What types of patients are typically admitted to a stepdown unit?

Typical Patients Admitted to a Stepdown Unit

Stepdown units (also called intermediate care units) are designed for patients who require more intensive monitoring and intervention than a general medical ward can provide, but who do not need the full resources of an intensive care unit—specifically, patients with moderate disease severity who are either clinically stable but at risk of deterioration, or who are improving from critical illness but still require continuous monitoring.

Core Characteristics of Stepdown Patients

The defining features of stepdown unit patients include:

• Need for continuous cardiorespiratory monitoring without requiring invasive mechanical ventilation or hemodynamic instability 1
• Requirement for frequent multidisciplinary interventions that exceed general ward capabilities 1
• Clinical stability with potential for deterioration requiring closer observation than standard ward care 1

Cardiovascular Patients

Post-Myocardial Infarction Patients

Low-risk STEMI patients who have undergone successful PCI can be admitted directly to the stepdown unit rather than the CCU 1. Additionally, STEMI patients originally in the CCU who demonstrate 12-24 hours of clinical stability (absence of recurrent ischemia, heart failure, or hemodynamically compromising dysrhythmias) should be transferred to the stepdown unit 1.

Patients recovering from STEMI with the following conditions are appropriate for stepdown care:

• Clinically symptomatic heart failure with facilities for continuous pulse oximetry monitoring and appropriately skilled nurses 1
• Hemodynamically well-tolerated arrhythmias such as atrial fibrillation with controlled ventricular response or paroxysms of nonsustained VT lasting less than 30 seconds, provided continuous ECG monitoring and defibrillators are available 1

Pediatric Cardiovascular Patients

In pediatric populations, stepdown units admit patients with:

• Non-life-threatening dysrhythmias with or without need for cardioversion 1
• Non-life-threatening cardiac disease requiring low-dose intravenous inotropic or vasodilator therapy 1
• Moderate complications of sickle cell crisis with respiratory distress but without acute chest syndrome 1

Respiratory Patients

Adult Respiratory Patients

Patients recovering from STEMI with clinically significant pulmonary disease requiring high-flow supplemental oxygen or noninvasive ventilation (BIPAP/CPAP) may be considered for stepdown care provided continuous pulse oximetry monitoring and appropriately skilled nurses with sufficient nurse-to-patient ratios are available 1.

COPD patients with acute exacerbations requiring non-invasive positive pressure ventilation (NPPV) are appropriate for stepdown units, particularly those with mild to moderate respiratory acidosis (pH 7.25-7.35) who respond to initial treatment 2, 3, 4. These patients benefit from early NPPV intervention on general respiratory wards, which reduces mortality and intubation rates 2, 3.

Pediatric Respiratory Patients

Pediatric stepdown units admit patients with moderate pulmonary or airway disease including:

• Patients with potential need for endotracheal intubation 1
• Patients requiring minimal mechanical ventilation support via mature and stable tracheostomy (primarily children with chronic respiratory insufficiency) 1
• Progressive pulmonary disease of moderate severity with risk of progression to respiratory failure 1
• Patients acutely requiring supplemental oxygen (FiO2 ≥0.5) regardless of cause 1
• Patients with stable tracheostomy 1
• Patients requiring frequent nebulized medications (at intervals shorter than 2 hours) 1
• Patients requiring apnea work-up and cardiorespiratory monitoring 1

Neurologic Patients

Patients with non-life-threatening neurologic disease requiring frequent monitoring and neurologic assessment not more often than every 2 hours are appropriate for stepdown care 1:

• Seizure patients responsive to therapy requiring continuous cardiorespiratory monitoring without hemodynamic compromise but with potential for respiratory compromise 1
• Patients with altered sensorium in whom neurologic deterioration is unlikely but neurologic assessment is required 1
• Postoperative neurosurgical patients requiring cardiorespiratory monitoring 1
• Patients with acute CNS inflammation or infections without neurologic deficiency or complications 1
• Head trauma patients without progressive neurologic signs or symptoms 1
• Patients with progressive neuromuscular dysfunction without altered sensorium requiring cardiorespiratory monitoring 1

Hematologic/Oncologic Patients

Patients with potentially unstable hematologic or oncologic disease requiring close monitoring include 1:

• Severe anemia without hemodynamic or respiratory compromise 1
• Moderate sickle cell crisis complications with respiratory distress but without acute chest syndrome 1
• Thrombocytopenia, anemia, neutropenia, or solid tumors with risk of cardiopulmonary compromise but currently stable, requiring close cardiorespiratory monitoring 1

Endocrine/Metabolic Patients

Stepdown units admit patients with potentially unstable endocrine or metabolic disease 1:

• Moderate diabetic ketoacidosis (blood glucose ≥500 mg/dL or pH ≥7.2) requiring continuous insulin infusion without altered sensorium 1
• Moderate electrolyte abnormalities requiring cardiac monitoring, including hypokalemia (K+ ≤2.0 mEq/L), hyperkalemia (K+ ≥6.0 mEq/L), hyponatremia/hypernatremia with altered clinical status, hypocalcemia, hypercalcemia, hypoglycemia, hyperglycemia, or moderate metabolic acidosis requiring bicarbonate infusion 1
• Inborn errors of metabolism requiring cardiorespiratory monitoring 1

Gastrointestinal Patients

Appropriate gastrointestinal patients include 1:

• Acute gastrointestinal bleeding without hemodynamic or respiratory instability 1
• Gastrointestinal foreign body requiring emergency endoscopy without cardiorespiratory compromise 1

Postoperative Patients

All postoperative patients requiring multidisciplinary intervention and frequent monitoring without hemodynamic or respiratory instability are appropriate for stepdown care 1, including those who have undergone:

• Cardiovascular surgery 1
• Thoracic surgery 1
• Neurosurgical procedures 1
• Upper and lower airway surgery 1
• Craniofacial surgery 1
• Treatment for thoracic or abdominal trauma 1
• Treatment for multiple traumatic injuries 1

Renal Patients

Patients with potentially unstable renal disease include 1:

• Hypertension without seizures or encephalopathy requiring frequent intermittent therapeutic IV or oral medication 1
• Noncomplicated nephrotic syndrome with chronic hypertension requiring frequent blood pressure monitoring 1
• Renal failure regardless of cause 1
• Patients requiring chronic hemodialysis or peritoneal dialysis 1

Common Pitfalls to Avoid

Do not admit terminally ill "do not resuscitate" patients to stepdown units, as their clinical and comfort needs can be provided outside of a critical care environment 1.

Avoid keeping patients on bed rest for more than 12-24 hours if they are free of recurrent ischemic discomfort, symptoms of heart failure, or serious heart rhythm disturbances 1.

Do not provide inappropriate oxygen therapy (saturation >92%) in COPD patients, as this is associated with respiratory acidosis; target saturation should be 88-92% 4, 5.