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Admission and Discharge Criteria for the IMC Status in F4/4 (2.1.31)

Admission and Discharge Criteria for the IMC Status in F4/4 (2.1.31) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.31


UW HEALTH CLINICAL POLICY 1
Policy Title: Admission and Discharge Criteria for the IMC Status in the F4/4
Trauma/Surgical IMC
Policy Number: 2.1.31
Category: UW Health
Type: Inpatient
Effective Date: October 20, 2017

I. PURPOSE

To ensure the appropriate use of the Surgical and Trauma Intermediate Care unit (IMC), and to outline the
guidelines for admission, transfer, and discharge from the F4/4 IMC beds.

II. POLICY ELEMENTS
A. Scope of Services: The IMC has been designed to care for the adult surgical patient who does 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. Priority for admission to IMC status is given to the Trauma and Surgical Critical Care attending
physicians.
B. Trauma Medical Director: The Trauma Medical Director or designee will assist with patient flow issues
relating to admission or transfer criteria.
C. IMC level of care staffing is 3:1 nursing ratio
III. PROCEDURE
A. Admission Criteria: What follows are examples of patient populations who are appropriate for IMC admission
(please note this list is not comprehensive):
i. Cardiac System
a. Hypotension controlled with fluid replacement or hypertension without evidence of end
organ damage.
b. Infusion of vasoactive medications as is consistent with UWHC Guidelines for the
Intravenous Administration of Formulary Drugs in Adults (Level 3 medications) that are
being administered per MD order.
c. Invasive monitoring to include arterial lines and central lines to measure CVP.
d. Stable dysrhythmias with low to moderate physiologic instability requiring continuous
monitoring of ECG and/or continuous anti-arrhythmic drug infusions.
e. Patients requiring closely titrated fluid management.
f. Patients with low to moderate physiologic instability who require fluid resuscitation and or
transfusion not to exceed 6 units of blood products with in 24 hours.
g. Decompensation of a general care patient’s condition, requiring cardiac monitoring of vital
signs, urine output, respiratory status, or other systems on a frequency of every 2-4 hours.

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 disease with the
potential for worsening respiratory insufficiency.
1. Flail chest (2 or more contiguous/adjacent rib fractures)
2. Patients 65 years or older with 2 or more rib fractures and/or pulmonary
contusions
3. Continuous non-invasive positive pressure ventilation (CPAP and BiPAP) or
High Flow Nasal Canula
4. Increasing pulmonary support (ex. Oxy Mask)
5. Pneumothorax/hemothorax requiring frequent monitoring
6. 2 or more chest tubes
7. Chest tube with output greater than 150ml/hour for more than 2 hours
c. Patients who require vital signs every 2-4 hours or aggressive pulmonary physiotherapy.
iii. Neurologic System



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge Criteria for the IMC Status in the F4/4 Trauma/Surgical IMC
Policy Number: 2.1.31

a. Traumatically brain injured patients who require neurological exams and nursing
interventions every 2-4 hours.
b. Stable severe traumatic brain injured patients with a surgical airway who require
pulmonary toilet every 2-4 hours.
c. Delirium characterized by fluctuating level of consciousness, impaired ability to focus,
sustain or shift attention; impaired cognition (disorganized behavior, disorientation or
impaired memory) and perceptual disturbance.
iv. Spinal Cord Injuries
a. Patients with stable spinal cord injuries, including spinal cord syndromes
v. Trauma
a. Patients post-trauma with abdominal/retroperitoneal organ contusion/laceration/injury
1. Non operative management grade 3 or higher splenic, kidney, liver laceration
2. Post splenectomy for 24 hours
3. Post embolization for 24 hours
b. New neurological deficits (weakness, numbness, tingling, paralysis of extremities)
c. Upper or lower penetrating extremity injury with monitoring for ongoing hemorrhage,
hemodynamic instability and/or every 2-4 hour neurovascular checks for compromise of
extremity
d. Post Trauma or postoperative patients who require frequent nursing observation or
assessments in the first 24 hours to 48 hours (assessments every 1 hour x 4 then every 2
hours)
vi. Ortho-Trauma
a. Unstable pelvis
b. unstable c-spine
c. traumatic amputation
d. traumatic re-plantation for 24-48 hours
vii. Surgical
a. Post operative patient with low to moderate physiologic instability who requires fluid
resuscitation and or transfusion
b. Postoperative/post procedure patient who require monitoring every 2-4 hours in the first
24-48 hours
viii. Other
a. Decompensation of a general surgery patient requiring cardiac monitoring of vital signs,
urine output, respiratory status, or other systems every 2-4 hours.
b. Patients with appropriately treated and resolving sepsis.
c. Patients requiring extensive time for wound management.
d. Abdominal wound vac (ex Abthera)
e. Acute substance intoxication or active withdrawal requiring frequent monitoring and
interventions.
f. Any patient requiring monitoring of vital signs, urine output, respiratory status, or other
systems every 2 - 4 hours. This could include new postoperative patients and/or
decompensation of current general care patients.
B. Patients not appropriate for admission to the F4/4 IMC:
i. Patients with severe physiologic instability requiring ICU care, including:
a. Patients with acute MI, including temporary pacemaker, angina, severe hemodynamic
instability, or severe dysrhythmia.
b. Patients with acute respiratory failure not responding to positive airway pressure and at
imminent risk of requiring intubation.
1. Ventilator support changes every 2 hours
c. Patients with respiratory compromise requiring to be placed back on a ventilator with
every 1 hour monitoring of ABG’s will be transferred to an ICU. Patients requiring
monitoring of pulmonary artery catheter.
d. Patients in status epilepticus.
e. Patients requiring intracranial pressure monitoring.
f. Patients meeting general care criteria – unless a general care bed is not available
elsewhere.
C. Admission Process:



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge Criteria for the IMC Status in the F4/4 Trauma/Surgical IMC
Policy Number: 2.1.31

i. Patients who meet admission criteria for the F4/4 IMC will be admitted upon the request of the
attending MD or designee by contacting the Nursing Coordinator. Bed availability must be
determined prior to admission.
ii. Contact person for physician orders and emergencies must be clearly assigned at time of
admission
iii. In the event that the patient load exceeds capacity, the Clinical Nurse Manager or designee will
work with the Nursing Coordinator and the Trauma Medical Director or designee to evaluate
appropriateness of admission and to resolve disputes.
iv. Ventilated patients must be managed by attending MD experienced in ventilator management.
v. Complete admission/transfer orders must be written by the primary service prior to admission to the
IMC.
vi. The final decision regarding appropriateness of the patient for F4/4 IMC care is at the discretion of
the Trauma Medical Director, Nurse Manager, or designee.
vii. Under optimal circumstances, general care status patients will not be admitted to the F4/4 IMC. If it
is necessary for a patient to be placed in the F4/4 IMC for lack of a general care bed, that patient
will be transferred out as soon as a general care bed is available.
viii. As census permits, the F4/4 Trauma and Surgical IMC may accept patients in IMC status for other
services in the event that beds are not available in the IMC unit that would normally manage these
patients at the IMC level.
D. Transfer Criteria:
i. The nursing and medical staff will review the patient condition and readiness for transfer
daily. Patients will be transferred out of the IMC when physiologic status has stabilized, intensive
monitoring and treatments are no longer needed, or the condition which required IMC care has
been resolved. The admitting attending must have admission privileges to a higher level of care to
manage patients in F4/4 IMC.
ii. Patients will be transferred to intensive care when physiologic status has deteriorated and or
intensive care is required or likely, or patient workload, based on the physiologic condition, exceeds
the capacity of the IMC unit.
E. