vamasoncriticalcareunitptplacementguidelines2009.pdf

Virginia Mason Medical CenterClinical Policy & Procedure Manual

Scope of Care

Critical Care Unit Patient Placement Guidelines1 of 6

Critical Care Unit Patient Placement Guidelines

PolicyAll patients admitted to the Critical Care Unit (CCU) will be cared for by a qualified registered nurse and delegated managing physician.

PurposeTo provide standardized care for critically ill patients admitted to the CCU. Technical support will be indicated by the criteria below.

Guidelines Admission to the Critical Care Unit is based on the combined medical and nursing demands of the patient and bed availability. Routinely, but especially when bed availability is limited, patient placement within the Critical Care Unit is assessed for ALL patients currently in the Unit and those potentially in need of its services. The Critical Care Assistant Nurse Manager (ANM) or Charge Nurse (CN) and the Medical Director or his/her designee together coordinates triage, transfer and staffing to meet those needs. In general, the demands of care may include, but are not necessarily limited to:

a. Multiple vasopressor/inotropic dripsb. PA catheter placement and monitoringc. Ventilator supportd. Intra-aortic balloon pumpinge. CPAP/BIPAP for respiratory failure, unstable or deteriorating patientsf. A combination of monitoring and nursing intensity best managed in Critical

Care.g. Continuous Renal Replacement Treatment (CRRT)

Patients designated as "Do Not Resuscitate" either prior to transfer into the Unit, or during a stay in the Unit, are accepted in the Unit, as long as their medical/ nursing requirements include the criteria stated above.

In the event of high hospital occupancy, CCU may be considered for routine acute care admissions providing:

a. Staffing is available for quality careb. One bed remains available for a Critical Care admission as “bed ahead”,

which means if no bed is available, the CCU ANM/CN needs to iden tify patients for transfer and placement of next admit

c. Select IMC patients to be placed in CCU when assigned IMC/telemetry units are not able to accommodate due to staffing and/or physical constraints.


Scope of Care


Cardiac Medical Patient Admission:(Patients requiring one or more of the following criteria)

Admission Criteria Discharge Criteria• Acute myocardial infarction (MI) or high

suspicion of acute infarction• Decreasing cardiac enzymes and

troponin levels• 12 lead EKG has no evidence of

actively infarcting• All patients who have received thrombolytic

therapy for an MI• Thrombolytic therapy complete • Meets discharge criteria for acute

coronary syndrome

• Acute coronary syndrome requiring frequent titration of intravenous nitroglycerine or clinical instability requiring critical care nursing

• Stable and no chest pain on NTG or off infusion.

• Complicated or potential lethal arrhythmias with hemodynamic instability

• No arrhythmias • Hemodynamically stable

• Requiring continuous intravenous vasoactive medications which require active (<2 hour) adjustment; e.g. inotropic, vasopressor, antihypertensive and/or antiarrhythmic agents

• Weaned off vasoactive infusions• Stable/not titrating single infusion

for IMC transfer

• Cardiogenic shock • Weaned off vasoactive infusions• Stable/not titrating single infusion

for IMC transfer

Non-Cardiac Medical Patient Admission:(Patients eligible for CCU admission

Admission Criteria Discharge CriteriaRESPIRATORY INSUFFICIENCY with:

• Respiratory muscle fatigue• Acute C02 retention• Hypoxia not correctable with supplemental

02

• Altered sensorium• Potential/difficult upper airway intubation• Pharmacologic ventilatory paralysis• Upper airway management compromise• Pulmonary emboli with hemodynamic and

respiratory instability

• Acute issues resolved • Patient requiring minimal

supplemental oxygen • Acceptable ABGs• Not SOB• CPAP/BiPAP remains off for

4-6 hours and not being used for bridge to potential intubation


Scope of Care


• CPAP/BiPAP for respiratory failure that cannot remain off for at least 4 to 6 hours

GASTROENTEROLOGY EMERGENCIES:• GI bleeding: active, arterial and/or variceal

bleeding

• Complicated pancreatitis with respiratory failure or hemorrhage

No evidence of bleeding demonstrated by:• Stable serial hematocrit results• Hemostasis achieved• Hemodynamically stable

• Acute issues resolved • Patient requiring minimal

supplemental oxygen (<50%)• Acceptable ABGs• Not SOB• Hemodynamic/respiratory stable

with minimal support (fluid resuscitation completed, no vasoactive infusions or oxygen supplement

ENDOCRINE EMERGENCIES: * DKA or hyperosmolar coma requiring frequent (Every 1-2 hours)

• Monitoring • Treating of blood glucose• Electrolytes and fluids

* Acute life-threatening electrolyte disturbances

• Blood glucose and electrolytes stabilized with minimal insulin gtt titration (meets acute/IMC floor criteria) and electrolyte/fluid requirements

• Electrolytes within normal limits and not requiring replacement incompatible with acute care infusions (KCL)

NEUROLOGICAL EMERGENCIES: * Acute neurological syndromes requiring close observation/intervention

