What is a Cardiac Surgery Step Down Unit Like?

[VANurse2010]

Hi All,

I just got offered a residency position in a cardiac surgery step-down unit and I am not quite sure what to expect. Is cardiac surgery step-down similar to the CCU? Is there a difference between cardiac surgery step-down and telemetry? What population of patients would I see? Also, what is the best way for me to prepare for this position? I'd appreciate any advice!

The best person to answer these questions is your unit director, but in general...

Telemetry and step-down are the same thing in some hospitals, and in others step-down is higher acuity with lower patient:nurse ratios. Step-down may take more and different drips than telemetry and have the ability to titrate, depending on the unit. Some step-downs also take arterial lines and chronic or newly-chronic ventilators. Telemetry typically does not take patients with anything more invasive than IV access and often any cardiac drips are non-titratable in telemetry units. Ratios can go as high as 6:1, maybe more in a really bad hospital.

Either will be a crap storm of admissions and discharges. From my perspective as a critical care nurse (and former telemetry and step-down nurse), those two are the worst! Sometimes very high acuity with lots of admits/discharges and turnover. It's my hell on Earth.

[anchorRN, BSN, MSN, RN, APRN]

Hello! I'm a CTICU nurse by trade (although currently in the military), and have sent many post-cardiac surgery patients to stepdown. The biggest difference between a tele floor and stepdown is the patient population. You will mainly see post CABG/Valve/Thoracotomy, etc patients on the stepdown who have different needs than a normal tele patient. This includes getting the patient up to walk many times per day (thoracic surgery is painful and patients can end up with a nasty pneumonia if not up and moving alot). Also you will be monitoring chest tube outputs in case there is something bleeding, and of course arrhythmias (Afib is a very common post cardiac surgery complication). The ratios are typically lower on a stepdown also, since the majority of these patients are being admitted from an ICU (versus from the ER or a clinic/cath lab on a tele floor). There are many other considerations/duties but these stick out the most for me.

[anchorRN, BSN, MSN, RN, APRN]

I think it would be a great learning experience! I was hired as a new grad into an ICU and never looked back. I had a great preceptor and caught on quick. Its a big learning curve but you can do it!

[Nurse SMS, MSN, RN]

I formerly worked on a Cardiac Stepdown unit. We were considered to be the "other half" of the cardiac ICU. We cared for cardiac and thoracic surgeries for the most part. They would go to ICU for 24 hours to be weaned off the vent and then transferred to us within a few hours if that went well and they were stable. Ratios were 3-4:1. There was a lot to remember and lots of critical little details to be checked off, particularly in patients who had open heart surgery. There were a lot of chest tubes, lots of thoracotomies. Lots of patient interaction...getting them up and showered, getting them walking, removing staples, etc. I really enjoyed it.

The ratios changed though to 4-5:1 and they started giving us med-surg overflow. That was a nightmare. Having 3 fresh postop hearts plus two total cares, sometimes one with C-Diff or other precautions going on, was not just scary from an infection standpoint, but was a huge source of exhaustion and burnout. Cardiothoracic surgery patients aren't necessarily hard to care for, but they are time consuming and detailed with a certain amount of emotional support needed.

You will learn a LOT. Little things matter a great deal and charting must be A+ every shift. The patient population is generally a very grateful one, but anxious...after all, a lot of them just had a heart attack and are lucky to be alive. There can be family dynamics and visitor issues, but those are just part and parcel of being afraid most of the time.

It is a good area for a new grad. Congratulations on the job offer and I hope you enjoy it!

[rcnursing]

Thank you for the advice! My school does a residency program for selected students over the summer between junior and senior year. My goal for this experience is to see and learn as much as possible. I am not obliged to work on the floor after the residency. Do you think that working in cardiac surgery step-down unit would be a good learning experience?

[rcnursing]

Perfect! Thank you so much!

[rcnursing]

I formerly worked on a Cardiac Stepdown unit. We were considered to be the "other half" of the cardiac ICU. We cared for cardiac and thoracic surgeries for the most part. They would go to ICU for 24 hours to be weaned off the vent and then transferred to us within a few hours if that went well and they were stable. Ratios were 3-4:1. There was a lot to remember and lots of critical little details to be checked off, particularly in patients who had open heart surgery. There were a lot of chest tubes, lots of thoracotomies. Lots of patient interaction...getting them up and showered, getting them walking, removing staples, etc. I really enjoyed it.

The ratios changed though to 4-5:1 and they started giving us med-surg overflow. That was a nightmare. Having 3 fresh postop hearts plus two total cares, sometimes one with C-Diff or other precautions going on, was not just scary from an infection standpoint, but was a huge source of exhaustion and burnout. Cardiothoracic surgery patients aren't necessarily hard to care for, but they are time consuming and detailed with a certain amount of emotional support needed.

You will learn a LOT. Little things matter a great deal and charting must be A+ every shift. The patient population is generally a very grateful one, but anxious...after all, a lot of them just had a heart attack and are lucky to be alive. There can be family dynamics and visitor issues, but those are just part and parcel of being afraid most of the time.

It is a good area for a new grad. Congratulations on the job offer and I hope you enjoy it!

Thank You not.done.yet ! I am excited to start and really hope the experience will be a positive one!