What are the guidelines for determining whether a patient should be admitted to a telemetry unit versus a stepdown unit based on their level of acuity?

Guidelines for Determining Patient Placement in Telemetry versus Step-Down Units Based on Acuity

Patients should be placed in telemetry or step-down units based on their monitoring needs, hemodynamic stability, and required level of nursing care, with step-down units being appropriate for patients who need more intensive monitoring than general wards but do not require ICU-level care. 1

Definitions and Distinctions

Step-Down Units

• Function as intermediate care between ICU and general wards
• Provide higher nurse-to-patient ratios than general wards
• Allow for more intensive monitoring and nursing care
• May include capacity for invasive monitoring and vasoactive infusions 2
• Often referred to as progressive care units, high-acuity units (HAU), or intermediate care units

Telemetry Units

• Focus specifically on continuous cardiac monitoring
• May have lower staffing ratios than step-down units
• Primarily for patients requiring arrhythmia detection and monitoring
• Often used when cardiac monitoring is the primary concern without need for other intensive interventions

Patient Selection Criteria for Step-Down Units

Appropriate for Step-Down Units:

1. Post-ICU transition patients:

   • Patients discharged from ICU who still require close monitoring but are hemodynamically stable 3
   • Particularly beneficial for high-risk patients with higher illness severity 3

2. Post-procedural monitoring:

   • Patients after successful interventional procedures (e.g., PCI for STEMI) who are stable 4
   • Patients after transcatheter structural interventions who require arrhythmia monitoring 1

3. Neurological monitoring needs:

   • Stroke patients after initial 24-hour monitoring period in acute stroke unit 1
   • Patients with neurological conditions requiring frequent neurological checks but not ICU-level care 1

4. Hemodynamically improving patients:

   • Patients with improving hemodynamic status who still require more monitoring than general wards
   • Patients weaned from vasopressors but still requiring close observation 1

Patient Selection Criteria for Telemetry Units

Appropriate for Telemetry Units:

1. Cardiac monitoring needs:

   • Patients requiring continuous ECG monitoring for arrhythmia detection
   • Patients with ventricular assist devices (VADs) admitted with non-cardiac problems 1
   • Patients on QT-prolonging medications requiring QTc monitoring 1

2. Specific patient populations:

   • Stable patients with gastrointestinal bleeding with associated SVT 1
   • Patients with electrolyte abnormalities at risk for arrhythmias 1

Decision Algorithm for Patient Placement

1. Assess hemodynamic stability:

   • Unstable vital signs → ICU
   • Stable but requiring close monitoring → Step-down unit
   • Stable requiring only cardiac monitoring → Telemetry unit
   • Stable without monitoring needs → General ward

2. Evaluate monitoring requirements:

   • Need for invasive monitoring (arterial lines, central venous pressure) → Step-down unit
   • Need for continuous cardiac monitoring only → Telemetry unit
   • Need for frequent neurological checks → Step-down unit

3. Consider nursing care intensity:

   • Requiring 1:2 nursing ratio → Step-down unit
   • Can be managed with 1:3-4 nursing ratio → Telemetry unit
   • Can be managed with 1:5+ nursing ratio → General ward

4. Evaluate specific clinical scenarios:

   • Stroke patients: First 24 hours in acute monitored beds, then step-down 1
   • Post-PCI STEMI patients: Can be managed in step-down units rather than CCU if stable 4
   • VAD patients: Typically require telemetry units with staff trained in VAD care 1

Clinical Benefits of Appropriate Unit Placement

• Step-down unit care for ICU patients with higher illness severity is associated with:

  • 2.5% absolute decrease in in-hospital mortality
  • 1.1-day decrease in remaining hospital length of stay
  • 3.6% decrease in ICU readmission within 5 days 3

• For lower-acuity ICU patients, step-down unit care is associated with:

  • 3.9% absolute decrease in 30-day hospital readmission 3

• High-acuity postoperative units for medium-risk surgical patients allow:

  • Enhanced detection of early complications
  • Decreased incidence of subsequent complications after ward transfer
  • Increased days at home at 30 days 2

Common Pitfalls to Avoid

1. Using telemetry as a surrogate for better staffing ratios rather than for specific cardiac monitoring needs 1

2. Keeping patients in higher-acuity settings longer than necessary, which can lead to resource constraints and decreased availability for patients who truly need higher levels of care

3. Placing patients in lower-acuity settings than required, which may lead to delayed recognition of deterioration and worse outcomes

4. Failing to consider staff competencies in specialized care (e.g., VAD management) when making unit placement decisions 1

Implementation Considerations

• Ensure clear admission and discharge criteria for each level of care
• Develop standardized protocols for patient transfers between units
• Provide adequate staff training for each level of care
• Regularly review appropriate utilization of step-down and telemetry units
• Consider cost-effectiveness in unit placement decisions, as step-down units can be cost-effective alternatives to higher-acuity settings with non-inferior outcomes 4