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Admission and Discharge of Patients to and from D6/5 PCU (2.1.28)

Admission and Discharge of Patients to and from D6/5 PCU (2.1.28) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.28


UW HEALTH CLINICAL POLICY 1
Policy Title: Admission and Discharge of Patients to and from D6/5 PCU
Policy Number: 2.1.28
Category: UW Health
Type: Inpatient
Effective Date: July 25, 2017

I. PURPOSE

To ensure the use of a uniform policy when patients are admitted to and discharged from the beds
designated as the Progressive Care Unit (PCU) on D6/5.

II. POLICY ELEMENTS
A. Scope of Services: The PCU has been designed for adult patients who do not meet criteria for admission to
the ICU or to a general care floor. These patients have moderate physiologic instability and require frequent
monitoring for early recognition and treatment of potentially life threatening events. All medical and surgical
specialties may admit to the PCU and must be available at all times. The Hospitalist Service is available as a
medicine consult or primary management to all patients admitted to the PCU. Only attending physicians
experienced in ventilator management and PCU level of care should be admitting to the D65 PCU.
B. The Division Head of Hospitalist Medicine, Hospital Medicine Clinical Services Chief or their designee (i.e.:
Triage Hospitalist) on the inpatient service will assist with patient flow issues relating to admission or transfer
criteria.
III. PROCEDURE
A. General Admission Criteria: Decompensation requiring cardiac monitoring and/or assessment of vital signs,
urine output, respiratory status, or other systems every two hours.
B. The following examples are specific conditions or diseases that may be appropriate for PCU admission. This
is not a comprehensive list.
i. Cardiac System
a. Rule out myocardial infarction.
b. Myocardial infarction with low to moderate physiologic instability.
c. Dysrhythmia with low to moderate physiologic instability.
d. Decompensated heart failure with low to moderate physiologic instability.
e. Hypertensive urgency without evidence of end-organ damage.
f. Hypotension without the need for vasopressors
ii. Pulmonary system
a. Ventilator patients with low to moderate physiologic instability and a surgical airway.
Patients with an endotracheal tube will be managed in the ICU.
b. Patients with evidence of compromised gas exchange and underlying lung disease with
the potential for worsening respiratory insufficiency who require frequent observation
and/or continuous noninvasive positive pressure ventilation (CPAP and BiPAP).
c. Patients who require frequent vital signs or aggressive pulmonary physiotherapy.
d. Patients requiring high flow oxygen
e. Treatment of chronic respiratory failure. However, if the patient is admitted to University
Hospital and uses a mechanical ventilator (not a CPAP or BiPAP device) placement will
be in a progressive care unit qualified to take ventilated patients.
iii. Neurologic system
a. Patients with established, stable stroke who require frequent neurologic assessments or
frequent suctioning or turning.
b. Stable severe traumatic brain or cervical spine injured patients with a surgical airway who
require frequent positioning and pulmonary toilet.
c. Patients with chronic neurologic disorders, such as neuromuscular diseases, who require
frequent nursing interventions.
iv. Drug ingestion and drug overdose
a. Any patient requiring frequent neurologic, pulmonary or cardiac monitoring for drug
ingestion or overdose who has low to moderate physiologic instability.
v. Alcohol Withdrawal



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge of Patients to and from D6/5 PCU
Policy Number: 2.1.28

