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Admission and Discharge to and from the Trauma and Life-Support Center (2.1.18)

Admission and Discharge to and from the Trauma and Life-Support Center (2.1.18) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.18


UW HEALTH CLINICAL POLICY 1
Policy Title: Admission and Discharge to and from the Trauma and Life-Support
Center
Policy Number: 2.1.18
Category: UW Health
Type: Inpatient
Effective Date: May 17, 2016

I. PURPOSE

To ensure appropriate utilization of the Trauma and Life-Support Center (TLC).

II. POLICY ELEMENTS

A. The TLC is a Medical - Surgical Intensive Care Unit (ICU) that serves unstable or critically ill adult patients
w ho require an intensive level of monitoring and/or care. The patient in the TLC typically has an actual or
potential life-threatening illness. These patients require frequent to constant nursing observation and
interventions, active or stand-by life support systems, sophisticated monitoring equipment and concentrated
support services. The patient in the TLC may demonstrate or develop hemodynamic, respiratory, neurologic
or metabolic instability. Patients admitted to TLC commonly have diagnoses related to:
i. Acute or chronic respiratory distress or failure requiring assisted ventilation.
ii. Septic, hypovolemic, cardiogenic shock and other types of shock.
iii. Severe traumatic injuries.
iv. Major post-operative care to include but not limited to: liver transplants, vascular surgery, general
surgery and neurosurgery w ith/w ithout pre-existing conditions, e.g., MI, hypertension, COPD,
IDDM, w hich create higher than normal post-operative risks, requiring intensive or prolonged post-
operative monitoring or ventilatory support. Such patients may also require monitoring,
instrumentation, evaluation and/or observation prior to surgery.
v. Severe hepatic dysfunction.
vi. Multiple organ system failure.
vii. Monitoring/support follow ing cardiac or respiratory arrest.
viii. Acute gastrointestinal bleeding.
ix. Acute alterations in consciousness.
x. Drug overdoses resulting in loss of consciousness or need for frequent/continuous monitoring.
xi. Critical f luid and/or electrolyte or metabolic imbalances.
B. As census permits, the unit serves patients as overflow from other critical care units, as appropriate in the
event that beds are not available in the ICU that w ould usually manage those patients. In these cases,
admission to the TLC Unit w ill follow the admission and discharge policies in place for the unit that w ould
usually manage those patients, and is coordinated by the Nursing Coordinator.
C. Admission to TLC may not be appropriate for patients w ith terminal disease, for w hom death is imminent
and anticipated, and for w hom intensive monitoring and/or management offers no hope of signif icant
survival. Particular thought should be given to the admission of patients for w hom a "Do Not Resuscitate"
order has been w ritten. While such patients may be admitted to the TLC for specif ic monitoring or
intervention, the potential benefits to be accrued should be carefully considered before admission.
D. The TLC is a HEPA filtered unit. TLC has four airborne infection isolation (AII) rooms and patients are
admitted or transferred to an AII room w hen an order is submitted for airborne precautions, per UWHC
clinical policy #13.07, Standard Precautions & Transmission-based Precautions (Isolation) for Inpatient
Settings.

III. PROCEDURE

Criteria and mechanisms for the admission and transfer of patients to and from TLC.

A. Admission Criteria
i. Priority I:
a. Acute respiratory failure requiring complex ventilator management
b. Hemodynamic status requiring continuous assessment for critical blood loss or f luid shifts
from the vascular space and/or replacement w ith blood, blood components, volume, e.g.,
SBP 20mmHg below baseline, or requiring continuous renal replacement therapy, e.g.,
circulatory collapse requiring addition of intravenous vasoactive drug infusions, cardiac
status requiring the treatment of lethal dysrhythmias, frequent titration, or increasing



