What is a cardiac stepdown?

[Thedevinestman]

I recently started my first nursing job on a cardiac unit. Many of the experienced nursing staff have voiced their opinions regarding the patient populations we are serving and that the acuity of these patients is too high. My hospital has two general icu's with one of them taking only cabg/valve patients, one cath lab, and one cardiac unit. We can take any cardiac patient that isn't vented including patients on vasoactive drips, patients on heparin, patients in active chest pain etc. As well as post EP patients, post angio/stent patients, and patients with femoral art lines. We can take 4 patients on my floor (though it is more often 5). I have heard many of my preceptors say that our staffing ratio's are unfair because our floor is "basically a stepdown." I've never heard this term before and because this is my first job I don't really have any global perspective. Could anyone that works on a stepdown, or knows what they are, shine some light on the subject?

[Rose_Queen, BSN, MSN, RN]

Basically, a step-down is a transition unit between the ICU and the regular floor. Patients who don't require the intensity of an ICU setting but who are still a bit beyond the med/surg or tele unit.

[VANurse2010]

You shouldn't be taking anything beyond diltiazem and/or amiodarone for non-ventricular arrythmmias (meaning if they need it for active VT, they need to be in the unit) with the ratios you're describing. Femoral art line is also inappropriate for 4-5 patients. I don't see a problem with active chest pain on a unit like this provided there are minimal to no EKG changes and non-crazy troponins.

In more general terms, a cardiac stepdown is a hot mess of constant admissions and discharges and variable, often inappropriate, acuity. Your mileage may vary.

[martymoose, BSN, RN]

you must have misunderstood. It stands for cardiac step -dump.

[BSN16]

we call our step down unit a post critical unit, but it's all the same...a step down from icu or post icu

[martymoose, BSN, RN]

ok I'll try to provide some useful information.

My "stepdown" gets pts on cardizem, labetelol( not too often) amiodarone, lidocaine( rarely) heparin, lasix,diuril, nitroglycerin ,milrinone,natrecor( haven't seen that one in a while)dobutamine (rarely)drips, and sepsis pts such as endocarditis who are on q4 hr atc abx. A fibbers on tikosyn,AC's, cardioversions, TAVR's, TEE's , PE's ,MI's cath lab pts, pacers/aicds/BiVIcds. Art lines, venous lines.TRBands.The other day we got a pt who had ballooning of the femoral/iliac artery- thats a new one for us.

We also get the rest of ED pts to fill beds- psych, geripsych, dementia, dialysis, sepsis,general medical pts' etc.

We have lots of turnover- we move pts to other floors for cath lab pts. Not unusual to turn your whole assignment over(5 pts sometimes) usually 4 on days. But if short, have had up to 6 pts.

HTH.

[VANurse2010]

martymoose said:

ok I'll try to provide some useful information.

My "stepdown" gets pts on cardizem, labetelol( not too often) amiodarone, lidocaine( rarely) heparin, lasix,diuril, nitroglycerin ,milrinone,natrecor( haven't seen that one in a while)dobutamine (rarely)drips, and sepsis pts such as endocarditis who are on q4 hr atc abx. A fibbers on tikosyn,AC's, cardioversions, TAVR's, TEE's , PE's ,MI's cath lab pts, pacers/aicds/BiVIcds. Art lines, venous lines.TRBands.The other day we got a pt who had ballooning of the femoral/iliac artery- thats a new one for us.

We also get the rest of ED pts to fill beds- psych, geripsych, dementia, dialysis, sepsis,general medical pts' etc.

We have lots of turnover- we move pts to other floors for cath lab pts. Not unusual to turn your whole assignment over(5 pts sometimes) usually 4 on days. But if short, have had up to 6 pts.

HTH.

Yep. I just couldn't deal with that BS anymore, which is why I moved to critical care. Life's too short to deal with that nonsense when there are other opportunities that pay the same.

[Thedevinestman]

Thank you everyone for your comments. It's nice to know more about other hospitals and how they run their units.

Warm Regards

[CCU BSN RN]

I recently moved from a hospital where I was on the Surgical Telemetry floor, we got all the CT surgery patients directly from CCU. Our ratios were that of a normal med/surg unit, ideal ratio 4-5 but often 6-8 patients. New hospital CT surgery patients go from CCU to CT Surg Stepdown to Telemetry. Stepdown has 3:1 ratios. My experience has been that:

1. It's SUPER AWESOME to have somewhere in between to send your patients because

2. There are a lot of grey areas in terms of when a patient doesn't quite need the ICU but isn't stable for a nurse with a 6 patient assignment yet.

