/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/gen-care/,/policies/clinical/uw-health-clinical/gen-care/admission-discharge-transfer/,

/policies/clinical/uw-health-clinical/gen-care/admission-discharge-transfer/2127.policy

201708215

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,General Care and Procedures,Admission, Discharge, Transfer

Triage of Critically Ill Patients (2.1.27)

Triage of Critically Ill Patients (2.1.27) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.27


UW HEALTH CLINICAL POLICY 1
Policy Title: Triage of Critically Ill Patients
Policy Number: 2.1.27
Category: UW Health
Type: Inpatient
Effective Date: July 25, 2017

I. PURPOSE
A. To establish clear cut lines of communication for the triage process.
B. To ensure provision of optimal and efficient medical and nursing care to critically ill patients when critical
care resources are limited.

II. POLICY ELEMENTS

Critical Care beds at UW Health are utilized for patients requiring intensive medical and nursing
interventions or monitoring. Assignment of patients to critical care beds will be a collaborative effort between
the Nursing Coordinator, nursing staff and medical staff.
A. General Principles
1. Intensive care unit beds are assigned to patients on a priority basis, dependent upon immediacy of
need and severity of illness.
2. Every effort will be made to accommodate anticipated needs for ICU beds, and anticipation and
communication of such needs is crucial. ICU beds are never reserved, they are requested as
needed.
3. During periods of ICU bed shortage, patients may need to be transferred to non ICU nursing units
at unconventional times. It is assumed that such transfers will be made only when necessary and
that the receiving nursing unit will accommodate the transfer in a timely manner. Inability to accept
a patient in transfer will be discussed immediately with the Nurse Manager (NM) and the Nursing
Coordinator. Additionally, the Director of Nursing Operations Support and/or Nursing Administrator
on-call may be involved for further consultation, as needed.
4. Transfer of patients requiring critical care will occur as expeditiously as possible.
5. A guiding principle of the triage system is to place patients in the special care ICU that can, under
normal circumstances, offer the optimal care for that patient's problems. Inter ICU transfer of
patients may be necessary to adhere to this principle. Except under extraordinary circumstances,
no patient will be subject to more than one inter ICU transfer, unless the transfer is dictated by the
patient's medical condition.
6. During periods of ICU bed shortage, the principles of triage to special care units cannot be used
inclusively or exclusively. That is, patients may need to be placed in ICUs other than those to which
they would normally be admitted (e.g., patients with medical problems placed in surgical ICUs and
adult patients placed in pediatric ICU). Such flexibility in patient placement, while it may place an
added burden on the staff caring for the patient, is essential for optimal ICU bed utilization. The NM
and/or Clinical Nursing Director of the respective unit will work with the staff to obtain the necessary
resources (consultation, education, etc.) to assure safe care of these patients.
7. To avoid restriction of the Emergency Department during times of ICU bed shortages, the PACU
can be used as an ICU overflow system. Patients will be managed by the responsible medical or
surgical service.
III. INDIVIDUAL RESPONSIBILITIES
A. Nursing Coordinator
The Nursing Coordinator facilitates all patient movement into and out of ICUs. In doing so, they gather and
transmit data about level of care needs, census, staffing and patient traffic in each ICU. They receive
requests from various areas (e.g., Access Center intake staff, ED, OR, general and intermediate care units,
Med Flight) for patient placement
B. Nurse Manager/Care Team Leader/Medical Directors of Critical Care Units
Communication between the medical and nursing leadership on individual critical care units will ensure:
i. An overview of admissions and discharges from the unit.
ii. A system or plan for identification of patients who could be safely transferred out of the ICU in the
event of a bed constraint.



UW HEALTH CLINICAL POLICY 2
Policy Title: Triage of Critically Ill Patients
Policy Number: 2.1.27

iii. A system for timely transfer/discharge of patients from the ICU.
C. Director of Nursing Operations Support
The Director of Nursing Operations Support will maintain an overview of admissions and discharges to
critical care beds. The Director of Nursing Operations Support, with the NM, assures available staffing for
predicted patient care acuity and volumes. The Director of Nursing Operations Support will be consulted by
the Nursing Coordinator for complex patient placement issues and when serious critical care bed shortages
exist and communicate to the SVP, Patient Care Services and Chief Nursing Officer.
IV. PROCEDURE
A. Routine Triage Procedure
i. All primary communication regarding patient placement to an ICU will be made through the Nursing
Coordinator. There is no reason for physicians, nurses, Med Flight personnel, etc. to contact the
physician directly for bed placement.
ii. The Nursing Coordinator will review the surgery schedule the day prior to the surgery schedule and
again each morning. When there is an anticipated bed shortage, the Director of Nursing Operations
Support will be notified and s/he will work with the appropriate Clinical Director.
iii. If appropriate plans cannot be made for all ICU requests, the OR staff will be informed of the
situation the preceding day by the Sr. VP for Medical Affairs. The OR staff will participate in
establishing a plan for managing patients who require ICU care (i.e., activate PACU as ICU
overflow). When bed availability is constrained, an attempt should be made to plan for the
availability of at least one additional ICU bed following the placement of OR patients.
B. Triage Procedure for Severe Critical Care Bed Shortages
During periods of severe ICU bed shortages, when it appears that the ICU system may not be able to
accommodate any more patients, the following steps should be taken:
i. The situation will initially be reviewed by the Medical Director, the Nursing Coordinator,
the Director of Nursing Operations Support (or Nursing Administrator on-call) and the appropriate
NM. Such review will be aimed at identifying patients who are candidates for early transfer from an
ICU, anticipating short term ICU needs for post operative patients, and assessing short term ICU
staffing patterns.
ii. If the problem is not resolved by the above mechanism, other short term solutions, such as deferral
of elective surgery and temporary extended care of patients in the Emergency Department and the
PACU will be considered. The Nursing Coordinator will work with the Director of Nursing
Operations Support, appropriate Clinical Director, individual ICU nursing and medical staffs to
expedite appropriate patient transfers out of the ICU. All problem solving will be guided by the
principle that highest priority is given to providing the optimal standard of care while also
maintaining access to UW Hospital and Clinics for all critically ill patients.
iii. If there are insufficient critical care beds to meet current or anticipated needs, the Medical Directors
will be involved in decisions that evaluate balancing the consequences of modifying the OR
schedule or temporarily limiting access to UW Hospital and Clinics Emergency Department.
iv. When the admission of critically ill patients must be restricted, the Director of Nursing Operations
Support, Nursing Administrator and Hospital Administrator on call must be notified. In addition, the
Emergency Department staff, Med Flight staff and the other city hospitals must be made aware of
the restriction. During this process, there will be an attempt to ascertain the number of available
critical care beds in other city hospitals.
V. COORDINATION

Author: Director, Nursing Operations Support
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: none
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: July 17, 2017

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



UW HEALTH CLINICAL POLICY 2
Policy Title: Triage of Critically Ill Patients
Policy Number: 2.1.27

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

Peter Newcomer, MD
Chief Clinical Officer

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

VII. REVIEW DETAILS

Version: Revision
Last Full Review: July 25, 2017
Next Revision Due: July 2020
Formerly Known as: Hospital Administrative policy #7.45