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge of Patients to and from the Trauma and Life-Support Center
Policy Number: 2.1.18

amounts and/or complex monitoring, e.g., PA catheter.
c. Acute deterioration in neurological status requiring constant monitoring and intervention,
e.g., osmotic therapy, ICP monitoring, barbiturate therapy.
d. Critical metabolic imbalances, e.g., acidosis/alkalosis, and/or electrolyte imbalance,
requiring continuous intervention and management.
e. Acutely traumatized patient w ith poly-trauma or single system involvement w ith signif icant
potential to deteriorate.
f. Post-operative liver transplant patients and complex post-operative vascular surgical
patients that require frequent monitoring, assessments, and interventions.
ii. Priority II:
a. Acute respiratory failure/insuff iciency requiring assisted mechanical ventilation, respiratory
support or continuous non-invasive respiratory support to treat and/or prevent respiratory
failure/insuff iciency, e.g., CPAP or BiPAP.
b. Hemodynamic status requiring management of hyper- or hypotension episode,
maintenance of vasoactive drug infusions, frequent IV bolus drug administration, or
monitoring for recurrent but stable arrhythmias and/or infusion of anti-arrhythmic drugs.
c. Neurological status requiring continuous monitoring, e.g., ICP monitoring to rapidly detect
untow ard changes, e.g., post-operative bleeding, post-traumatic sw elling.
d. Metabolic/endocrine status, e.g., signif icant acidosis/alkalosis or electrolyte imbalance
requiring continuous observation or management, e.g., hourly.
e. Post-operative surgical patients that require frequent monitoring, assessments, and
interventions.
iii. Priority III:
a. Acute respiratory failure/insuff iciency requiring frequent monitoring and intermittent
intervention to treat and/or prevent respiratory failure/insuff iciency, e.g., CPAP q 1-4 hours
or chronic respiratory failure/insuff iciency requiring long-term w eaning of mechanical
ventilation in an otherw ise stable patient.
b. Hemodynamic status requiring maintenance of low dose, or w eaning of, vasoactive drug
infusions or cardiac status requiring monitoring for potential life-threatening arrhythmia
e.g., electrolyte imbalance, cardio/toxic drug infusion and/or w eaning of anti-arrhythmic
drug infusions.
c. Neurological status requiring close observation, e.g., clinical assessment to rapidly detect
untow ard changes.
d. Metabolic/endocrine status requiring close observation e.g. clinical assessment.
B. Admission Procedure. Admission to the TLC is at the discretion of the Surgical Critical Care (SCC) Medical
Director or Critical Care Service (CCS) Medical Director or designee. Admission w ill be based on the
admission criteria as w ell as upon the guidelines set for in the UWHC clinical policy #7.45, Triage of
Critically Ill Patients.
i. Identif ication of patient's need for intensive care management is made by the responsible house
staff in conjunction w ith the attending physician. In situations requiring immediate transfer, the
responsible attending staff must be notif ied by the resident as soon as possible after transfer.
ii. The house off icer or attending staff physician caring for the patient makes a request for patient's
transfer and admission to TLC to the Nursing Coordinator/Access Center. Requests w ill be
transmitted to the TLC admitting service. The Nursing Coordinator then notif ies the TLC Care Team
Leader. The admitting physician w ill notify the Nursing Coordinator or Access Center if the patient
meets “TLC only admission criteria.” An effort w ill be made to place the patient w ho meets “TLC
only criteria” in TLC as opposed to a lateral placement in another ICU. If unable to place a patient
who meets “TLC only criteria” in TLC, daily discussions should occur betw een nursing coordinators
and TLC Care Team Leaders, attempting to transfer the patient to TLC. The TLC only admission
criteria include, but are not limited to patients w ith:
a. Acute respiratory failure requiring complex invasive or non-invasive ventilatory
management
b. Frequent vasoactive drug titration
c. Hypotension despite >3 liter IV f luid replacement
d. Polytrauma
e. Severe encephalopathy/gastric intestinal bleeding (GIB)/coagulopathy
iii. Patients may be received from the Operating Rooms, Post Anesthesia Care Unit (PACU), the
Emergency Department and other patient care units. How ever, patient's admission to the TLC w ill



