proning (prone positioning)
  • Intracranial pressure measurements (ICP)
  • Arterial lines
  • Extracorporeal membrane oxygenation (ECMO)

SDU nurses are not expected to provide the above treatments. Unstable patients remain in ICU until they are stabilized. ICU patients no longer requiring an intensive level of care can be transferred to SDU or to MedSurg/Telemetry, depending on the level of care required.

Step Down vs Intermediate Care Unit

Intermediate Care Units is another name for an SDU and they can be considered equivalent.

Step-Down vs. MedSurg/Telemetry

Despite the name "step-down,” the majority of patients in SDU are inpatients transferred from MedSurg (general wards), telemetry, or the emergency department, making it more of a "step-up"1.

Patients on SDU require more intensive nursing  care than MedSurg/Telemetry nurses are staffed to provide3.

Examples of MedSurg/Tele patients who are candidates for SDU include

  • A patient in diabetic ketoacidosis (DKA) who is otherwise stable but requires one-hour fingersticks and subsequent insulin adjustments 
  • A post-op patient with transurethral resection of the prostate (TURP) and continuous bladder irrigations who requires hourly urine measurements and manual irrigations
  • Patients showing signs of deteriorating conditions, such as early sepsis or increasing respiratory failure

SDUs Vary

SDU patient populations vary by the hospital, the medical needs of its community, and the healthcare service lines provided. Examples of service lines include orthopedics, cardiology, women's care, cancer treatment, organ transplant, cardiac, and more. They may consist of patients with organ transplants, craniotomies, open-heart surgeries, and unstable patients.

Differences in nursing practice vary by hospital policy. Some SDUs allow

  • Arterial lines
  • Mechanical ventilation
  • Certain titratable drips according to facility policy: insulin drips, cardizem drips, amiodarone drips, heparin drips, lasix drips, metoprolol, dopamine, and dobutamine. 
  • Immediate post-operative recovery

Types of Patients on SDU

SDU patients include those with complex medical conditions and multiple co-morbidities  requiring close monitoring and frequent nursing interventions.  
Patients who may be cared for on step-down units include those with 

  • Acute respiratory failure 
  • Sepsis
  • Acute renal failure 
  • Neurological conditions such as strokes or brain injuries
  • Ventilator-dependent patients with tracheostomies 
  • Diabetic ketoacidosis
  • Pulmonary hypertension 
  • CHF 
  • Lung transplants post-op
  • Heart transplants post-op
  • Comfort care or palliative care on a morphine drip
  • CIWA alcohol withdrawal
  • Bariatric surgeries post-op
  • Cardiothoracic surgeries post-op

In other words, a wide variety of diagnoses. It is not the patient's diagnosis but the patient's acuity and workload that makes them step-down level. 

Patient Ratios in SDUs

SDU nurse-to-patient ratios vary by hospital and are typically from 1:2- 1:41,2.

SDU Nursing Competencies 

According to the American Association of Critical-Care Nurses (AACN), SDU nurses must be competent to care for patients who are unstable, unpredictable and require complex care4.

Nurses in the SDU are responsible for recognizing cardiopulmonary emergencies and monitoring patients at the bedside.

Commonly required competencies include the management of:

  • Chest tubes (pleural and mediastinal)
  • Post-op drains (hemovac, jackson-pratt)
  • Urinary catheters (suprapubic, urethral, nephrostomy)
  • Tracheostomies (suctioning, dressing changes)
  • Gastrostomy tubes (G-tubes) and percutaneous endoscopic gastrostomy tubes (peg tubes) 
  • Oxygen delivery devices  (mechanical ventilation, high-flow oxygen, bipap, C-pap, blow-by, cannula, masks)
  • Blood and blood products, transfusions
  • Wound vacs
  • IVs: PICC lines, implanted ports, dialysis lines, arteriovenous (AV) shunts, peripheral
  • Sequential compression devices (SCDs) 

SDU nurses also need: 

  • Stroke assessment (NIH stroke scale)
  • Basic dysrhythmia 
  • Basic life support (BLS) and advanced cardiac life support (ACLS)
  • 02 sat and arterial blood gasses (ABGs) interpretation skills
  • Knowledge of pressure injury prevention and treatment
  • Knowledge of palliative care and comfort care

Patients receiving dialysis can be on SDU but a contract dialysis nurse will perform the procedure.

How Do You Become a Step-Down Nurse?

Many hospitals hire newly graduated registered nurses directly into step-down units and provide additional training as needed. Others take nurses with 1-2 years of MedSurg/Tele experience.3

Speciality Certification PCCN 

Progressive Care Critical Nurse (PCCN)  is the AACN certification for Telemetry and SDU unit nurses. Eligibility includes practice as an RN or APRN for 1,750 hours in direct care of acutely ill adult patients during the previous two years, with 875 of those hours accrued in the most recent year preceding application. 4

Day-to-Day Role, Responsibilities and Salary

SDU nurses' salaries are often the same as other hospital nurses. Nursing salaries typically vary from hospital to hospital and according to union contracts, but not by specialty.

