HSC SICU Collection Guide: Difference between revisions
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This article contains collection information specific to the | This article contains collection information specific to the [[HSC_SICU]]. | ||
''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at | ''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at HSC in the program or unit level articles. '' | ||
See the following for more general information: | See the following for more general information: | ||
* [[HSC General Collection Guide]] | * [[HSC General Collection Guide]] | ||
* [[HSC Critical Care Collection Guide]] | * [[HSC Critical Care Collection Guide]] | ||
== Ward contacts == | == Ward contacts == | ||
see [[HSC SICU#Contacts]] | see [[HSC SICU#Contacts]] | ||
== Work Space == | == Work Space == | ||
* 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 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 and it is often used by the CRNs. | ||
* There is a larger space at the North Nursing Station which may be free. | * There is a larger space at the North Nursing Station which may be free. There are electrical outlets there. | ||
* If not being used, the X-ray viewing room may also be used by collectors. | |||
== | == Log Book == | ||
We no longer use the log book to track admissions in SICU See [[Using Cognos2 to keep track of patients]] instead. | |||
== | ==SICU overflow in PACU== | ||
SICU | SICU patients often overflow into PACU, which is captured in the tmp file using [[Boarding Loc]]. | ||
*For admissions from PACU, use the time they are '''accepted by SICU''' as the admit time. The SICU physician will enter the admission to SICU on the order sheet or it is sometimes charted in the PACU Record by the nurse. TISS starts when the patient is accepted by SICU. | |||
**The SICU log book may not reflect the accurate time of admission from PACU. Always check the chart to ensure the '''accepted by SICU''' date/time is used. | |||
*For transfers to PACU who wait for transfer elsewhere, use the time they leave PACU as the discharge time. | |||
*For patients who are temporarily moved to PACU during their admission, and then return back to SICU, use the [[Boarding Loc]] tmp file to capture all the moves. | |||
**Make sure to check the SICU log book, as these patients are often written in there as a second admission, when in fact this is a bed borrow scenario. | |||
*Occasionally a code blue patient from a ward is admitted to PACU under SICU or MICU service, due to lack of beds in either unit. | |||
**The [[Previous Location]] should be the ward that the patient came from. | |||
**[[Service Location]] should be either HSC_CC | |||
**Ensure that the appropriate [[Boarding Loc]] information is entered, as this is also an example of a bed borrow in PACU. | |||
== Rounds == | |||
Rounds start at 09:00, so charts may not be available at that time. On Wednesdays Rounds start an hour or 2 later. | |||
== APACHE == | |||
See [[Apache II General Collection Guidelines]] | |||
These numbers are collected from the SICU CCFS. | |||
GCS data is obtained from the IPN, or from the Neurological Assessment Record. | |||
*The best source for the GCS is the admitting RN's notes. Patients are often initially sedated and this is shortly DC'd, which then allows a proper assessment and GCS data. | |||
*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 sedation. | |||
If the patient comes from PACU, use the PACU Vital Sign Record, from the time the patient was accepted by SICU service. | |||
For [[Admit Type for APACHE II]], the surgery must be an E1 to qualify as Emergent, otherwise enter Elective. | |||
*This info is found on the OR Record. | |||
== Clipboards == | == Clipboards == | ||
These are kept at each bedside and have | These are kept at each bedside and have: | ||
* the current Flowsheet | *the current Flowsheet | ||
* possibly the Flowsheet for the day before for reference during Rounds | *possibly the Flowsheet for the day before for reference during Rounds | ||
* the MARs | *the MARs | ||
== Charts == | == Charts == | ||
The charts are kept at each bedside. Lab sheets are usually in the chart. | The current charts are kept at each bedside. Lab sheets are usually in the chart. | ||
Thinned charts and old charts are kept on the high shelf at the front desk. | |||
SICU does '''not''' save charts of patients who where discharged home or transferred to another facility for data collectors. They must be requested from MR. See [[HSC Medical Records requests]]. | |||
Charts of deceased patients are '''not''' kept in the Unit for data collectors. As is true for all deceased patients' charts, they are at the [[HSC Death Registry]]. | |||
== CCFS == | |||
The flow sheets contain various data points that we collect, but they are not always complete. They must be used in conjunction with the chart to ensure that data is not missed. Some of the information found in the CCFS includes: | |||
*VS (first vitals = arrive time) | |||
*Medication infusions (these must be confirmed with MAR Sheets) | |||
*IV medications, including regularly scheduled and STAT (these must be confirmed with MAR Sheets) | |||
*Daily fluid intake | |||
*Blood products (must be confirmed with the Blood Administration Record) | |||
*Dressing changes (also check IPN) | |||
*CAM | |||
*Respiratory information, including modes of ventilation, presence of ETT/trach, extubations, etc. | |||
*Various interventions including ICP, drainage tubes, lines, TF, TPN, HD, CRRT, CT's, MRI's, EEG, ECHO, scopes, etc. | |||
== Additional Info == | |||
A white board by the front desk lists the patients. It also lists: | |||
*patients on the transfer list | |||
*MICU patients borrowing a bed in SICU | |||
*SICU patients borrowing a bed in PACU | |||
*other valuable info | |||
== Other HSC site specific info == | == Other HSC site specific info == | ||
Latest revision as of 17:06, 2022 January 15
This article contains collection information specific to the HSC_SICU. Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at HSC in the program or unit level articles.