UW HEALTH CLINICAL POLICY 3
Policy Title: Admission and Discharge of Patients to and from the Trauma and Life-Support Center
Policy Number: 2.1.18

not occur until bed space availability is confirmed through the Nursing Coordinator and the unit
Care Team Leader.
iv. Patients that w ent to the OR from TLC may bypass the PACU postoperatively and receive phase
one recovery after extubation if TLC nursing 1:1 staff ing is available. The OR must communicate
w ith the TLC Care Team Leader before bypassing the PACU.
v. Patients may also be directly admitted to TLC from referring hospitals w ith physician acceptance
through the Access Center.
vi. Prior to, or as soon as possible follow ing the actual transfer of the patient to TLC, a transfer note
w ill be placed in the Progress Notes by the house staff or attending staff initiating the transfer.
vii. Upon transfer of the patient to the TLC, the Care Team Leader or unit clerk on the transferring unit
w ill update the unit census in Health Link.
viii. Bed needs for postoperative patients should be anticipated and discussed w ith the Nursing
Coordinator and the appropriate treating critical care service attending physicians or designee.
While anticipation of bed needs is necessary, bed space in a particular ICU cannot be reserved or
guaranteed.
ix. All patients w ill be monitored by the eICU in accordance w ith e-Care standards.
C. Assignment of Patients
i. The transferring staff physician and service responsible for the patient's care w ill clearly document
in the orders the patient's level of care and the physicians responsible for care during the patient's
stay in the TLC. The Critical Care Service (CCS) or Surgical Critical Care (SCC) Service w ill
participate in the care of all patients w ith ICU level of care admitted to the TLC w ith the exception of
those services w ith in house residents and w hose attending physician is credentialed for critical
care management by UWHC. In this case, these patients w ill be seen only by consultative request.
The patient must be as identif ied in the critical care admission attending and service order in Health
Link as one of the follow ing:
a. CCS or SCC Primary Managed Patients: The primary care is the responsibility of, and
assigned to the attending staff and team. The team w ill w rite all orders, provide patient
care, and document daily progress of the patient's care in the Progress Notes.
b. CCS or SCC Managed Patients w ith Consulting Services: Specialty medical or surgical
patients (e.g. neurology, peripheral vascular service) w ithout in-house residents and/or
attending physician not credentialed for critical care management by UWHC w ill be
managed w ith the CCS or SCC attending leading the team in partnership w ith the
specialty service as a consult service. Ideally, both services w ill discuss and approve of
major changes in patient care plans. Timely and respectful communication w ill occur
betw een services regarding patient care issues. Communication and agreement about the
role and responsibilities of each team in the care of the patient, including delegation of
order-w riting responsibilities, w ill be clearly defined.
c. IMC Status and General Care Patients: Patient care is the exclusive responsibility of the
admitting or transferring staff physician and service. The CCS or SCC physician w ill
respond to patient care emergencies until the primary team is available in the unit.
d. Observation status patients w ill not be admitted to TLC unless approved by the CCS
medical director, SCC Medical Director or designee.
ii. Consultants w ill not w rite orders on TLC patients unless approved by the primary team caring for
the patient.
a. Overflow patients from other ICU's must be categorized in the same manner as patients
entering from other sources. Overflow patients w ho are admitted to the TLC in times of
bed shortage w ill only be seen by the CCS w hen consultatively requested, similar to those
services w ith an in house resident and w hose attending physician is credentialed for
critical care management by UWHC.
D. Transfer Criteria
i. In general, transfer criteria include resolution or reduction of the acuity of the underlying problem(s),
w hich necessitated admission, to the extent, that ICU monitoring and/or management is not
required. This implies that cardiovascular, pulmonary, central nervous system and metabolic
functions have stabilized and can be monitored and managed w ith the capabilities available on the
unit to w hich the patient is being transferred. Patient should:
a. Be hemodynamically stable.
b. Have stable respiratory status.
c. Demonstrate stable neurological status.



