What is a Step-Down Unit?

We spoke with Syed T. Raza, MD, Medical Director of the Cardiothoracic Surgery Step-Down Unit at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, about the importance of a step-down unit and how Columbia's approach differs from other units.

Can you tell us what a step-down unit, or SDU, is?

The step-down unit is the postoperative surgical floor where heart surgery patients come to from the ICU [intensive care unit]. Once their procedure is complete, they initially go to the ICU to recover on day one after surgery; some stay for day two or three, sometimes even longer. They then come to the step-down unit on their way to discharge.

Here at Columbia, we have a very unique model that was created by Dr. Craig Smith. I don't believe it exists in any other place. Here, you'll find a semi-retired heart surgeon managing postoperative patients on the floor with a group of PAs covering patients 24/7/365.

As I said, it's a unique model.

What was the model you've seen?

Well, I used to work for 35 years in Buffalo, and once you got to the step-down unit, there was a surgeon at home and a nurse at the bedside. That's it. There was no middle coverage.

There was a team of PAs before I got here, but I was able to organize our unit a little bit more when I took charge. We hired a large enough team for 24/7 coverage. Now, I mostly hire and train them. They do all the work, and I keep getting all the credit <laugh>. They're very good, and they make ME look very good.

How big is the team?

We have 23 PAs who work with me. We usually have five PAs during the day, five days a week, three PAs on the weekends during the day, and two PAs every night, seven nights a week. So, in addition to a nurse who's taking care of three patients, a PA is usually taking care of five or six patients. But they see the patients every morning, and they do all the necessary things that surgeons would want done.

And what is your role?

I supervise them and make rounds with them. I don't see all 36 patients every day, but I see the more critical ones, the new ones, or somebody who needs some help. And of course, if the PA needs help, they'll call me. I think the patients benefit from this model. They get very good care. People have told me that things have changed dramatically since we started this intense coverage.

What do you see as the primary benefits of using this approach?

The constant care. If a patient starts to get into trouble, I have a PA right there on the floor who will see them immediately. The PAs don't go anyplace else. And I'm always here, too. We take care of whatever needs to be done. In another place, such as where I worked before, I would be at home. If a patient needs help in an emergency, it would take me half an hour to get there.

Why don't you think that model is more widely adopted?

Money. How many physicians and PAs can you afford? Yeah. First of all, not many retired surgeons are willing to do this.

You don't sound very retired.

Well, maybe semi-retired <laugh>. I still work 10, 11 hours a day. And 23 PAs are a lot of PAs covering the postoperative floor; I don't think many places can afford that.

Do you think that's also a product of our surgical volume at Columbia?

No, not really. While we do a large amount of volume, I think it's their commitment. Dr. Craig Smith should get the credit because he came up with these ideas and supported me in achieving them.

What does a typical visit to the step-down unit look like, say, for someone coming off of bypass surgery?

In a typical case, somebody who gets surgery today is transferred from the ICU to the step-down unit the next morning. They usually have four chest tubes in place after surgery; two will be removed in the ICU before they transfer, and two of them will be removed on day one in the SDU. On day two, the other test tube will be removed. On day three, the temporary pacemaker wires will be removed.

In the meantime, physical therapists are helping patients walk, get out of bed, and go to the bathroom. Sometimes, an occupational therapist also sees patients who need help relearning how to brush their teeth or perform simple activities of daily living.

And by day three or four, we can see if this patient will go home or to rehab.

Are you involved in the discharge process?

Our discharge process is quite extensive. Our PAs will make all the follow-up appointments for the patient. They're usually seen within 48 hours; they'll have a telephone call from the nurse on the floor and one of the NPs or physician assistants in the office.

At one week, we usually have a telehealth visit with a physician assistant or nurse practitioner in the office. At two weeks, they're instructed to see their cardiologist. At six weeks, they're instructed to come back in person and see the surgeon; at this point, they can be cleared for driving, going back to work, or whatever needs to happen.

That's the most typical case. If, at any point, somebody experiences a complication, then, of course, you react differently and take care of those things immediately.

What are the most common complications?

Simple arrhythmia or atrial fibrillation is the most common complication; about 30% of patients after isolated coronary artery bypass surgery will have atrial fibrillation, and at some point in their recovery, 40% of valve patients will have that. So it's very common.

We see other minor complications, like a sore throat, a husky voice, or the inability to eat properly. While they're a nuisance, they're not serious complications. Between 50 and 60% of patients will have some minor complication, but major complications are rare.

