Start Date: 07/17/2022

End Date: 10/15/2022

Status: Open

Total Positions: 1

Skill: *Registered Nurse

Duration: 13 - Weeks

Location: NY - St. Peter's Hospital

Shift Start Time: 19:00:00

Shift End Time: 07:30:00

Description:
Type of Patients Served
The step down Unit (SDU) is a 15 bed telemetry unit that delivers care to patients whose needs fall along the less acute end of the critical care continuum utilizing a patient focused care model. SDU patients are moderately stable with less complexity, require moderate resources, and require intermittent nursing vigilance or are stable with a high potential for becoming unstable and require an increased intensity of care.

Ages of Patients Served
The primary population of SDU includes the adult and geriatric population.

Current Services for Patients and Patients’ Families:

Scope and Complexity of Patient’s Care Needs

The SDU is a place where specialty-educated and trained nurses combine the knowledge and skills of assessment, surveillance, and provision of complex nursing care to provide high-quality patient care. The level of care in the SDU is a higher level of care than that available on standard cardiac telemetry or medical surgical units. A dedicated hospitalist will manage the care of patients in the unit, including and in collaboration with the primary physician of record for those patients primarily admitted to services other than the hospitalist service. Expected length of stay for patients in the SDU is 24 to 72 hours. The dedicated hospitalist will facilitate patient flow to appropriate care level designation.


Provider Coverage

A dedicated hospitalist will provide coverage to the SDU from 7a-7p with overnight coverage provided by cardiology service from 7p-7a 7 days per week. A brief direct provider to provider Sign-out will occur at both 7am and 7pm

During 7p-7a the cardiology service will be addressing overnight calls, and managing acute issues for established SDU patients and those patients admitted by the hospitalist A1 (see Admission Process for SDU section below).

Patients managed by the dedicated hospitalist will include:
o Patients that are primarily admitted to hospitalist service
o Hospitalist will be consulted on all patients that are primarily admitted to other services (with the exception of cardiology) and serve as consultant for both co-management of the primary medical issue, as well as general management of other medical comorbidities.

Patients who will NOT be managed by the dedicated hospitalist will include:
o Patients primarily admitted to Cardiology service with Cardiologist as attending
• Cardiologist (or identified covering service for 7p-7a) will manage the care of these patients


Multi-Disciplinary Bedside rounds will occur M-F at 8:30am and will include bedside nurses, charge nurse, case management and pharmacy

The hospitalist will be assigned a dedicated Zone phone to facilitate communication with other providers.

Frequent Procedures, Processes, Services
• Cardiac Monitoring
• Arterial and Central Venous Pressure Monitoring
• Central Line Placement

Admission Process for SDU
1) Admitted by Cardiology Group (AAC or CCA)
o Patient is admitted and managed by Cardiologist
o After 7pm the cardiology coverage team will then take over responsibility for ongoing issues until 7am
2) Admitted from ER (excluding those with cardiologist as attending):
o All Potential New ER admits will be first called by ER providers to the Hospitalist A1. If it is determined that this patient would be SDU appropriate, the A1 will then call the SDU provider zone phone to discuss the patient. If the patient is SDU appropriate, the SDU hospitalist will determine based on their present work flow if they will personally admit that patient and perform a full H&P, or if they would like another provider to assist by performing that initial H&P.
o Initial admission holding orders will be entered by the A1.
3) Direct provider to provider discussion will be required for patients admitted under a specialist service (excluding cardiology) with hospitalist team on consult to discuss patient care and clearly delineate care responsibilities for patients requiring admission from the following routes:
o Patients being transferred out of ICU
o Transfer from PACU
o Transferred from floor
o Direct Admits from outside hospitals
o Level of care upgrades following a rapid response
4) For admissions after 7pm (excluding those with cardiologist as attending):
o Patients will be evaluated and have an H&P performed by the hospitalist A1. After the admission is completed, the admitting provider will call the SDU coverage zone phone to discuss the patient and items that may require follow up. The cardiology coverage team will then take over responsibility for ongoing issues until 7am
o Hospitalist covering providers have the authority to determine if a patient can should be transferred to SDU in the overnight period

Criteria for Entry to Services
A. Cardiac System:
1. Any cardiac arrhythmia requiring a higher level of care
2. Cardiac medication (beta blocker, digoxin) related overdose
3. Hemodynamically stable myocardial infarction (MI)
• ST-Elevated MI (STEMI)
• Non-ST elevated MI (NSTEMI)
4. Hemodynamically stable complete heart block
5. Any hemodynamically stable patient without evidence of myocardial infarction but requiring temporary or permanent pacemaker
6. Symptomatic or decompensated heart failure
• Including those requiring pressers or inotropes
7. Hypertensive urgency without evidence of end-organ damage
8. Hypotension
• Requiring aggressive volume resuscitation, including patients that may require central lines and arterial lines
• Requiring single Intravenous vasopressor therapy
9. Unstable angina
10. Unstable Endocarditis/Myocarditis/Pericarditis/Coronary Insufficiency
11. Evaluation for Coronary Artery Disease (CAD)
12. Acute Coronary Syndrome, hemodynamically stable
13. Patients having received interventional/diagnostic procedures such as aortic balloon valvuloplasty, pericardial drain placement
14. Patients requiring cardiac intravenous infusions with or without invasive hemodynamic monitoring
B. Vascular System
1. Patients requiring frequent and/or invasive hemodynamic monitoring post procedure
• Endovascular aneurysm repair (EVAR)
C. Pulmonary System:
1. Patients with evidence of compromised gas exchange and/or underlying disease with the potential for worsening respiratory insufficiency who require high-flow oxygenation (High flow nasal cannula), Venti Mask, or non-invasive continuous positive airway pressure (BiPap) and/or invasive hemodynamic monitoring.
2. Examples of Conditions include (but not limited to):
• Severe COPD exacerbations
• Severe CHF with pulmonary edema
• Sepsis due to pneumonia
D. Neurologic Disorders:
1. Patients experiencing stroke symptoms and requiring frequent and/or invasive hemodynamic monitoring
D. Endocrine
1. Patients requiring constant intravenous infusion if insulin.
E. Surgical
1. The postoperative patient who, following major surgery, requires fluid resuscitation, and/or transfusion, due to major fluid shifts.
2. The postoperative patient who, following surgery, requires invasive hemodynamic monitoring.
F. Metabolic
1. Patients who are being evaluated, treated, and/or resolving early Sepsis defined by suspicion of infection and 2 criteria of SIRS
2. Severe Sepsis/ Lactic acidosis
• Patients with borderline blood pressures due to sepsis (ex. MAPS in 70s) or with elevated lactate (in 3-5 range) that did not promptly improve with appropriate care in the Emergency Department
G. GI
1. High output ostomies
2. GI bleed patients in which there is concern regarding the potential of brisk