Step down unit is one of the initiatives of the new Model of Care (MoC) in the Al-Qassim Region, linked within the programs of the planned care system.

It aims to To alleviate ICU congestion by providing a safe environment for post-ICU patients, even shifting stable patients to the general ward, increase bed turns overs and decrease average length of stay.    

step down unit will be mainly applied at secondary care (hospitals) level

before the establishment of step down unit, there is increase in average length of stay in hospitals.

The patient will be shifting from ICU to step down unit depend on Admission criteria:

Cardiac system :(such patients are usually admitted in CCU)

Low-probability myocardial infarction; rule out myocardial infarction.

Hemodynamically stable myocardial infarction.

Any hemodynamically stable dysrhythmia.

Any hemodynamically stable patient without evidence of myocardial infarction, but requiring temporary or

permanent pacemaker.

Mild-to-moderate congestive heart failure without shock.

Hypertensive urgency without evidence of end-organ damage.

Pulmonary System

Medically stable ventilator patients for weaning and chronic care.

Hemo-dynamically stable patients with evidence of compromised gas exchange and underlying disease

with the potential for worsening.

respiratory insufficiency who require frequent observation and/or nasal/face mask continuous positive

airway pressure.

Patients who require frequent vital signs or aggressive pulmonary Physiotherapy.

Neurologic Disorders

Patients with established, stable stroke who require frequent neurologic assessments or frequent

suctioning or turning

Acute traumatic brain injury patients who have a Glasgow Coma Scale above 9, but require frequent

monitoring for signs of neurologic deterioration.

severe traumatic brain injury patients who require frequent positioning and pulmonary toilet.

Subarachnoid hemorrhage patients post-aneurysm clipping who require observation for signs vasospasm

or hydrocephalus.

Stable neurosurgical patients who require a lumbar drain for treatment of cerebrospinal fluid leak.

Stable cervical spinal cord injured patients.

Patients with chronic but stable neurologic disorders, such as neuromuscular disorders, who required

frequent nursing interventions.

Grade I-II subarachnoid hemorrhage patients awaiting surgery.

Patients with ventriculostomies who are awake and alert awaiting ventriculo- peritoneal (V-P)shunt.

Drug Ingestion and Drug Overdose :

Any patient requiring frequent neurologic, pulmonary, or cardiac monitoring for drug ingestion or overdose

who is hemo-dynamically stable

Gastrointestinal (GI) Disorders:

GI bleeding with minimal orthostatic hypotension responsive to fluid therapy.

Variceal bleeding without evidence of bright red blood by gastric aspirate and stable vital signs.

Acute liver failure with stable vital signs.

Endocrine:

Diabetic keto-acidosis patients requiring constant intravenous infusion of insulin or frequent injections of

regular insulin during the early regulation phase after recovery from diabetes keto-acidosis.

Hyperosmolar state with resolution of coma.

Thyrotoxicosis, hypothyroid state requiring frequent monitoring.

Surgical:

The post-operative patient who following major surgery, is hemo-dynamically stable but may require fluid

resuscitation and transfusion due to major fluid shifts.

The postoperative patient who requires close nurse monitoring during the first 24 hours. Examples include

but are not limited to carotid endarterectomy; peripheral vascular reconstruction; the neurosurgical patient

requiring frequent neurological exams; V-P shunt revision, renal transplant, etc.

Miscellaneous:

Appropriately treated and resolving early sepsis without evidence of shock or secondary organ failure

Patients requiring closely titrated fluid management.

Obstetrical patients admitted at any point in them pregnancy and postpartum period

for treatment of pre-eclampsia / eclampsia or other medical problems.

Any patient requiring frequent nursing observation or extensive time requirement for wound management

who does not fall under the above categories may be considered for admission (example:Addison's

disease, renal failure, delirium tremens, hypercalcemia).

Patient Monitoring: Patients in the step-down unit often require continuous monitoring of vital signs, cardiac rhythm, oxygen saturation, and other parameters. Monitoring equipment, such as cardiac monitors, pulse oximeters, and telemetry devices, may be used to track the patient's condition closely.

Specialized Care: The step-down unit is staffed by healthcare professionals, including nurses, respiratory therapists, and physicians, who have specialized training in caring for patients with complex medical needs. They provide comprehensive care, including administering medications, performing procedures, and managing medical devices.

Transition from ICU: Many patients admitted to the step-down unit are transferred from the ICU as they stabilize and no longer require the level of care provided in the ICU. The transition process involves ongoing assessment, monitoring, and adjustment of treatment plans to ensure a smooth transition and continuity of care.

Multidisciplinary Approach: Care in the step-down unit often involves a multidisciplinary team, including nurses, physicians, respiratory therapists, physical therapists, occupational therapists, pharmacists, and social workers. Collaboration among team members ensures comprehensive and coordinated care tailored to the individual needs of each patient.

Education and Support: Patients and their families receive education and support to help them understand the patient's condition, treatment plan, and self-care instructions. This may include information about medications, dietary restrictions, activity level, and signs of complications to watch for after discharge.

Goal-Oriented Care: Treatment plans in the step-down unit are focused on achieving specific goals, such as stabilizing vital signs, improving respiratory function, managing pain and discomfort, and facilitating rehabilitation. Regular reassessment of the patient's condition helps track progress toward these goals and adjust the treatment plan as needed.

Discharge Planning: As patients in the step-down unit progress in their recovery, discharge planning begins to ensure a safe transition to the next level of care or discharge home. This may involve arranging follow-up appointments, coordinating home healthcare services, and providing instructions for ongoing care and management of the patient's condition.

Complete blood count (CBC): To assess for anemia, infection, or other blood disorders.

Basic metabolic panel (BMP) or comprehensive metabolic panel (CMP): To evaluate electrolyte levels, kidney function, and liver function.

Coagulation studies: Such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) to monitor coagulation status.

Arterial blood gases (ABG): To assess oxygenation, ventilation, and acid-base balance in patients with respiratory compromise.

Chest X-ray: To assess for pulmonary conditions, such as pneumonia, pulmonary edema, or pneumothorax.

Echocardiogram: To evaluate cardiac function, assess for valvular abnormalities, or detect pericardial effusion.

Ultrasound: To assess for fluid accumulation, such as pleural effusion or ascites.

Pulse oximetry: To monitor oxygen saturation levels continuously.

Respiratory rate monitoring: To assess respiratory effort and detect respiratory distress.

Cultures: To identify the causative organism in cases of suspected infection (e.g., blood cultures, sputum cultures).

Serological tests: To detect specific antibodies or pathogens (e.g., viral PCR testing, fungal serology).

Specialized biomarkers: Such as cardiac enzymes (troponin) or inflammatory markers (C-reactive protein, erythrocyte sedimentation rate) for specific diagnostic purposes.

Creatinine and blood urea nitrogen (BUN): To assess kidney function and monitor for acute kidney injury or renal impairment.

Step down toolkit:

https://drive.google.com/file/d/1oZXwPjSXo-hd6MnaMXeGblKdbttKV4rC/view?usp=sharing

Step down policy:

https://drive.google.com/file/d/1MWJrtFiruJebRMqE4LmVzj0mjlGYeGMK/view?usp=sharing