Guidelines for Hospital Unit Admission: Floor, Telemetry, and Step-Down Units
Primary Decision Framework
The decision to admit patients to floor, telemetry, or step-down units should be based on hemodynamic stability, arrhythmia risk, and need for continuous cardiac monitoring, with clinical parameters such as blood pressure, heart rate, oxygenation, mental status, and symptoms of angina guiding the level of care. 1
Hierarchical Admission Criteria
ICU-Level Care Required When:
- Hemodynamic instability requiring vasopressors (e.g., gastrointestinal bleed with hypotension requiring pressors) 1
- Patients requiring mechanical ventilation 1
- Immediate post-operative period for complex procedures (e.g., ventricular assist devices) 1
- Acute decompensated heart failure requiring intensive management 2
Telemetry/Step-Down Unit Appropriate When:
- Hemodynamically stable but requiring continuous cardiac monitoring 1
- Patients extubated, weaned from vasopressors, with stable vital signs and heart rhythm 1
- Gastrointestinal bleeding with associated supraventricular tachycardia causing lightheadedness or chest pain 1
- Demand ischemia requiring ST-segment monitoring 1
Medical Floor Appropriate When:
- Hemodynamically stable without arrhythmia risk 1
- Gastrointestinal bleeding requiring transfusion but stable vital signs 1
- Patients with DNR/DNI status when monitoring would not change management 1
Specific Clinical Indications for Telemetry
Class I (Monitoring Definitely Indicated):
- Implantable cardioverter-defibrillator firing 2
- Type II or complete atrioventricular block 2
- Prolonged QT interval with ventricular arrhythmia 2
- Acute coronary syndrome 2
- Acute cerebrovascular events 2
- Massive blood transfusion 2
Class II (Monitoring Probably Indicated):
Class III (Monitoring NOT Indicated):
- Minor blood transfusions 2
- Low-risk chest pain with normal electrocardiography 2
- Stable patients receiving anticoagulation for pulmonary embolism 2
Surge Capacity Prioritization
During mass casualty or surge situations, prioritize bed allocation in the following order: expanding existing ICUs, post-anesthesia care units and emergency departments to capacity, then step-down units, large procedure suites, telemetry units, and finally hospital wards 1
Contingency Care Strategies:
- Move stable ICU patients to step-down units 1
- Transfer step-down patients to non-monitored beds as appropriate 1
- Transfer patients from monitored to non-monitored beds when clinically stable 1
Critical Pitfalls to Avoid
Inappropriate Telemetry Use:
- Do not use telemetry monitoring as a surrogate for better staffing ratios 1
- Approximately 22% of patients are inappropriately assigned telemetry at initial admission 3
- 56% of appropriately assigned patients continue monitoring longer than recommended 3
- Telemetry rarely contributes to ICU transfer decisions (only 1% of cases) 4
Reassessment Requirements:
- Telemetry orders should expire after 48 hours unless renewed 1
- Daily review of telemetry necessity by nursing staff in consultation with treating team 1
- Frequent reassessment prevents alarm fatigue and unnecessary healthcare expenditures 3
Special Populations
Ventricular Assist Devices:
- Immediate post-operative: ICU with continuous monitoring 1
- After stabilization: Telemetry unit if staff competent in VAD care 1
- Noncardiac admissions: May use non-monitored units if appropriate VAD management available 1
DNR/DNI Status:
- Monitoring indicated only if findings would trigger interventions consistent with patient wishes 1
- Not indicated when data will not be acted upon and comfort-focused care is the goal 1
Practical Implementation
Clinical judgment should assess stability using: blood pressure, heart rate, oxygenation, mental status, and angina symptoms to determine appropriate unit placement 1. The same patient condition (e.g., sepsis, gastrointestinal bleeding) may require ICU, telemetry, or floor care depending on hemodynamic status 1.