Step-Down Nursing Unit (SDU) Overview, Differences to ICU (2024)

Step-Down Nursing Unit (SDU) Overview, Differences to ICU (1)

What is a Step-Down Unit (SDU)?

SDUs fill a gap between ICU and the MedSurg/Tele units by providing a:

  • lower level of care than resource-intensive ICUs and a
  • higher level of care than MedSurge/Tele units

SDUs provide care to stable but critically ill patients of varying acuity. SDUs have been found to significantly improve patient outcomes, especially in high-risk patients2.

SDUs are known by a variety of names. Hospitals may call SDUs transitional care units (TCUs), progressive care units (PCUs), or specialty care units such as surgical, medical, neuro, coronary care units, or other names, depending on their population.

Table of Contents

  • What is a Step-Down Unit (SDU)
  • Step-Down Unit vs ICU
  • Types of Patients in an SDU
  • SDU Nursing Competencies
  • How Do You Become a Step-Down Nurse?
  • Role, Responsibilities and Salary
  • Pros and Cons

Step-Down Unit vs. ICU

ICU nurses manage more technical equipment and more unstable patients than SDU nurses. Many procedures reserved for ICU settings include

  • Continuous renal replacement therapy (CRRT)
  • Invasive and non-invasive hemodynamic monitoring
  • Titratable vasoactive drips such as norepinephrine, dopamine, and dobutamine
  • Intra-aortic balloon pump therapy (IABP)
  • Mechanical ventilation with propofol sedation
  • Temporary cardiac pacing
  • Ventricular drain management
  • Proning (prone positioning)
  • Intracranial pressure measurements (ICP)
  • Arterial lines
  • Extracorporeal membrane oxygenation (ECMO)

SDU nurses are not expected to provide the above treatments. Unstable patients remain in ICU until they are stabilized. ICU patients no longer requiring an intensive level of care can be transferred to SDU or to MedSurg/Telemetry, depending on the level of care required.

Step Down vs Intermediate Care Unit

Intermediate Care Units is another name for an SDU and they can be considered equivalent.

Step-Down vs. MedSurg/Telemetry

Despite the name "step-down,” the majority of patients in SDU are inpatients transferred from MedSurg (general wards), telemetry, or the emergency department, making it more of a "step-up"1.

Patients on SDU require more intensive nursing care than MedSurg/Telemetry nurses are staffed to provide3.

Examples of MedSurg/Tele patients who are candidates for SDU include

  • A patient in diabetic ketoacidosis (DKA) who is otherwise stable but requires one-hour fingersticks and subsequent insulin adjustments
  • A post-op patient with transurethral resection of the prostate (TURP) and continuous bladder irrigations who requires hourly urine measurements and manual irrigations
  • Patients showing signs of deteriorating conditions, such as early sepsis or increasing respiratory failure

SDUs Vary

SDU patient populations vary by the hospital, the medical needs of its community, and the healthcare service lines provided. Examples of service lines include orthopedics, cardiology, women's care, cancer treatment, organ transplant, cardiac, and more. They may consist of patients with organ transplants, craniotomies, open-heart surgeries, and unstable patients.

Differences in nursing practice vary by hospital policy. Some SDUs allow

  • Arterial lines
  • Mechanical ventilation
  • Certain titratable drips according to facility policy: insulin drips, cardizem drips, amiodarone drips, heparin drips, lasix drips, metoprolol, dopamine, and dobutamine.
  • Immediate post-operative recovery

Types of Patients on SDU

SDU patients include those with complex medical conditions and multiple co-morbidities requiring close monitoring and frequent nursing interventions.
Patients who may be cared for on step-down units include those with

  • Acute respiratory failure
  • Sepsis
  • Acute renal failure
  • Neurological conditions such as strokes or brain injuries
  • Ventilator-dependent patients with tracheostomies
  • Diabetic ketoacidosis
  • Pulmonary hypertension
  • CHF
  • Lung transplants post-op
  • Heart transplants post-op
  • Comfort care or palliative care on a morphine drip
  • CIWA alcohol withdrawal
  • Bariatric surgeries post-op
  • Cardiothoracic surgeries post-op

In other words, a wide variety of diagnoses. It is not the patient's diagnosis but the patient's acuity and workload that makes them step-down level.

Patient Ratios in SDUs

SDU nurse-to-patient ratios vary by hospital and are typically from 1:2- 1:41,2.

SDU Nursing Competencies

According to the American Association of Critical-Care Nurses (AACN), SDU nurses must be competent to care for patients who are unstable, unpredictable and require complex care4.

Nurses in the SDU are responsible for recognizing cardiopulmonary emergencies and monitoring patients at the bedside.