2% of patients will end up with a stroke after heart surgery. And maybe 1 or 2% of patients will have prolonged ventilation or some other reason for a prolonged stay in the ICU. Those are not common, but they're more serious and delay their discharges.

What would you say is the average length of stay?

The average stay following cardiovascular surgery is about eight or nine days. That accounts for patients who may stay longer and for patients who may have a typical recovery and discharge on day five.

In those cases where we have to address serious complications like stroke, we are connected to the care they need. Not just cardiothoracic, but also neurosurgery, vascular, all potential areas that may need to respond.

What does that response look like?

Fast and efficient. Recently, we've had some dramatic cases where seconds really mattered. If a patient gets a stroke from a cardioembolism, we call neurosurgeons immediately and take the patient back to the neurosurgical operating room for a thrombectomy. Because of that response speed, I've seen a complete reversal of their stroke symptoms. It helps that we have a fantastic neurosurgical and neurological institute, which is considered number one or two in the country.

And also, I should say that we have, we are very fortunate to have the skill and experience of our nurses. Our team has received many awards for excellence in nursing. This year they received an award called the Golden Beacon Award. There are three levels of beacon awards for excellence in nursing: bronze, silver, and gold. This year, they received gold.

I think a lot of people have this idea that there's this long convalescence after major surgery, but it sounds like many hospital stays are much shorter than people realize. How active are patients when they're on the step-down unit?

I always tell the patient the same thing: I will let you go home when I can see that you can get out of bed yourself and walk to the bathroom. Because that is the minimum you need to do at home. Can you go to the kitchen to get a sandwich or make a cup of coffee? If they can't even get out of bed, I would say they need to be here for a few more days. In some cases, they may need to go to a rehab center.

When you were at Buffalo, were you involved with their SDU?

<laugh> They don't have a step-down; they just have a regular floor. From the ICU, the patient went up to a floor where the nursing care ratio was one nurse to five patients. Here, nursing care is one nurse to three patients.

What about technologies? Are you using any monitoring breakthroughs or other technologies to make it easier to see problems before they happen or to help manage their cases as they're getting out the door?

No, it really is all about the people. It's the number and skill of the people who are seeing the patient, having a team who picks up problems. The technology here is the same as that used at other hospitals for monitoring that. Telemetry monitors, blood pressure monitors, oxygen saturation monitors—they're everywhere available.

Being able to pick up a problem early and react to it immediately makes a difference. Our presence on the floor is the real benefit.

How helpful is your surgical experience in this scenario? Do you think that it gives you insight into anticipating or reacting to problems?

I think so. As a surgeon, I can detect problems much earlier because I've seen all of the complications of surgery. Many of these complications can be managed on the floor without a consult.

Can you tell me a little bit about your surgical history? What was your area of expertise?

I did a wide variety of surgeries, including both thoracic and heart surgery. From pacemakers to coronary bypass to valves to heart transplants. Everything. Columbia is a little bit different in that it has so many specialists. I was more of a general cardiothoracic surgeon who did everything.

That probably gives you an advantage in your role then, right?

Yes, it does help to have performed a wide range of surgeries, to be familiar with many procedures. And to know what to look for in recovery.

Does the SDU also cater to transplant patients?

Yes. Heart transplant patients come here, where their care is shared between my team and the transplant cardiologists who manage all their anti-rejection medications, general medications, and so on. And they do the biopsies here. My role is to see them daily with the PAs but only get involved if there are surgical issues. If the incision is not healing well, or if there's a need for some thoracentesis, issues like that. So, I will supervise the PAs and take care of the surgical issues, while transplant cardiologists will take care of the medical issues.

So the lesson here is better coverage equals better care?

Yes, but also that complications are easier to address before things get worse when you have a skilled team nearby. I'll give you an example. Just the other night, around two in the morning, a patient who had come out of the ICU earlier in the day developed a 12-second pause on his EKG. The PA ran over to the room. While evaluating the patient, they called the rapid response team to the room. The patient had another 12-second pause, so they immediately connected the pacemaker wire to the pacemaker and brought him back to the ICU. The next day he got a new pacemaker, and he was discharged not long after.

This is just one example of why this model works so well. If there was no PA on the floor for the nurses to call, getting somebody there to evaluate the patient would take time. And saving time in these moments makes a world of difference.