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Transitioning a Patient to Step Down Status: Using a SOAP note format to guide decision making - CT surgery

Posted by Liza Szelkowski, PA-C on Feb 2, 2017 12:06:00 PM

 Your patient has made it out of the operating room, and you have succeeded in stabilizing him or her. Perhaps you were able to wean the patient from the ventilator quickly, or maybe the patient was in cardiogenic shock for weeks. Regardless of how the journey started the sign out is that your patient is now ready to transition to step down status, and it's your job to determine if he or she is ready.

 The down grade to a lower level of care is an important stepping stone in the journey of the cardiac surgery patient. For the inexperienced PA, it may be difficult to tell which patients are ready to transfer, and which are not. It is an important decision because when a patient requires transfer back to an ICU, it not only creates physical setbacks, but it can also set the patient back mentally.

 Determining if a patient will succeed on the step down unit can be broken down into four different parts, similar to a SOAPnote. We already know our plan- to transfer the patient to step down status. Now, it's a matter of using our available data to help us make the most educated decision. Simply put, search for anything to disprove your theory that this patient is ready for transfer.


 The easiest place to start is what would be under the objectivepart of your SOAP note. This means looking at vital signs. The patient should have a stable blood pressure. The numbers will vary depending on patient specific factors such as age, and procedure. This number should be able to be maintained without the use of IV vasopressors or vasodilators. Oxygen saturations should be at least 92% on nasal cannula. Ideally, the patient should be on less than 6 liters/minute of oxygen, so there is room for titration if the patient has respiratory distress. Heart rate should be controlled. If you are aggressively treating arrhythmias, this is not the time to transfer your patient. If the patient is being paced with epicardial wires, make sure there is a rhythm that supports a blood pressure underneath. Turn off the pacer and check a cuff blood pressure before transfer. You want to make sure that if the patient was accidentally disconnected from the pacemaker, he or she would still be safe.

 After seeing that all your vital signs check out, move on to lab work. The big three concerns for transfer are hematocrit, creatinine, and electrolytes. Check to make sure the hematocrit is stable. If not, check another set of labs before transfer. Ideally, in the setting of acute kidney injury, the patient’s creatinine should have, at least, hit a plateau. Urine output should be at least 0.5 to 1 ml/kg/hour. This is also a good time to assess the need to start or continue diuretics. Make sure that potassium, magnesium, and sodium have been checked recently, and you have a plan to deal with any abnormalities. High potassium, especially, would make me watch someone in an ICU setting a bit longer. Finally, do a quick examination of the patient. Listen to the heart and lungs for any new murmur, distant heart sounds, or absence of breath sounds. Check incisions. Check for abdominal pain or distension from impending ileus. Make sure the patient feels warm to the touch. Look for any abnormal swelling or upper or lower extremities.

 Your final piece of objective information to gather is what the patient looks like. At the same time, you will be able to obtain your subjective data by talking with the patient. With time, you will develop the ability to know when something is wrong just by looking at the patient. Asking the patient’s opinion of how he or she is doing, will also give you clues as to whether or not the patient is ready to transfer. If the patient is resting comfortably in the bed or chair, and say they are feeling well, he or she will probably do well with transitioning to step down status. On the contrary, patients who have labored breathing, uncontrolled pain, questionable mental status, or tell you they don't feel well may warrant further evaluation.

 It is now time to make your assessment. Mentally review your patient, system by system, and look for reasons to keep him or her in the ICU. Even if everything checked out on your objective list, if the patient didn't look good, go with your instincts and observe a little longer in the ICU. Sometimes, pushing the patient a little will reveal if he or she has the reserve needed to succeed. Have the nurse walk the patient. Wean the oxygen a little. If you are unsure, and your patient passes small tests like this, it is probably safe to transfer.

 The SOAP note format is something we are all familiar with, so why not use it as a tool to guide decision making? After all, it is meant to be a way to gather information on a patient, and that is a large part of what transferring a patient is all about. Transfer is all about making educated decisions. This is an easy tool to help you accomplish that, and provide a safe transition for your patient.

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Topics: CT Surgery, Cardiac Surgery