HSC Critical Care Collection Guide: Difference between revisions
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'''''See also: | '''''See also: | ||
*''''' [[HSC General Collection Guide]] for information that applies to | *''''' [[HSC General Collection Guide]] for information that applies to both HSC Medicine and HSC ICU Data collection. | ||
*''''' [[Medicine Curriculum]] for information that applies to Medicine Data Collection | *''''' [[Medicine Curriculum]] for information that applies to Medicine Data Collection at all sites | ||
*''''' [[ICU Curriculum]] for information that applies to ICU Data Collection | *''''' [[ICU Curriculum]] for information that applies to ICU Data Collection at all sites | ||
== Information relevant to all HSC ICU collectors == | == Information relevant to all HSC ICU collectors == | ||
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If a MICU patient overflows into another unit, it is still MICU patient in the location on the laptop. Return to the MICU is not a transfer. | If a MICU patient overflows into another unit, it is still MICU patient in the location on the laptop. Return to the MICU is not a transfer. | ||
Order charts to Shelf 59 medical records (it has been changed from audit 59 september 2014)Limit to 20 charts. | |||
The ward clerks will order the TISS and green sheets if you ask them.Monitor to see if they are getting low. | |||
== Pharmacy== | == Pharmacy== | ||
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If patients are transferred to the wards the medication records may be in the nurses Mar binder or in a thinned chart.The ward clerks will help locate these thinned charts. | If patients are transferred to the wards the medication records may be in the nurses Mar binder or in a thinned chart.The ward clerks will help locate these thinned charts. | ||
25% Albumin is often given and is often not on the intake and output sheet but | 25% Albumin is often given and is often not on the intake and output sheet but will be found on the medication record. Cross reference the blood administration record. | ||
== Transfer times == | |||
To determine transfer times the first set of vital signs is the guide. Medicine collectors at HSC can find the transfer time by looking at the first set of vital signs in MICU. Unless there is a clearly documented time elsewhere in the chart the ward transfer time is usually 10 minutes prior to first set of vitals. It is a rare occurrence that those vital signs are not done. Collectors do need to be careful as there can be many days of addendum sheets. | |||
STB CCU is used as a bed borrow sometimes post angio and then patients are sent to HSC CCU. The only way to tell if it was a bed borrow or not | STB CCU is used as a bed borrow sometimes post angio and then patients are sent to HSC CCU. The only way to tell if it was a bed borrow or not is to look for a nursing transfer record or check our data base's transfer tracker. | ||
If patients overflow in to SICU they remain MICU data collectors patients.Surgical patients that come to MICU under the MICU attending care are also the MICU collector's patients. | If patients overflow in to SICU they remain MICU data collectors patients.Surgical patients that come to MICU under the MICU attending care are also the MICU collector's patients. | ||
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===PACU=== | ===PACU=== | ||
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. | 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. | ||
=== Transfer Ready Date === | |||
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. | |||
The preferred source for the Transfer Ready date and time is the Green Sheet. If that is blank, the next source is the doctors' order sheet. | |||
=== Patient Type === | === Patient Type === | ||
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Rounds start at 09:00 so the chart may not be available at that time. On Wednesdays Rounds start an hour or 2 later. | Rounds start at 09:00 so the chart may not be available at that time. On Wednesdays Rounds start an hour or 2 later. | ||
=== | ===APACHE=== | ||
*These numbers are collected from ICU flowsheets. | *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 | *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. | ||
=== Clipboards === | === Clipboards === | ||
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Thinned charts and old charts are kept above the desk by the FAX machine at the South Desk. | Thinned charts and old charts are kept above the desk by the FAX machine at the South Desk. | ||
Charts of deceased | Charts of deceased patients are not kept in the Unit for the Data Collector. As is true for all deceased patients' charts, they are at the Death Desk. | ||
===Flowsheets=== | ===Flowsheets=== | ||
*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. | *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. | ||
===Antibiotic counting=== | ===Antibiotic counting=== | ||
*When counting antibiotics, be sure to check the yellow STAT | *When counting antibiotics, be sure to check the yellow STAT sheet for antibiotic boluses. | ||
** {{discussion}} Are these unique to HSC SICU? Also used as MICU? How about at other sites? | ** {{discussion}} Are these unique to HSC SICU? Also used as MICU? How about at other sites? | ||
=== Labs === | === Labs === | ||
There was a reference to where labs were listed but I lost it. Please replace this section with where they are documented. | There was a reference to where labs were listed but I lost it. Please replace this section with where they are documented. | ||
==HSC IICU Collection Guide== | ==HSC IICU Collection Guide== | ||
If the patients come from a surgical area the SICU data collector will collect on them but they will be typed as medical patients. | If the patients come from a surgical area the SICU data collector will collect on them but they will be typed as medical patients. | ||
A test book is kept on the shelf behind the main desk and | A test book is kept on the shelf behind the main desk and completed TISS and green sheets are kept there. | ||
TISS are kept on the clipboards at the bedside. You really have to watch the dates and numbers on these as time goes on it is easy to get mixed up! | TISS are kept on the clipboards at the bedside. You really have to watch the dates and numbers on these as time goes on it is easy to get mixed up! | ||
Green sheets are in the same binder as the tiss sheets | |||
Collect the TISS and hand it in as soon as the page is complete. TISS sheets are filled in poorly in this unit, management is aware. | Collect the TISS and hand it in as soon as the page is complete. TISS sheets are filled in poorly in this unit, management is aware. | ||