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Step-Up Unit

Step-Up Unit

  • Reserved for those patients admitted to General Internal Medicine who require a level of care that is intermediate between the Intensive Care Unit and the ward.
  • Patients can only be admitted to the Step-Up Unit through the Emergency Room or from the General Internal Medicine ward.
  • If a patient in the ER requires a Step-Up Unit bed and one is not available:
    • Review current Step-up unit patients to see if anyone can be moved out (will need to review with other medicine teams)
    • If no bed will be available, the bed-flow manager may ask for the patient to be admitted instead to the ICU (ICU flex policy).

Admission criteria for Step-Up based on specific condition or disease:

Any patient, who at the discretion of the admitting staff physician or senior resident, would benefit from more frequent monitoring of vital signs and/or nursing interventions.

What can be done in the step-up unit?

  • Q1H vitals and labwork
  • Arterial and central venous lines may be inserted if clinically indicated.
    • The Chief Medical Resident, Anasthesia on-call or ICU on-call can also be contacted for assistance with lines.
    • All catheter insertions must be documented as “procedure notes” in the patient chart.
    • Central venous lines can be used for CVP monitoring ONLY. NO MEDICATIONS can be given via central lines in the step up unit.
    • Arterial lines can be used for continuous blood pressure monitoring
    • The respiratory therapist assigned to the Step-Up Unit may insert (or assist in insertion) of arterial lines.
  • Bipap
  • IV insulin

Types of patients that can be admitted to the step up unit:

  • DKA or HHS requiring an insulin infusion
  • Hyponatremia requiring frequent blood work and frequent urine output monitoring
  • CHF requiring Bipap (but otherwise stable)
  • COPD exacerbation requiring Bipap (but otherwise stable)
  • Sepsis requiring frequent IV fluid boluses and close hemodynamic monitoring (but NOT requiring pressors)

Exclusion criteria for Step-Up based on specific condition or disease:

  • Any patient who fulfills admission criteria to the ICU or CCU should not be admitted to the Step-Up Unit.

Patients with the following conditions are not appropriate candidates for the Step-Up Unit:

  • Patients requiring inotropic or vasopressor support for any reason
  • Patients who require intubation or who are at imminent risk of requiring intubation
  • Patients from whom aggressive therapy is being withheld and are receiving only comfort measures
  • Patients immediately post-cardiopulmonary resuscitation
  • Patients requiring pulmonary catheter-based monitoring
  • CARDIAC conditions (should be admitted to CCU):
    • Hemodynamically unstable arrhythmias
    • Congestive heart failure or pulmonary edema with EKG changes or positive cardiac enzymes
    • Hypertensive emergencies with end organ damage requiring intravenous medications and continuous monitoring
    • Acute myocardial infarction (complicated or uncomplicated)
    • Cardiogenic shock
    • Cardiac tamponade
    • Complete heart block

Caring for patients in the Step-Up Unit:

  • Given their higher level of acuity, Step-Up Unit patients should be rounded on by the senior resident immediately following Bullet Rounds.
  • The most responsible housestaff will make decisions about his/her respective patient’s suitability for discharge from the Step-Up Unit.

  • The length of stay of patients admitted to the Step-Up Unit is expected to be 24-48 hours.

  • It is important that the senior resident on a team with patients in the Step-Up Unit give direct signover to the on-call senior resident at the end of every day as they may be called upon to co-manage sick patients.

 

Discharge of patients from the Unit will take place when:

  • The clinical status has stabilized and the need for intensive patient monitoring is no longer necessary--> Transfer to GIM ward
  • A patient's status has deteriorated--> Transfer to MSICU