a. Any patient with low to moderate physiologic instability requiring frequent monitoring and
interventions or requiring a continuous infusion.
vi. Gastrointestinal system
a. GI bleeding with minimal orthostatic hypotension responsive to fluid therapy.
b. Acute liver failure with low to moderate physiological instability.
vii. Endocrine system
a. DKA patients requiring insulin infusion and electrolyte replacement.
b. Patients with hyperosmolar state.
c. Severe hypothyroid state requiring frequent monitoring.
viii. Surgical
a. The postoperative patient with low to moderate physiologic instability who requires fluid
resuscitation and/or transfusion.
b. The postoperative patient who requires frequent nursing observation in the first 24 hrs.
ix. Miscellaneous
a. Patients with appropriately treated and resolving sepsis with evidence of fluid refractory
shock.
b. Patients requiring closely titrated fluid management.
c. Any patient requiring frequent nursing observation or extensive time requirement for
wound management or other treatments who does not fall under the above categories.
C. Patients not appropriate for admission to IMC:
i. Complicated acute MI with temporary pacemaker, angina, severe hemodynamic instability or
severe dysrhythmia.
ii. Patients with acute respiratory failure not responding to positive airway pressure and at imminent
risk of requiring intubation.
iii. Patients requiring monitoring of pulmonary artery or intracranial pressures.
iv. Patients who are palliative care only.
v. Patients who require ongoing 1:1 nursing care.
vi. Patients with severe physiologic instability requiring ICU care.
vii. Patient requiring titration of vasoactive drips.
viii. Comatose patients or obtunded patients not protecting their airway.
D. Admission Process:
i. Patients who meet admission criteria for the PCU will be admitted upon the request of the attending
MD through the Nursing Coordinator or designee. Bed availability must be determined prior to
admission. To determine availability, the nursing coordinator is to be contacted prior to admission.
ii. In the event that patient load exceeds capacity, the Nurse Manager or designee will work with the
Patient Placement Coordinator and the: Triage Hospitalist to evaluate appropriateness of
admission and to resolve disputes.
iii. Ventilated medical patients:
a. Ventilated medical patients must be accepted and managed by the Hospitalist Service.
b. Non-medicine ventilated patients must be managed by Attending’s who are experienced
in ventilator management (Hospitalist Service or ICU privileges). If the Attending of the
non-medical service is not experienced in ventilator management, a Hospitalist consult
must be obtained to manage the patient’s ventilator.
iv. Hospitalist Service will care for all Family Medicine patients in the PCU. This includes patients at
the time of admission and/or in transfer from General Care or Intensive Care Unit.
v. Hospitalist Triage is available when non-hospitalist patients are decompensating and need medical
attention quickly or when questions are raised.
vi. Complete admission/transfer orders must be electronically entered by the primary service prior to
admission to the PCU.
vii. Decisions regarding the appropriateness of the patient for PCU care are at the discretion of Triage
Hospitalist on the inpatient service. Admissions will be coordinated through the Patient Placement
Coordinator and the Care Team Leader. The l Nurse Manager may also be contacted with
questions regarding appropriateness related to patient care needs.
viii. Under optimal circumstances, General Care status patients will not be admitted to the PCU. If it is
necessary for a patient to board in the PCU due to lack of General Care beds, that patient will be
transferred out as soon as a General Care bed is available.
E. Discharge/Transfer Criteria:



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge of Patients to and from D6/5 PCU
Policy Number: 2.1.28

i. Patients will be transferred out of PCU when physiologic status has stabilized, intensive monitoring
and treatments are no longer needed or the condition which required PCU care has been resolved.
ii. Patients will be transferred to Intensive Care when physiologic status has deteriorated and
intensive life support is required or highly likely.
iii. Patients may be discharged to home or an appropriate care facility directly from the PCU.
F. Transfer Process:
i. Patients will be reviewed by nursing and the admitting service on a daily basis for the
appropriateness for PCU level of care. The Triage hospitalist will assist when differences arise.
ii. Complete transfer orders must be electronically entered by the primary service at the time the
patient is transferred from the PCU unit.
iii. Patients with transfer orders will be physically transferred out of the unit as soon as an appropriate
transfer bed is available.
iv. The receiving unit will be contacted prior to transfer and arrangements made for the transfer.
Report on the patient's hospitalization and current condition using the SBAR format will be given to
the receiving nurse either at the time of transfer or by phone prior to the patient's transfer.
v. The Patient Placement Coordinator will be notified of any transfer by the Care Team Leader prior to
the actual transfer to determine bed placement.
vi. All patients on IMC status must be transported off unit by an ACLS certified RN and telemetry
monitoring are required during patient transport out of the PCU when the patient is to return to the
PCU.
G. Conflict Resolution:
i. Conflicts that arise regarding the admission/discharge of patients and/or priorities, which cannot be
adequately resolved by the parties involved, should be promptly referred to the Division Head of
Hospitalist Medicine, Hospital Medicine Clinical Services Chief or their designee (i.e., Triage
Hospitalist). The decisions of the Division Head of Hospitalist Medicine, Hospital Medicine Clinical
Services Chief or their designee (i.e., Triage Hospitalist)may be appealed to the Senior Vice
President for Medical Affairs.
IV. COORDINATION

Author: Clinical Nurse Manager, D6/5 Acute Medical/Progressive Care Unit
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Medical Director, PCU; Director, Medical Nursing
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: June 19, 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
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.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

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

VI. REFERENCES

UWHC policy #8.14, Guidelines for Administration of Continuous Invasive and Non-Invasive Respiratory
Support

VII. REVIEW DETAILS

Version: Revision



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge of Patients to and from D6/5 PCU
Policy Number: 2.1.28

Last Full Review: July 25, 2017
Next Revision Due: July 2020
Formerly Known as: Hospital Administrative policy #7.47