HSC Critical Care Collection Guide: Difference between revisions

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===Discussion===
===Discussion===
*{{Discussion}} - [[User: Jpeterson | Joyce Peterson]] to enter information here.
*{{Discussion}} - [[User: Jpeterson | Joyce Peterson]] to enter information here.




**{{Discussion}}
**{{Discussion}}
  The SICU log/census book is kept at the South nursing station.  This is seen when first entering the unit.  The log is in a shelf next to the unit clerk.  The binder with the completed TISS Sheets and Record of Special Treatment and Test Sheets is in the same shelf. These sheets are a good source for admission and discharge dates and times that may not have been put in the log book.  Patients who were not entered in the log book may also show up there, especially after a weekend as they may have float clerks who will not know to do the entry.
  There is a desk space nest to the FAX machine which may be vacant for a workspace, but there is no electrical outlet available.  There is space at the North nursing station with a computer to access KEA and an electrical outlet.  Next to it is a ste of shelves holding papers, where extra TISS and geen sheets must be restocked by the data collecor.
   
  The numbering for SICU patients goes from 51-100, eg patient 14599 is followed by 14600 then 14651.
  The patient type is always surgical in SICU, is medical in IICU.  If there is an SICU patient overflow into MICU, they will be entered in SICU's numbering on its laptop but the data will be collected by the MICU data collector.  If an MICU is overflowed into SICU, SICU's collector will get a number from the MICU log and collect on that patient.


   If an SICU is overflowed into PACU, SICU follows them there.  The PACU staff do not complete TISS forms.
   The SICU log census book is kept at the South Nursing station.  This is seen when first entering the unit.  The log is in a shelf at the desk, next to the Unit Clerk.  The binder with the completed TISS and Record of Special Treatment and Test sheets is in the same shelf.  The test sheets are a good source for admission and discharge dates and times that may not have been put into the log book.  Patients who were not entered into the log book may also show here her, especially after a weekend as they may have float clerks who will not know to do the entry.


REG/ADL/VAR:
   The Green sheets are in a binder on the Rounds Table. When not being used in rounds, it is usually kept in the side corridor which will leads to the new hotel.  Completed Green Sheets are left in the binder after the patient is discharged.
   The admission time for a patient admitted from PACU may not be entered accurately in the log book if they had to hold on to them due to lack of space.  The SICU physician will enter the admission to SICU on the order sheet and that is to be considered the time of admission.  Any extra time in PACU is then considered overflow into PACU.


   A patient may be listed in the log book as being admitted from HSC ER, but this must be checked since they may have originated from another hospital/nursing staion and just had passed through the HSC ER.
   There is a desk space next to the FAX machine at the South desk that may be vacant for a workspace, but there is no electrical outlet available.  There is a larger space at the North Nursing Station which may be free.  it has electrical outlets and a computer which accesses KEA. Next to this desk is an upright set of shelves which has a space for the TISS and Green sheets which the data collector keeps stocked.


   SICU/IICU must have a 'transfer ready date/time' collected. This should be in the doctors' orders. If is is not there, it may be on the Green Sheet, or in the doctor's notes.  Patients who are transferred to another ICU (not including IICU), do not have a transfer ready date/time.
   The numbering for SICU/IICU patients goes from 51-100, e.g. patient 14599 is followed by 14600, then 14651.


  Discharge date and time for a patient who is an organ donor is not the time of death, but when they leave SICU.
    
    
   All patient who suffer a cardiac arrest must have the BRR/XBR completed.  This is the cooling protocol.
   REG/ADL/VAR:
  The admission time for a patient admitted from PACU may not be entered accurately in the log bookif they have been held in PACU due to lack of space.  Always check to ensure the time used for the database is accurate.  The SICU physician will enter the admission to SICU on the order sheet and that is considered the time of admission. Any extra time in PACU is then considered overflow in PACU.


   The Filter section is relevant if a patient is on Long-Term ventilation.
   A patient may be listed in the log book as admitted from HSC ER, but this must be checked since they may have originated from another hospital/nursing station and just passed through the HSC ER.


DIAGNOSES:
  SICU/IICU must have a 'transfer ready date/time; entered, unless they are transferring to another ICU bed (not including IICU).  Transfer to IICU is treated like a transfer to a ward, but the data collection once there is treated like an ICU patient.


   If a patient is admitted from the OR, the first admit diagnosis must be a surgery.
   Discharge date and time fror a patient who is an organ donor is not the time of death, but the time/date they leave the ICU to go to the OR.


   If the patient was a trauma who went to the OR, the diagnosis will be under Trauma -post-op, e.g. craniotomy to evacuate a traumatic SDH, will be 'Subdural hematoma-POST-OP - MVA'.
   The patient type is always 'surgical' in SICU and 'medical' in IICU.


   If a patient has a diagnosis of septic shock, at present the Septic Shock Study requires that the Temp Studies must have a date and time for the first low bp and first antibiotic related to that septic episode.  This information may be in the charting from another hospital or ward flowsheets/vital sign sheets.
  The Filter section is relevant if a patient is on Long-Term Ventilation.
 
  Variables:
  All patients who suffer a cardiac arrest must have the BRR/XBR completed. 
   If a patient is overflowed into PACU, SICU follows them there.  The PACU staff do not complete TISS sheets and transfers out may not get into the log book.
  If patient overflows into another unit, it is still called by its home unit in the location, and the number must be taken from the home unit log. The data is collected by the collector where the patient resides and put onto the home unit database.  Return to the home unit is not a transfer.