Because SDU patients require close monitoring, SDU nurses frequently accompany their patients off the unit for diagnostic testing, such as CT scans, called "road trips". SDU nurses also assist providers in bedside procedures, such as inserting a chest tube, or removing pacing wires.

Pros and Cons of Step-Down Nursing, Anecdotal

All nurses are different; what one nurse considers a pro, another may consider a con. For example, a slower pace is a pro for some and a con for others. Here are some common observations:

Pros Cons
  • Complexity of patients is stimulating
  • Promotes teamwork as the heavy physical care requires co-worker assistance
  • Gratification when a severely ill patient recovers
  • Increased interdisciplinary teamwork
  • Therapeutic relationships with families due to longer length-of-stay
  • Continuity of care
  • Higher patient: nurse ratio
  • Transferable skills, bridge to ICU for nurses seeking critical care
  • Bedside monitor provides visual cues and builds arrhythmia skills faster
  • Slower pace interspersed with rapid responses and codes
  • Internal validation 
  • Steep learning curve due to patient complexity
  • Physically demanding with regular patient positioning, assistance with ADLs
  • Futility of prolonging life or interventions
  • Increased rapid responses (RRTs)
  • Longer lengths of stay may be monotonous to some 
  • Slow patient progress 
  • Higher patient acuity and workload
  • Multiple competencies required
  • Risk of alarm fatigue5
  • Repetitive work
  • Less recognition and not viewed as specialty nurses as compared to ICU and ED counterparts

It is common for patients transferring out of the intensive care unit to have anxiety about losing their one-to-one nurse. It's important to anticipate patients' and family members' fears and reassure them.

With fewer patients, close collaboration, and rewarding patient care, the SDU can be considered a hidden jewel of a unit.

STAFF NOTE: Original Community Post 

This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post:

Quote

I am always hearing step-down unit and am afraid to ask anybody what it means. I thought it was ICU "a step down from med-surg" but I know that it sounds stupid. Can you tell me the difference between Step Down Unit and ICU?

References

1. Prin M, Wunsch H. The role of step down beds in hospital care. Am J Respir Crit Care Med. 2014 Dec 1;190(11):1210-6. doi: 10.1164/rccm.201406-1117PP. PMID: 25163008; PMCID: PMC4315815. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315815/ 

2. Lekwijit S, Chan CW, Green LV, Liu VX, Escobar GJ. The Impact of Step-Down Unit Care on Patient Outcomes After ICU Discharge. Crit Care Explor. 2020 May 6;2(5):e0114. doi: 10.1097/CCE.0000000000000114. PMID: 32671345; PMCID: PMC7259559. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259559/

3.Zhu, B., Armony, M., & Chan, C. W. (2013). Critical care in hospitals: when to introduce a step down unit. Working paper, Columbia University. 4.2. https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=4758cc435e0e8800071db76746c6f3352341debb 

4.AACN's Competence Framework for Progressive and Critical Care: Initial Competency 2022 https://www.aacn.org/~/media/aacn-website/nursing-excellence/standards/aacn-competence-framework-2022.pdf 

5. Storm, J., & Chen, H. C. (2021). The relationships among alarm fatigue, compassion fatigue, burnout and compassion satisfaction in critical care and step‐down nurses. Journal of Clinical Nursing, 30(3-4), 443-453. https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.15555

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Nurse Beth

About Nurse Beth, MSN

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Hi! Nice to meet you! I especially love helping new nurses. I am currently a nurse writer with a background in Staff Development, Telemetry and ICU.

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Specializes in Adult and Pediatric Vascular Access, Paramedic.

ICU is for patients who are either unstable or have a high potential of becoming unstable. A lot of these patients require invasive monitoring through arterial lines, medications to support certain functions like BP, and ventilators to assist with breathing. A step down unit from ICU would be a telemetry unit where patients who need to be on a cardiac monitor and have frequent VS taken stay. The cardiac monitor is actually only a small box that the patient wheres so they have more freedom as they are not attached to a wall monitor like the ICU patients. These patients are stable, but may require monetary because they have some potential of becoming unstable. Many of these patients end up being heart patients.

ICU is where the most critical patients go, telemetry (aka tele) is a step down from the ICU, and med surg is a step down from the telemetry unit. Just keep in mind not all patients stop at all those floors, some may go home from the tele floor, and how sick the patients are depends on the hospitals and its policies.

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rn2bn07 said:
Hello! I am always hearing step-down unit and am afraid to ask anybody what it means. I thought it was ICU " a step down from med-surg" but I know that it sounds stupid.

Can you tell me the difference, I graduate in May 2007 and I am trying to decide if ICU or "step-down" is the critical care unit I want to join.

Hey, there's no stupid question. Just the one that one is afraid to ask!

Before I got into nursing, I thought there was only the ICU and the med/surg general floor. Then I heard about stepdown or the intermediate unit. ICU patients are critically ill patients. Often they can be sedated or intubated, so you don't have much chance to interact with them. Intermediate or stepdown patients are generally on a monitor. They can talk and interact with you, but they aren't as well as the general med/surg patients or critically ill like ICU patients. The other difference is that in the ICU you may care for 1 or 2 patients, while in the stepdown, the ratio is 1:3 or 1:4 (depends on the hospital).

