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IMC Criteria for Hematopoietic Stem Cell Transplant (HSCT) - B6/6 (adult) or P4 (pediatric) (9.17)

IMC Criteria for Hematopoietic Stem Cell Transplant (HSCT) - B6/6 (adult) or P4 (pediatric) (9.17) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Patient Charges

9.17



UW HEALTH CLINICAL POLICY 1
Policy Title: IMC Criteria for Hematopoietic Stem Cell Transplant (HSCT) - B6/6(adult) or
P4(pediatric)
Policy Number: 9.17
Category: UW Health
Type: Inpatient
Effective Date: July 1, 2016

I. PURPOSE

To ensure the use of a uniform policy when HSCT patients are admitted and discharged
from B6/6 or P4 Intermediate Care (IMC) status

II. Definitions
HSCT – Hematopoietic Stem Cell Transplant

III. POLICY ELEMENTS

Scope of Service: B6/6/P4 IMC status has been developed to provide guidelines of care
for the adult or pediatric HSCT patient who does not require admission/transfer to the
Trauma Life Center (TLC) or Pediatric Intensive Care Unit (PICU), or higher level of
intermediate care. These patients do not require continuous mechanical cardio/pulmonary
support, but require frequent monitoring, assessments and use of supportive treatments
(Addendum A). It is the responsibility of the attending physician, and/or designee to
provide care for patients on B6/6 or P4 in IMC status, in collaboration with the
interprofessional team.

IV. PROCEDURE

A. Admission to IMC status:
i. Admission Criteria: the following are examples(not comprehensive) of
patient populations that are appropriate for IMC status :
ii. HSCT patients that require high levels of supportive care (outlined in
Standards of Practice “SOP’s” supported by FACT accreditation see
Addendum B)
iii. HSCT patients that meet one or more of the following “InterQual
Intermediate Care” Options (see Addendum C)
1. BMT or SCT post procedure
a. Hydration or nutrition support
2. BMT or SCT post procedure and awaiting engraftment
a. Hydration or nutrition support
b. Hypokalemia with ECG criteria
c. Isolation (includes protective precautions)
d. IV medication(specific group) with administration
monitoring (q 3-4 hr)
3. Graft versus Host Disease (grade and intervention criteria)


V. COORDINATION




UW HEALTH CLINICAL POLICY 2
Policy Title: Click to enter text.
Policy Number: Click to enter text.

Author: Director, Nursing Finance & Staffing Effectiveness, July 2016
Senior Management Sponsor: SVP, Chief Nursing Officer
Reviewers: Medical Director, HSCT Program, July 2016
Nurse Manager, Hematology/Oncology, July 2016
Clinical Nurse Specialist, Hematology/Oncology, July 2016
HSCT Case Manager, July 2016
Director, Oncology Nursing, July 2016
Outcomes Manager, AFCH, July 2016
Director, Pediatric Nursing, AFCH, July 2016

Approval committees: Nursing Administrative Policy & Procedure Committee, July 2016
UW Health Clinical Policy Committee Approval: Date of Approval

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospital and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Beth Houlahan, DNP, RN, CENP
VP, Chief Nursing Officer

VII. REFERENCES

InterQual2015
Policy 7.0 – Emergency Department Handoff Communication Guidelines
Policy 14.17 – Transfer of the Patient (Adult & Pediatric)
Policy 2.1.6 – Patient Transfers (Formerly 7.14)
Policy 2.1.18 – Admission and Discharge to and from the Trauma Life Support Center (Formerly 7.22)

VIII. REVIEW DETAILS
Version: Original
Next Revision Due: July 1, 2019


























UW HEALTH CLINICAL POLICY 2
Policy Title: Click to enter text.
Policy Number: Click to enter text.