   APACHE:
   DIAGNOSES:
   The APACHE score information is often initially on an ICU Addendum, or if the patient was in PACU, on the ICU flowsheet or the PACU flowsheet.  The informatioon for the Glascow Coma Scale may be obtained from the back of the ICU flowsheet or more accurately from the nurses' notes.
   If a patient is admitted from the OR, the first admit must be a surgery.


   If a patient has a VAP, only the date and not the time needs to be entered.
   If the patient is a traum who goes to the OR, the diagnosis is found under TRAUMA, e.g.  craniotomy to evacuate a traumatic SDH from an MVA, will be 'Subdural hematoma-POST-OP - MVA'.


   LABS:
   If a patient has a diagnosis of septic shock, at present the Septic Shock Study requires that the Temp Studies must have a date and time of the first low bp and antibiotic related to the septic episode.  This may have to be found in notes from another hospital or the Vital Signs record from the ward.  If a patient has a VAP, only the date and the time needs to be entered.
  Cautiion needs to be used when collecting the blood products and volume expanders as staff do not always chart these in red.  The total should not include OR administrations.


   The only x-ray viewer in SICU is in the Diagnostics room near the entrance to the unit.
    
 
--[[User:Jpeterson|Jpeterson]] 15:23, 4 May 2011 (CDT)
  PHARMACY:
  The Pharmacy section does not need to be completed and so can just be checked as Complete.
[[User:Jpeterson|Jpeterson]] 14:24, 4 May 2011 (CDT)


==HSC IICU Collection Guide==
==HSC IICU Collection Guide==

Revision as of 15:23, 4 May 2011

  • HSC ICU collectors, please document collection data guidelines for related to HSC ICU units here. If there are any collection details that are specific to your ward, they should be documented here also.

This will serve as a reference for any collector who is assigned or choices to pick up extra hours during sick or vacation at this site.

If you want to see current guideline for sites go to: Medicine Curriculum or ICU Curriculum and look at top of this article to find link to hosp/unit specific guideline in progress.--Thanks everyone.TOstryzniuk 20:18, 21 October 2010 (CDT)

HSC MICU/CCU Collection Guide

  • July 21.09 - HSC-MICU & CCU will now be on one collection device: (HSC_MICU). Serial number sequencing for MICU/CCU will now start at 25232 (using 1-50 of every group of 100)

HSC SICU Collection Guide

Discussion


  The SICU log census book is kept at the South Nursing station.  This is seen when first entering the unit.  The log is in a shelf at the desk, next to the Unit Clerk.  The binder with the completed TISS and Record of Special Treatment and Test sheets is in the same shelf.  The test sheets are a good source for admission and discharge dates and times that may not have been put into the log book.  Patients who were not entered into the log book may also show here her, especially after a weekend as they may have float clerks who will not know to do the entry.  

  The Green sheets are in a binder on the Rounds Table. When not being used in rounds, it is usually kept in the side corridor which will leads to the new hotel.  Completed Green Sheets are left in the binder after the patient is discharged.

  There is a desk space next to the FAX machine at the South desk that may be vacant for a workspace, but there is no electrical outlet available.  There is a larger space at the North Nursing Station which may be free.  it has electrical outlets and a computer which accesses KEA. Next to this desk is an upright set of shelves which has a space for the TISS and Green sheets which the data collector keeps stocked.

  The numbering for SICU/IICU patients goes from 51-100, e.g. patient 14599 is followed by 14600, then 14651.



  REG/ADL/VAR:
  The admission time for a patient admitted from PACU may not be entered accurately in the log bookif they have been held in PACU due to lack of space.  Always check to ensure the time used for the database is accurate.  The SICU physician will enter the admission to SICU on the order sheet and that is considered the time of admission. Any extra time in PACU is then considered overflow in PACU.

  A patient may be listed in the log book as admitted from HSC ER, but this must be checked since they may have originated from another hospital/nursing station and just passed through the HSC ER.

  SICU/IICU must have a 'transfer ready date/time; entered, unless they are transferring to another ICU bed (not including IICU).  Transfer to IICU is treated like a transfer to a ward, but the data collection once there is treated like an ICU patient.

  Discharge date and time fror a patient who is an organ donor is not the time of death, but the time/date they leave the ICU to go to the OR.

  The patient type is always 'surgical' in SICU and 'medical' in IICU.

  The Filter section is relevant if a patient is on Long-Term Ventilation.
  
  Variables:
  All patients who suffer a cardiac arrest must have the BRR/XBR completed.  
  If a patient is overflowed into PACU, SICU follows them there.  The PACU staff do not complete TISS sheets and transfers out may not get into the log book.
  If patient overflows into another unit, it is still called by its home unit in the location, and the number must be taken from the home unit log. The data is collected by the collector where the patient resides and put onto the home unit database.  Return to the home unit is not a transfer.

  DIAGNOSES:
  If a patient is admitted from the OR, the first admit must be a surgery.

  If the patient is a traum who goes to the OR, the diagnosis is found under TRAUMA, e.g.  craniotomy to evacuate a traumatic SDH from an MVA, will be 'Subdural hematoma-POST-OP - MVA'.

  If a patient has a diagnosis of septic shock, at present the Septic Shock Study requires that the Temp Studies must have a date and time of the first low bp and antibiotic related to the septic episode.  This may have to be found in notes from another hospital or the Vital Signs record from the ward.  If a patient has a VAP, only the date and the time needs to be entered.


--Jpeterson 15:23, 4 May 2011 (CDT)

HSC IICU Collection Guide

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