HSC SICU Collection Guide
This article contains collection information specific to the IICU 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 StB in the program or unit level articles.
See the following for more general information:
Ward contacts
Log Book
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.
Green Sheets
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 at the front of the binder after the patient is discharged. Next to the desk 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.
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 larger space at the North Nursing Station which may be free. There are electrical outlets there.
Admission times from 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.
SICU patients 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 use the overflow variable for SICU Pt 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.
Overflow
|
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
Related articles
| Related articles: |