Unit Manager wants to create a Step-down Bed, we think it's a terrible idea. HELP!

[WVRN2014]

So some background:

We are a small, 7 bed Pediatric unit (can accommodate up to 12, but we only room adults together). This is in a relatively small hospital, approximately 150 beds. Local clinic pediatricians have admitting privileges and are the primary service for inpatient peds (no hospitalist service). We admit patients for "floor" level of care - assessments q12h, V/S q4h (can be on continuous pulse oximetry), can do oxygen but no bipap, no tele. Typical pediatric patient population includes asthma exacerbation and acute respiratory infection, NAS babies, and some surgical patients. We do accommodate adults, and although we try to stick to ob/gyn females, that frequently is overruled by the house supervisor. Recently, there was a child who had been in an MVA and brought into the ER. From what we heard, the child had a grade 3 liver laceration, and one of the surgeons was willing to admit him and keep him in ICU (we do not have a peds ICU, but they will take children in DKA). The ICU nurses refused, and the child was transferred out.

This came up in a meeting with upper level management, and somehow or another, it was decided that we need to renovate one room to be a step down bed. This was mentioned casually by our manager about a month ago, but we haven't been told anything official about it until now. We are set to have an "open forum" staff meeting in a week, and we just found out that the vote to finalize this bed is happening earlier in the same day, prior to our staff meeting.

We staff nurses are all very concerned, as we do not think this level of care is appropriate for our facility considering our resources. For one, our staffing consists of two RN's regardless of patient census, and no CNA/tech (which is typically not a problem, but when we have adults they tend to have higher needs, especially when we have close to 10 patients). We do not have a secretary, nor are there transport personnel on at all times. While most of our pediatricians are decent, there is one doctor who is notorious for being difficult/impossible to reach for hours when on call, pretty consistently. Our manager recently purchased an expensive cardiac monitor to be placed in the room, one without remote monitoring capabilities. I am the only nurse on the unit that is able to interpret tele (background in adult ICU). And I hate to say it, but only three of the other nurses have ever worked anywhere besides this unit, and the majority of them really do not have the experience/stamina to keep up with something like an insulin drip.

Our manager is included in the number of those who haven't worked elsewhere, and we don't think she really understands the level of risk we would be assuming with this bed. Furthermore, the logistics of a single step-down bed don't make sense. Per her words, should we have to admit a child to this step-down bed, we would "flex staffing" to cover the admission and make it a 1:1 patient to nurse ratio. We are more often than not forced to work either alone, or with a CNA/tech as a substitute if one RN calls off, as there is limited staff elsewhere to pull from.

We (especially I) feel that this is a really bad idea. Coming from my background in ICU and having worked step-down before that, I really feel like it's exposing us to a great level of uncertainty and unsafe conditions. Not really sure what to do, we aren't really allowed any influence over decisions like this.

Any advice would be GREATLY appreciated, thank you.

[Rose_Queen, BSN, MSN, RN]

I don't work peds, but I would be sure that if this plan does move forward that all nurses are provided with education in interpreting rhythms and PALS at an absolute minimum. There should also be a policy and procedure developed for how adequate staffing will be provided should a step-down patient be admitted- will nurses be taking call/will someone float from another unit/what other options are available? It may be helpful to contact other facilities to learn what they are doing if they have a similar set up.

[AnnieOaklyRN, BSN, RN, EMT-P]

This sounds dangerous if there is no tele capability, a nurse would have to stay in the room!!

[JeanOfAllTraits]

Forgive me, but I feel a bit confused. What access do you have to a PICU?

Aome other things I'd ask wouls be: What is the process for moving a step down pt to a PICU bed? Who an admit to the step down bed?

[canoehead, BSN, RN]

You can get all the education you want, but if you don't get the experience (ie more than ONE bed at this level of care) you can't give those patients the level of care they need. 1-1 ratio for stepdown is a waste of money, so it's a losing idea financially and care wise.

[canned_bread]

I have not been in this situation, but I am glad that you are finding it troubling, because by what you describe, it has a high potential for something to go wrong.

If I was in your position I would speak to colleagues and see how they feel, and also speak to the union about your concerns. I would speak to the manager (although I am sure they feel tied up) and also use the forum as a way to speak up. Explain that it puts the staff at risk of registration problems and also stress, and it is a potential liability and concern for the hospital.

As it is, it sounds like you are seriously at capacity. I cannot imagine what would happen if one of your patients deteriorated and required 1-1 care, and then someone else needed help. It does sound scary.