Implementing step-down admission criteria

Jackie Savinon

Clinical Issue/Practice Problem: At an urban teaching hospital, admission criteria for step-down units were not defined leading to inappropriate bed assignments and a lack of available step-down beds.

Summary of Supporting Literature: Implementation of step-down admission criteria have resulted in reduced mortality, lower ICU length of stay, decreased ICU readmissions, decreased health care costs, and increased staff and patient satisfaction (Plate et al. 2017; Harding, 2009; Richards et al., 2012).

Project Implementation: Using evidence-based step-down admission guidelines from Johns Hopkins, focus groups were held with nursing, bed control, and physicians to develop step-down admission criteria. Training sessions were held with staff on the new step-down admission criteria prior to “go live” on a medical step-down unit. The electronic medical record was reviewed to compare the percentage of admissions that met step-down criteria at the initial admission and at transfer pre-implementation and post-implementation of the admission criteria.

Outcomes: There was no improvement in step-down bed assignments pre-implementation and post-implementation of the step-down criteria. Post-implementation 25.9% of admissions met criteria for step-down. Of the 74.1% of admissions that did not meet criteria, 99% could have gone to med-surg. 89.2% of transfers met criteria for step-down.

Clinical Implications for Practice and Next Steps: Education of the step-down admission criteria needs to occur hospital wide to reinforce bed assignments based on level of care. Future analysis is needed to determine the number of step-down beds needed to care for the population.