See the following for more general information:
Ward contacts
Work Space
- 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 and it is often used by the CRNs.
- There is a larger space at the North Nursing Station which may be free. There are electrical outlets there.
- If not being used, the X-ray viewing room may also be used by collectors.
Log Book
We no longer use the log book to track admissions in SICU See Using Cognos2 to keep track of patients instead.
SICU overflow in PACU
SICU patients often overflow into PACU, which is captured in the tmp file using Boarding Loc.
- For admissions from PACU, use the time they are accepted by SICU as the admit time. The SICU physician will enter the admission to SICU on the order sheet or it is sometimes charted in the PACU Record by the nurse. TISS starts when the patient is accepted by SICU.
- The SICU log book may not reflect the accurate time of admission from PACU. Always check the chart to ensure the accepted by SICU date/time is used.
- For transfers to PACU who wait for transfer elsewhere, use the time they leave PACU as the discharge time.
- For patients who are temporarily moved to PACU during their admission, and then return back to SICU, use the Boarding Loc tmp file to capture all the moves.
- Make sure to check the SICU log book, as these patients are often written in there as a second admission, when in fact this is a bed borrow scenario.
- Occasionally a code blue patient from a ward is admitted to PACU under SICU or MICU service, due to lack of beds in either unit.
- The Previous Location should be the ward that the patient came from.
- Service Location should be either HSC_CC
- Ensure that the appropriate Boarding Loc information is entered, as this is also an example of a bed borrow in PACU.
Rounds
Rounds start at 09:00, so charts may not be available at that time. On Wednesdays Rounds start an hour or 2 later.
APACHE
See Apache II General Collection Guidelines
These numbers are collected from the SICU CCFS.
GCS data is obtained from the IPN, or from the Neurological Assessment Record.
- The best source for the GCS is the admitting RN's notes. Patients are often initially sedated and this is shortly DC'd, which then allows a proper assessment and GCS data.
- 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 sedation.
If the patient comes from PACU, use the PACU Vital Sign Record, from the time the patient was accepted by SICU service.
For Admit Type for APACHE II, the surgery must be an E1 to qualify as Emergent, otherwise enter Elective.
- This info is found on the OR Record.
Clipboards
These are kept at each bedside and have:
- the current Flowsheet
- possibly the Flowsheet for the day before for reference during Rounds
- the MARs
Charts
The current charts are kept at each bedside. Lab sheets are usually in the chart.
Thinned charts and old charts are kept on the high shelf at the front desk.
SICU does not save charts of patients who where discharged home or transferred to another facility for data collectors. They must be requested from MR. See HSC Medical Records requests.
Charts of deceased patients are not kept in the Unit for data collectors. As is true for all deceased patients' charts, they are at the HSC Death Registry.
CCFS
The flow sheets contain various data points that we collect, but they are not always complete. They must be used in conjunction with the chart to ensure that data is not missed. Some of the information found in the CCFS includes:
- VS (first vitals = arrive time)
- Medication infusions (these must be confirmed with MAR Sheets)
- IV medications, including regularly scheduled and STAT (these must be confirmed with MAR Sheets)
- Daily fluid intake
- Blood products (must be confirmed with the Blood Administration Record)
- Dressing changes (also check IPN)
- CAM
- Respiratory information, including modes of ventilation, presence of ETT/trach, extubations, etc.
- Various interventions including ICP, drainage tubes, lines, TF, TPN, HD, CRRT, CT's, MRI's, EEG, ECHO, scopes, etc.
Additional Info
A white board by the front desk lists the patients. It also lists:
- patients on the transfer list
- MICU patients borrowing a bed in SICU
- SICU patients borrowing a bed in PACU
- other valuable info
Other HSC site specific info
see Category: Health Sciences Center Office
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