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Admission and Discharge of Patients to and from the Cardiac Intensive Care Unit (2.1.2)

Admission and Discharge of Patients to and from the Cardiac Intensive Care Unit (2.1.2) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.2


UW HEALTH CLINICAL POLICY 1
Policy Title: Admission and Discharge of Patients to and from the Cardiac Intensive
Care Unit
Policy Number: 2.1.2
Category: UW Health
Type: Inpatient
Effective Date: May 1, 2015

I. PURPOSE

To ensure appropriate use of the Medical Cardiac Intensive Care Unit (CCU) and to outline guidelines for
admission and discharge of patients to and from the CCU.

II. POLICY ELEMENTS

A. The CCU predominantly serves critically ill adult patients w ho have recently undergone major cardiac
procedures or for critical illness related to cardiovascular disease. The patient in Intensive Care status
demonstrates actual or potential acute or chronic life-threatening symptoms and/or injury, w ith a potential for
recovery. These patients require frequent or constant nursing observation and nursing intervention, w ith
active or stand-by life support systems, sophisticated monitoring equipment and support services. Typical
CCU patient populations may include:
i. Acute myocardial infarction
ii. Profound heart failure and cardiomyopathy
iii. Cardiogenic shock w ith or w ithout the need for peripherally inserted ventricular support systems
iv. Cardiac disease requiring pharmacologic or mechanical support
v. Life threatening arrhythmias w ith or w ithout transvenous or transcutaneous pacing, antiarrhythmic
infusions, or defibrillation
vi. Cardiac Tamponade
vii. Post cardiac procedures such as: angioplasty, atherectomy, stent, thrombolytic therapy,
electrophysiology, percutaneous ventricular assist devices insertion, valvuloplasty, alcohol septal
ablations, Transcatheter Aortic Valve Replacement (TAVR), Intra-aortic Balloon Pump (IABP)
therapy
viii. Continuous Renal Replacement Therapy (CRRT)
ix. Extracorporeal circulation via the CARDIOHELP® support system
x. Status post cardiac arrest w ith or w ithout targeted temperature management therapy
xi. Patients requiring electrical or pharmacologic cardioversions
xii. Critical medical illness status post heart transplantation excluding the immediate post-operative
period
B. As census permits, the unit serves patients as overflow s from other ICUs, as appropriate in the event that
beds are not available in the ICU that w ould usually manage those patients. Patients admitted as overflow
w ill be deemed appropriate by the CCU Medical Director, the Medical Cardiology CCU Nurse Manager and
the Patient Placement Coordinator.
C. Beds in the CCU should not, in general, be used for the care of patients w ith advanced malignancy or other
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, or useful prolongation of the dying process. 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 CCU for specif ic monitoring or intervention, the potential
benefits to be accrued should be carefully considered and discussed w ith family and caregivers before
admission.

III. PROCEDURE

A. Admission Criteria and Procedure:
i. Admission to the CCU is at the discretion of the Cardiology House Staff in conjunction w ith the
Cardiology Attending for cardiac admissions. Admission w ill be based upon the priority criteria
delineated below , as w ell as upon the guidelines set forth in the policy for Triage of Critically Ill
Patients (UWHC policy #7.45). Priority for admission to CCU is as follow s:
a. Priority I: STEMI Patients.
b. Priority II: Cardiovascular Medical Critically Ill Patients.
c. Priority III: Cardiovascular Surgical Patients Deemed Appropriate for CCU.
d. Priority IV: Critically Ill Other Medical Services Patients.



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge of Patients to and from the Cardiac Intensive Care Unit
Policy Number: 2.1.2

