HSC SICU Collection Guide
This article contains collection information specific to the SICU at HSC. 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
Log Book
The SICU log census book and the binder with completed TISS forms are kept at the South Nursing station. The white test sheets are also kept in that binder, and they may be discarded in confidential waste after 5 days. Patients who were not entered into the log book may be found by looking at the TISS sheets and on EPR. All admissions in the binder are numbered with the 1-11 sequence to divide workload between the 3 ICU collectors. See HSC ICU locations and serial number sharing.
TISS sheets
As of February 4, 2020, SICU keeps TISS forms of patients still in the unit on a clip board at the front desk (same as MICU). Label these with SICA-SICB-SICD to help keep track and avoid any missing forms. If any are not on this clipboard, check the patient's bedside table, as some staff are still getting used to the new system of keeping TISS forms all together at the desk.
Green Sheets
The Green sheets are in a binder on the Rounds Table, which is located in the side corridor to the left of the entrance into the unit. Completed Green Sheets (of discharged patients) are kept on the inside front cover of this binder, and may be retrieved before the start of rounds at 9 am.
- At the North nursing station is an upright set of shelves which has a space for the TISS and Green sheets which the data collector keeps stocked.
- Thinned charts are kept on the high shelf at the front desk.
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.
SICU patients 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 bed borrow in PACU.
- For SICU patients coming from PACU we use the time they are accepted by SICU as the admit time. For SICU patients transferred to PACU who are waiting to be transferred elsewhere we use the time they leave PACU as the discharge time. In both cases we enter this as bed borrows in the temp file.
Transfer Ready Date
SICU 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.
Overflow
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Is the following consistent with ICUotherService and how we do it now? Ttenbergen 16:55, 2020 April 9 (CDT) |
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 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 so must be followed up by the Data Collector.
Rounds
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 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 for APACHE II, 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.
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 charts are kept at each bedside. Lab sheets are usually in the chart.
Thinned charts and old charts are kept above the desk by the FAX machine at the South Desk.
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 HSC Death Registry.
Flowsheet s
- 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.
Other HSC site specific info
see Category: Health Sciences Center Office
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