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Abstract
Step down unit is being introduced in tertiary care hospitals as an alternate to intensive care/high dependency unit for patients who are relatively less sick but not fit enough to be shifted to ward. Being a third world country, our tertiary care hospitals face a serious turmoil regarding patient turn over especially pediatric patients from different part of the country. Pediatric patients make about 1/3rd of the patients being managed in our setups.
With our intensive care units fully packed leading to the exhaustion of resources, the idea of step-down unit comes as a relatively cost effective and human resource friendly alternate. Step down units for a pediatric surgery facility as our setup holds an especially important place as these units specialize in dealing with post-operative patients not requiring intensive ventilatory support. Also worth mentioning is that the active resuscitation of pre-operative patients can be easily done in these setups if only one organ system is involved.
Not long ago in 1968, Gotsman and Schrire introduced the concept of step-down units for cardiac patients no longer needing invasive mechanical ventilation but were not stable enough for general ward. If we take the example of the model being followed in England by NHS, the categories range from 0 – 3, 0 being general ward, 3 being the intensive care unit. In this categorization level 2 is being designated as Step down unit.
These units operate as a dynamic unit having the capability of being a step-up place for patients needing more intensive monitoring and level of care such as those to be shifted from ward or emergency department. On the other hand, it serves as step down unit taking patients from intensive care before shifting them to general ward. What is more interesting is the fact it can ideally be used to laterally transfer patients from operation theater replacing the need of post anesthesia care unit if the patient does not need invasive ventilatory support.
A recent study based in Aga Khan University Medical Centre; Karachi emphasized on the importance of step-down unit built in 1994 in the management of preterm babies. They concluded that stepping down the very low birth weight infants from intensive care to step down unit with their mothers being the primary care givers reduced the mean length of hospital stay from 34 to 14days, and out of 509 cases, 397 (75%) were successfully discharged while there was no significant difference in readmission rates.
Another review of 98 patients who underwent pediatric supraglottoplasty over the span of 5 years in tertiary pediatric referral hospital by Diane W.Chen concluded that 85% of the patients were managed in Step down unit whilst only 4% of the reintubation and were stepped up to ICU without further delay.
As described earlier that it is a cost effective and human resource friendly model as it the step-down unit doesn’t specifically need a designated separated area. These beds can be adjusted either with intensive care or general ward. And the nurse – patient ratio is 1:3 as compared to 1:1 in intensive care.
At the department of pediatric surgery, Holy Family Hospital, this unit model was followed using a public non profitable private partnership. This partnership was inspired by PPP(private public partnership) models being followed by different hospitals around the globe.
The Private finance initiative (PFI) in the United Kingdom follows Design, Build, Finance, Operate (DBFO) model which has been the primary means of financing major capital investments in the health, education and prison sectors during the past two decades.
Franchising is another PPP model followed in Sweden where either whole hospital or either one of the part of the hospitals are being managed by private contractors.
While another Al Zira model is a unique model in which a private institute is being held responsible for a definite set of population and in return for an annual per capita payment.