e. Priority V: Critically Ill Other Surgical Services Patients.
ii. Patients may be admitted to the CCU via several mechanisms:
a. Transfer from UWHC inpatient unit.
b. Direct admits from referring hospital or clinic as coordinated by the Access Center
according to UWHC policy #7.04, Inter-hospital Transfer/Direct Admissions.
c. From the UWHC Emergency Department.
d. Direct admit from Med Flight Program.
iii. Patients w ho meet admission criteria for the CCU w ill be admitted upon request of the attending
physician or designee by contacting the Patient Placement Coordinator. Bed availability must be
determined prior to admission. In the event that patient volume exceeds capacity, the Patient
Placement Coordinator w ill w ork w ith the Cardiovascular Medicine (CVM) attending or designee
and appropriate medical service regarding w hich patient(s) w ill be admitted and discharged from
the CCU. Request for a CCU bed w ill be communicated to the Patient Placement Coordinator w ho
w ill support and negotiate communication betw een the requesting medical team and the CVM
medical team.
iv. Patients may also be directly admitted to the CCU from referring hospitals arriving by Med Flight or
ambulance, follow ing the attending physicians' acceptance of the patient in transfer. The Access
Center w ill coordinate the direct admission of a patient.
v. The admission process w ill follow the admission and discharge policy in place for the ICU that
w ould usually manage these patients at the ICU or IMC level. (For example: patients on a medicine
service w ould follow UWHC policy #7.22, Admission and Discharge of Patients to & from the TLC.)
B. Transfer criteria for transfer out of the CCU: In general, the follow ing transfer criteria should be met:
i. Resolution of the underlying problem(s) w hich necessitated admission to the ICU; frequent
monitoring and management are no longer required. This implies that cardiovascular, pulmonary,
and central nervous system 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.
ii. Reduction of the acuity of the underlying problem(s) w hich necessitated admission, such that the
monitoring and management available on the unit to w hich the patient is being discharged is
suff icient for the proper care of the patient.
C. Transfer Process for transfer out of the CCU:
i. The decision for transfer from the CCU 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 CCU early in the day to facilitate subsequent admissions to the unit. When
disagreements about the suitability for discharge occur, the Medical Director of the CCU may be
consulted to negotiate a solution, w ith ultimate authority residing w ith the Medical Director.
ii. Order reconciliation, a change in patient status order, and a transfer note must be documented by
the primary service prior to the actual transfer. In the case of patients transferred to the CVM step-
dow n unit and retained by the same CVM team, the usual progress note for that day w ill suf f ice.
iii. When possible, patients should be transferred to the unit of the primary care team. The admissions
department and the Patient Placement Coordinator w ill be notif ied of any transfer by the Care
Team Leader or Health Unit Coordinator prior to the actual transfer.
iv. The receiving unit w ill be contacted prior to transfer and arrangements made for transfer of the
patient. A 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, a nurse w ill accompany the patient upon
transfer. If continuous telemetry is ordered, the patient w ill be transferred w ith a portable monitor
and accompanied by a registered nurse.
v. In the event a patient is transferred from the CCU to another facility, guidelines identif ied by the
coordinated care off ice w ill be follow ed.
D. Cardiac Intensive Care Unit Discharge Criteria:
i. When discharge to home from the ICU is appropriate, the discharge w ill be completed according to
current UWHC policy #7.15, Discharge Planning Process.
IV. CONFLICT RESOLUTION

Conflicts w hich arise regarding the admission and discharge of patients from the CCU and priorities w hich
cannot be adequately resolved by the parties involved should be promptly referred to the Nurse Manager
and/or the Cardiovascular Medicine (CVM) Medical Director, Director of the Access Center, and the Director
of Heart and Vascular Services.



UW HEALTH CLINICAL POLICY 3
Policy Title: Admission and Discharge of Patients to and from the Cardiac Intensive Care Unit
Policy Number: 2.1.2


V. COORDINATION

Author(s): Nurse Manager, Medical Cardiology
Senior Management Sponsor: SVP, Patient Care Services and Chief Nursing Officer
Review ers: Director, Heart, Vascular, and Thoracic Service Line; Clinical Nurse Specialist, Cardiology;
Medical Director, Cardiovascular Medicine
Approval committees: UW Health Clinical Policy Committee; Critical Care Coordinating Committee
UW Health Clinical Policy Committee Approval: February 16, 2015

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

Ronald Sliw inski
UWHC President and CEO

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

VII. REFERENCES

UW Health clinical policy 2.1.3, Admission and Discharge of Patients to and from the Medical Cardiology
Intermediate Care Unit (IMC)
UWHC policy #7.15, Discharge Planning Process
UWHC policy #7.04, Inter-hospital Transfer/Direct Admissions
UWHC policy #7.45, Triage of Critically Ill Patients
UWHC policy #7.22, Admission and Discharge of Patients to & from the TLC
UWHC policy #8.88, Hand-Off Communication
Pharmacy Departmental Policy #3.20 Inpatient Hand-Off Communications

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: May 7, 2018
Formerly Know n as: Hospital Administrative policy # 7.20