Step-Down Unit Acuity

[Claire825]

We are discussing acuity based staffing on our unit, and whether we should be considered ‘step down’, particularly in regards to some of the specialty patients we accept. We are officially deemed ‘med-surg’, except when residents sign their notes as ‘ICU’ (confusing, huh?). We take as little as POD#1 CABG/Valves/heart transplants, PA catheters (Swan-gantz catheters), post-Cath lab (including TR bands and femoral sheath pulls), an array of cardiac drips including remodulin, NTG and dopamine, and LVAD patients. We all take a critical care course and are ACLS cerified. We are fairly strict about a 4:1 ratio, with hardly any deviation from this ratio (never 5:1, basically never 3:1 unless you just had a discharge). We only have one mandatory assessment charted per day. We are trying to argue that some of these patients, particular fresh open hearts and SWANs would be on true ‘step down’ units or the ICU at other hospitals. Do any other facilities take these patients outside the ICU, and if so, what are your ratios? Do you think those ratios are safe at your own facilities? Any information or input is appreciated, as well as any literature references. I can find very few scholarly articles and very little consistency about the definition of a ‘step down’ unit, the types of patients that should be on them, and the recommended nurse:patient ratio on these units. Thank you!

[Corey Narry, MSN, RN, NP]

Where I work, patients with PA catheters are not admitted outside of the ICU's. Remodulin and other cardiac drips that no longer require hour to hour titration are admitted to Cardiac Step Down only. Per California law, Step Down must be staffed 1:3. In our setting, designations of where patients go depends on the skill level and training provided to specific staff in specific units. There are hospitals that have trialed PA catheters used outside of the ICU such as this one: Changing the Environment of Care for Patients With a Pulmonary Artery Catheter

[guardchick2012]

At my facility, all of our open heart patients go to the Cardiovascular ICU. A lot of the other things you described are often seen in our Coronary ICU and Coronary Stepdown, depending on what else is also going on with the patients. Our Stepdown unit can be pretty difficult at times; we aren't really supposed to have more than 4 patients, but oftentimes we are short-staffed and end up with a 5:1 ratio. This isn't very safe as sometimes I have been running my butt off all night even with a 3:1 ratio, and I've actually been considering leaving my facility because of it.