If you have the chance, ask if you can shadow a nurse in the ICU and the step-down units. Then you can observe the level of care for each patient and decide. Good luck! wave.gif.f76ccbc7287c56e63c3d7e6d800ab6c

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Specializes in Critical Care, Emergency.

There's one hospital I know of in NYC that has a step down unit and their patients are sicker than some ICUs I've been to.. I guess it depends on where you are.. I wouldn't blanket the statement that all step downs are the same.

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Specializes in ICU.

I have to agree that there isn't a single definition for a "step-down unit" because I work in a hospital where there is one 14-bed ICU and next door is a 16-unit "Intermediate Care Unit" where the ratio is 1:3, but often the patients are still as serious or worse, but often maybe the care is not going to be as aggressive, so there's more DNRs or nursing home patients, but still as heavy or more to take care of. Vitals are done q2, there's sometimes a. lines, insulin drips, and vasopressors, hopefully with less titration than in ICU, but not necessarily. If a pt. codes there, they often keep them instead of transferring, if it's doable with a 1:3 ratio. It's a lot of work...personally, ICU is a lot less stressful most of the time!!

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Specializes in ER/ ICU.

Depends on the capabilities of the step down unit. Ours take vents, a- lines, post carotid, post open heart( day 2) post AAA stents, post CVL patients etc... Ours is very progressive. We have taken Swans as well.

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Having worked on both units many times, I would say the biggest difference is not the type of medications on a drip but the rate and titration of those drips.

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Specializes in ER, progressive care.

Stepdown capabilities vary from facility to facility. I can tell you the stepdown that I work on now is different from the stepdowns I have worked on as a NT. Those stepdowns (when I worked as a NT) took vents, but I never saw A-lines or swans (maybe they had them, just not while I was working lol). Patients would be on titratable drips.

Where I work now - we do not take vents. We do not have A-lines or swans. Patients can be on drips; however, we are technically not supposed to titrate them. If they need to be titrated (and usually they do!) they need to be transferred to ICU. The only drip we are allowed to titrate is NTG for chest pain only, not for BP. The rationale is because my unit is more spread out than our ICU and the patient:nurse ratio is 4:1 whereas in ICU it is 2:1. For patients on a titratable drip, they need more monitoring. There have been times where I have titrated a cardizem drip (from 10 down to 5, because the patient's BP and HR wasn't tolerating it - nursing judgement call) but I did give the on-call cardiologist a buzz to explain the situation and to get an official order to have the dose changed down to 5 on the MAR.

Think of stepdowns as a "stepdown" from ICU. You have ICUs where the most critical patients go, then a stepdown unit where the patient is still semi-critical - not well enough to go to a med-surg unit. They need more monitoring with telemetry. Then of course you have med-surg. As HappyParamedicRN said, not all patients go from ICU to a stepdown to med-surg or vice versa. it just depends on the condition of the patient.

We still get very sick patients on my unit, too. We get a lot of cardiac/respiratory problems, but I've seen DKAers, HHNKSers, PE's, patients with tamponade, etc. Hope this helps!

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Specializes in Critical Care.

Step-down does vary depending on the hospital.

In my hospital, our ICUs are all the unstable with titrated vasopressors and sedation. They are 1:2

Our Progressive care is more stable but critical. Policy states they can have titrated pressors and sedation like the ICU, but they really only do pressors at set rates by the MD, but can still do titrated sedation. Most of the patients have already been trached and are often still vent dependant. They are on all the same bedside cardiac monitors as the ICU, but A-lines, Swan lines, and pretty much any other invaisive hemodynamic monitoring go to the ICU. CVPs and ICP monitoring can be done in the Progressive unit. Patients requireing q2 or more frequent neuro checks, accuchecks, vitals, etc are by policy required to be in a minimum of at least Progressive care. Ratio is also 1:2 like the ICU. Our progressive unit has sicker patients then most other ICUs in our region. Our prog unit is actually pretty difficult and is considered part of our ICU division. ICU nurses hate floating to Prog because they know they are going to have to work way harder then they ever do in the ICU.

Then we have our Step-down units. They have tele, and are used to getting people who come out of the ICU. They aren't sick enough to need ICU or Prog, but not well enough for a normal cardiac tele or med/surg. They are often medically stable, but have more frequent meds or time consuming dressing changes, full care or almost full care, etc. I think ratios are 1:4.

Cardiac tele is mostly walkie talkie patients who are in need of just cardiac tele monitoring. Ratios are 1:5.

Med/surg is probably pretty generic to other hospitals. The most stable of all hospitalized patients. Unmonitored. Ratios are 1:6.

All of these descriptions vary greatly by hospital. Even other hospitals within our own hospital system are entirely different.

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Specializes in SICU.

I work in a SICU stepdown, its funny really we play musical chairs with the SICU, the pts come/go back/come/go back as many as 4 times a week. Noone is stable, we just down have the invasive lines... oh not to mention the codes every night!

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