HSC Critical Care Collection Guide: Difference between revisions

==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 be found here, especially after a weekend as they may have float clerks who will not know to do the entry.  Another way to discover unlogged patients is by looking at the TISS sheets collected in the binder if the patient has already been discharged.

    

*The admission time for a patient admitted from PACU may not be entered accurately in the log book if 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.

*If a 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.

*If a patient is admitted from the OR, the first admit must be a surgery.  This is not true if they are admitted from PACU.

*Patients coming from PACU who are still intubated are often a "Failure-to-Wean-Post-Op".

* The charts are kept at each bedside. Rounds start at 09:00 so the chart may not be available at that time. On Wednesdays Rounds start an hour or 2 later.

* Charts of deceased or transferred patients are not kept in the Unit for the Data Collector.

*These numbers are collected from the ICU Addendum Sheet/s and the flowsheets. If the patient comes from PACU, they do not use the ICU Addendum sheets.  Under Admit Type, the surgery must be an E1 to qualify as Emergent.  This info is found on the white typed OR sheet which indicated the start and end times, procedure, etc. (Not the Anesthetic Record).

*The best source for the GCS is the admitting RN's notes.  Patients are often initally on Propofol and this is shortly DC'd which then allows a proper assessment.  The neuro patients or head trauma patients may be sedated for long periods of time and the admission GCS may need to be used.  Those patients will generally have a very poor neuro status even without Propofol.   

*These are kept at each bedside and have the current Flowsheet and possibly the Flowsheet for the day before for reference during Rounds.  The MAR's are kept on the clipboard, but the lab sheets are usually in the chart.

*The infusion drugs are listed under the vital signs and not on the MAR's.  The IV med's given are listed on the Fluid Balance section of the Flowsheet, as wellas any colloid.  The colloids should be in red, but are not always.  The number of the unit may be listed, but not the type, e.g. FFP vs PRB.  This may require checking the Blood Admin record for clarification.  

*When counting antibiotics, be sure to check the yellow STAT sheet for antibiotic boluses.

*The colloids are listed here.  Each administration of platelets is counted as 5 units.  FFP is about 250-300 cc. per unit and are often given 500 at a time. CT's done on the way to the Unit e.g. from the ER, are not counted since they occur before admission to the Unit.

==HSC IICU Collection Guide==