In my new hospital things that CANNOT go to telemetry but most stay in stepdown include but are not limited to:

1. CPAP/BIPAP dependent, more than just at hs or for a couple of hours if they flash (hell even high flow nasal cannula ends up there)

2. Titrating vasoactives- Dopamine, Diltiazem, Labetalol, Cleviprex, Dobutamine, NTG, even Milrinone etc.

3. No underlying rhythm or a non-perfusing rhythm under their epicardial pacemaker

4. Still requires arterial line or Cordis

5. Still on an insulin gtt postop (tele will sometimes take these but not for more than 4-6h before gtt scheduled to be turned off)

6. Needing VS/Neuro Checks/etc. q2h instead of q4h

7. Anyone with a transvenous pacer or complete heart block requiring PPM placement (they go to tele after the EP lab)

Things I would feel unsafe caring for with your ratios:

1. Any pressor other than renal dose dopamine or dobutamine (e.g. I hope you don't have vasopressin, levo, epi at that level of care)

2. Arterial Lines

I'm sure I'm forgetting a few more but I'm post night shift, have mercy!

Keep in mind that all of the above pertains to Cardiothoracic Surgery patients, not to general stepdown units, I can't speak to those.

Something I've heard of hospitals doing is designating some of their CICU beds or some of their Tele beds as 'Stepdown rooms', where you essentially have a mini stepdown unit within your unit, and the RNs staffing those rooms have a 3:1 ratio instead of a 5:1 ratio to allow them to provide care to a wider variety of patients. E.g. Rooms 1-30 are telemetry beds and rooms 30-36 are stepdown beds, can take art lines and titrate gtts, etc. Might be something to research or suggest to management, because the expectations seem like they might in fact be unreasonable at times on your current unit.

Cheers

[VANurse2010]

CCU BSN RN said:

I recently moved from a hospital where I was on the Surgical Telemetry floor, we got all the CT surgery patients directly from CCU. Our ratios were that of a normal med/surg unit, ideal ratio 4-5 but often 6-8 patients. New hospital CT surgery patients go from CCU to CT Surg Stepdown to Telemetry. Stepdown has 3:1 ratios. My experience has been that:

1. It's SUPER AWESOME to have somewhere in between to send your patients because

2. There are a lot of grey areas in terms of when a patient doesn't quite need the ICU but isn't stable for a nurse with a 6 patient assignment yet.

In my new hospital things that CANNOT go to telemetry but most stay in stepdown include but are not limited to:

1. CPAP/BIPAP dependent, more than just at hs or for a couple of hours if they flash (hell even high flow nasal cannula ends up there)

2. Titrating vasoactives- Dopamine, Diltiazem, Labetalol, Cleviprex, Dobutamine, NTG, even Milrinone etc.

3. No underlying rhythm or a non-perfusing rhythm under their epicardial pacemaker

4. Still requires arterial line or Cordis

5. Still on an insulin gtt postop (tele will sometimes take these but not for more than 4-6h before gtt scheduled to be turned off)

6. Needing VS/Neuro Checks/etc. q2h instead of q4h

7. Anyone with a transvenous pacer or complete heart block requiring PPM placement (they go to tele after the EP lab)

Things I would feel unsafe caring for with your ratios:

1. Any pressor other than renal dose dopamine or dobutamine (e.g. I hope you don't have vasopressin, levo, epi at that level of care)

2. Arterial Lines

I'm sure I'm forgetting a few more but I'm post night shift, have mercy!

Keep in mind that all of the above pertains to Cardiothoracic Surgery patients, not to general stepdown units, I can't speak to those.

Something I've heard of hospitals doing is designating some of their CICU beds or some of their Tele beds as 'Stepdown rooms', where you essentially have a mini stepdown unit within your unit, and the RNs staffing those rooms have a 3:1 ratio instead of a 5:1 ratio to allow them to provide care to a wider variety of patients. E.g. Rooms 1-30 are telemetry beds and rooms 30-36 are stepdown beds, can take art lines and titrate gtts, etc. Might be something to research or suggest to management, because the expectations seem like they might in fact be unreasonable at times on your current unit.

Cheers

Your hospital seems to have a good system. you should be able to take milrinone on telemetry though. I'd consider that less dangerous than dopamine or dobutamine

[CCU BSN RN]

I agree re: milrinone v. dopa but in actuality pretty much all drips stay in stepdown for us. Allows telemetry nurses to focus on early ambulation and all that stuff while providing basic monitoring, and keeps the ICU from being clogged every time a patient needs slightly closer monitoring.