• Stroke Center Patients including:1. Subarachnoid hemorrhage2. Thrombolytic therapy for stroke (Stroke

Protocol)3. Intracerebral hemorrhage

• Acute posterior circulation disturbances with respiratory or hemodynamic compromise

• Acute cerebral edema• Fluctuating neurological deficits and

consciousness• Brain death in preparation for organ donation

• Resolving neurological and cardiac status requiring less frequent monitoring/intervention with hemodynamic/respiratory stability

SEPSIS SYNDROME/SHOCK EMERGENCIES:


Scope of Care


• Meets entry criteria for sepsis code pathway:o SIRS criteria (2 or more)o Evidence of Infection (1 or more)o Malperfusion

• Hemodynamically/respiratory compromised

o Requiring Early Goal Directed Therapy and not responding to 2 liters of fluid resuscitation in first 1 hour

• Hemodynamically/respiratory stable with minimal support (fluid resuscitation completed, no vasoactive infusions or oxygen supplement >50%

Surgical Patient Admission:(Patients meeting one or more of the following criteria)

Admission Criteria Discharge Criteria• Cardiothoracic surgery patients (CABG,

valve replacements• Meeting CTS criteria for Tele/IMC

transfer

• Neurosurgical patients requiring invasive monitoring (ICP) and/or intense/frequent neurological function assessment

• No longer requiring frequent neurological monitoring/ assessment

• Vascular, thoracic or abdominal surgery patients whose post-operative fluid and respiratory management, or peri-operative cardiac or bleeding risk requires intense monitoring/intervention available only in the CCU (See Admission to CCU demands of care) Consider placement in Telemetry/IMC if cardiac and/or oxygen saturation monitoring is primary need.

• Fluid, respiratory, cardiac and bleeding risks resolved

• Not requiring intense monitoring/intervention

• Any post-surgical patient with hemodynamic, rhythm or respiratory instability who is not stabilized in the Post Anesthesia Care Unit (PACU) (See CCU policy on Admission to the CCU Directly from the OR)

• See Aldrete Score Tool for discharge criteria from phase I and transfer to appropriate unit for care

Procedure1. Admissions Coordination:

a. Flow Supervisor-Manager/Bed Control will notify Critical Care ANM/CN b. Notify Managing Physician for the admission, and the PCPc. Notify the Admitting Resident for the CCU, beeper 2222-400 (medical

patients)2. Route of Admission:

a. Direct from outpatient setting


Scope of Care


b. Emergency Roomc. Medic Id. Transfers: 1) From in-house, 2) From another hospital: Transfer Coordinators:

AOD or Nursing Supervisore. Overflow from IMC/telemetry or med-surgical floor (rarely)

3. The House Flow Supervisor-Manager is contacted regarding transfers from another hospital, admissions from Emergency Department, or in-hospital transfers. S/he coordinates the transfer with the Critical Care ANM/CN and contacts Bed Control.

4. PACU notifies the Critical Care ANM/CN when they receive a patient who needs critical care post-anesthesia recovery to determine Critical Care bed availability.

5. Information to include in the discussion between personnel arranging for admissions: patient's name, age, diagnosis, current status, and any special considerations or equipment, particularly isolation, invasive monitoring, dialysis or ventilators. The CCU ANM/CN assigns the patient a bed and estimates a time the unit will be ready to receive the patient.

6. A physician and/or transferring registered nurse accompanies patients transferred to Critical Care. A monitored stretcher is used if indicated.

7. Patients transferred to Critical Care have all orders reviewed/rewritten/reconciled to and from CCU.

8. Patients meeting criteria for admission to the CCU are admitted under the management of the specialist most appropriate to the acute major problem prompting admission. That specialist is designated “Managing Physician” for the CCU stay.

9. Patients with predicted hospital extended length stay >6 days require a consult to the Clinical Nurse Leader for coordination of complex care.

DocumentationUsing the appropriate documentation tools, document the following:• Patient admission assessment to support admission to the CCU

ReferencePatient Classification/Recommended Staffing Guidelines, Standards of perianesthesia nursing practice. 2000.

Critical Care Unit Progressive Activity Plan

Responsible Department The Critical Care Unit is accountable for the content, implementation and monitoring of this policy.

Policy Approval Senior Vice President and Chief Nursing OfficerAdministrative Director, Specialty CareMedical Director of Critical Care & Respiratory Therapy

Author Penny Gilliatt, RN, BSN, CCRN Assistant Nurse Manager –


Scope of Care


Critical Care Unit Shirley Sherman, RN, BSN, CCRN Assistant Nurse Manager - Critical Care Unit

Approved By: Date:Senior Vice President and CNO: Charleen Tachibana, RN, MN, CNA June 2007Administrative Director, Specialty Care: Janine Wentworth, RN, MN June 2007Medical Director of Critical Care & Respiratory Therapy: Michael Westley, MD

June 2007

Due for Review: June 2010

vamasoncriticalcareunitptplacementguidelines2009.pdf

Documents