Commonly required competencies include the management of:

  • Chest tubes (pleural and mediastinal)
  • Post-op drains (hemovac, jackson-pratt)
  • Urinary catheters (suprapubic, urethral, nephrostomy)
  • Tracheostomies (suctioning, dressing changes)
  • Gastrostomy tubes (G-tubes) and percutaneous endoscopic gastrostomy tubes (peg tubes)
  • Oxygen delivery devices (mechanical ventilation, high-flow oxygen, bipap, C-pap, blow-by, cannula, masks)
  • Blood and blood products, transfusions
  • Wound vacs
  • IVs: PICC lines, implanted ports, dialysis lines, arteriovenous (AV) shunts, peripheral
  • Sequential compression devices (SCDs)

SDU nurses also need:

  • Stroke assessment (NIH stroke scale)
  • Basic dysrhythmia
  • Basic life support (BLS) and advanced cardiac life support (ACLS)
  • 02 sat and arterial blood gasses (ABGs) interpretation skills
  • Knowledge of pressure injury prevention and treatment
  • Knowledge of palliative care and comfort care

Patients receiving dialysis can be on SDU but a contract dialysis nurse will perform the procedure.

How Do You Become a Step-Down Nurse?

Many hospitals hire newly graduated registered nurses directly into step-down units and provide additional training as needed. Others take nurses with 1-2 years of MedSurg/Tele experience.3

Speciality Certification PCCN

Progressive Care Critical Nurse (PCCN) is the AACN certification for Telemetry and SDU unit nurses. Eligibility includes practice as an RN or APRN for 1,750 hours in direct care of acutely ill adult patients during the previous two years, with 875 of those hours accrued in the most recent year preceding application. 4

Day-to-Day Role, Responsibilities and Salary

SDU nurses' salaries are often the same as other hospital nurses. Nursing salaries typically vary from hospital to hospital and according to union contracts, but not by specialty.

Because SDU patients require close monitoring, SDU nurses frequently accompany their patients off the unit for diagnostic testing, such as CT scans, called "road trips". SDU nurses also assist providers in bedside procedures, such as inserting a chest tube, or removing pacing wires.

Pros and Cons of Step-Down Nursing, Anecdotal

All nurses are different; what one nurse considers a pro, another may consider a con. For example, a slower pace is a pro for some and a con for others. Here are some common observations:

  • Complexity of patients is stimulating
  • Promotes teamwork as the heavy physical care requires co-worker assistance
  • Gratification when a severely ill patient recovers
  • Increased interdisciplinary teamwork
  • Therapeutic relationships with families due to longer length-of-stay
  • Continuity of care
  • Higher patient: nurse ratio
  • Transferable skills, bridge to ICU for nurses seeking critical care
  • Bedside monitor provides visual cues and builds arrhythmia skills faster
  • Slower pace interspersed with rapid responses and codes
  • Internal validation
  • Steep learning curve due to patient complexity
  • Physically demanding with regular patient positioning, assistance with ADLs
  • Futility of prolonging life or interventions
  • Increased rapid responses (RRTs)
  • Longer lengths of stay may be monotonous to some
  • Slow patient progress
  • Higher patient acuity and workload
  • Multiple competencies required
  • Risk of alarm fatigue5
  • Repetitive work
  • Less recognition and not viewed as specialty nurses as compared to ICU and ED counterparts

It is common for patients transferring out of the intensive care unit to have anxiety about losing their one-to-one nurse. It's important to anticipate patients' and family members' fears and reassure them.

With fewer patients, close collaboration, and rewarding patient care, the SDU can be considered a hidden jewel of a unit.

STAFF NOTE: Original Community Post

This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post:


I am always hearing step-down unit and am afraid to ask anybody what it means. I thought it was ICU "a step down from med-surg" but I know that it sounds stupid. Can you tell me the difference between Step Down Unit and ICU?


1. Prin M, Wunsch H. The role of step down beds in hospital care. Am J Respir Crit Care Med. 2014 Dec 1;190(11):1210-6. doi: 10.1164/rccm.201406-1117PP. PMID: 25163008; PMCID: PMC4315815.

2. Lekwijit S, Chan CW, Green LV, Liu VX, Escobar GJ. The Impact of Step-Down Unit Care on Patient Outcomes After ICU Discharge. Crit Care Explor. 2020 May 6;2(5):e0114. doi: 10.1097/CCE.0000000000000114. PMID: 32671345; PMCID: PMC7259559.

3.Zhu, B., Armony, M., & Chan, C. W. (2013). Critical care in hospitals: when to introduce a step down unit. Working paper, Columbia University. 4.2.

4.AACN's Competence Framework for Progressive and Critical Care: Initial Competency 2022

5. Storm, J., & Chen, H. C. (2021). The relationships among alarm fatigue, compassion fatigue, burnout and compassion satisfaction in critical care and step‐down nurses. Journal of Clinical Nursing, 30(3-4), 443-453.

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