UW HEALTH CLINICAL POLICY 4
Policy Title: Admission and Discharge of Patients to and from the Trauma and Life-Support Center
Policy Number: 2.1.18

d. Demonstrate stable metabolic/endocrine status.
ii. Patients transferred to "intermediate" level units should fall w ithin the admission criteria of the
respective unit.
iii. Inter ICU transfers of patients may be necessary to ensure optimal care for the patient's diagnosis.
The Nursing Coordinator w ill be consulted for all inter ICU patient transfers that are necessitated by
ICU bed shortages. The Nursing Coordinator, or designee, w ill review the need for such transfers
w ith a physician member of the team caring for the patient, coordinate the transfer and act as an
arbitrator in times of conflict. The ultimate triage decision rests w ith the medical director or
designee. Except under extraordinary circumstances, no patient should be subject to more than
one inter ICU transfer, unless the transfer is dictated by the patient's medical condition.
E. Transfer Procedure
i. The decision for transfer from the TLC to another UWHC patient care unit w ill be made jointly by
the staff physicians and members of the interdisciplinary team. Attempts should be made to identify
transfers from the TLC early in the day to facilitate subsequent admissions to the unit. When
disagreements about the suitability for discharge occur, the SCC Medical Director or CCS Medical
Director of the TLC may be consulted to negotiate a solution.
ii. Order reconciliation, a change in patient status order, and a transfer note must be documented by
the primary service assuming responsibility for the patient prior to the patient's transfer to another
unit if this service is different from the service responsible for the patient in the ICU. Upon w riting of
transfer orders, the accepting service w ill assume care for the patient.
iii. The Nursing Coordinator w ill be notif ied of any transfer by the Care Team Leader or Health Unit
Coordinator prior to the actual transfer. Likew ise the receiving unit w ill be contacted prior to transfer
and arrangements made for transfer of the patient.
iv. An SBAR handoff report w ill be given to the receiving nurse in person or via telephone by the
transferring nurse caring for the patient. If necessary (e.g., ongoing telemetry monitoring), a
registered nurse w ill accompany the patient upon transfer.
v. For patients w ith a prolonged stay in TLC (greater than a w eek or w ith a change in service), a
dictated ICU discharge summary should accompany the patient to the receiving unit if this service
is different from the service responsible for the patient in the ICU.
vi. An interim and f inal discharge summary w ill be completed by the designated service on any patient
transfer to another facility from the TLC and on any patient w ho expires w hile in the TLC. This
summary must be completed on the day of death or transfer out of TLC.
vii. UW Health clinical policy #2.1.6, Patient Transfers should be follow ed to ensure a consistent
process is used as w ith all patient transfers.
F. Discharge Criteria/Procedure
i. Patient discharge directly to home or to another facility from the TLC occurs infrequently. When
direct discharge is appropriate, it w ill be completed according to UWHC clinical policy #7.15,
Discharge Planning Process.

IV. CONFLICT RESOLUTION

Conflicts, w hich arise regarding the admission and discharge of patients, and priorities, w hich cannot be
adequately resolved by the parties involved, should be promptly referred to the TLC Medical Director or
designee. Conflicts that arise regarding admission or transfer of patients in the instances of acute ICU bed
shortages w ill be managed according to UWHC's Triage Policy. The decisions of the Medical Director may
be appealed to the Senior VP of Medical Affairs and/or to the Critical Care Committee of the Medical Board.

V. COORDINATION

Author: Medical Director of TLC; CNM, Trauma and Life-Support Center
Senior Management Sponsor: SVP, Medical Affairs
Approval committees: Critical Care Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: April 18, 2016

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 Hospitals 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



UW HEALTH CLINICAL POLICY 5
Policy Title: Admission and Discharge of Patients to and from the Trauma and Life-Support Center
Policy Number: 2.1.18

responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UWHC clinical policy #13.07, Standard Precautions and Transmission-based Precautions (Isolation) for
Inpatient Settings
UWHC clinical policy #7.45, Triage of Critically Ill Patients
UW Health clinical policy #2.1.6, Patient Transfers
UWHC clinical policy #7.15, Discharge Planning Process

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: May 2019
Formerly Know n as: Hospital Administrative policy #7.22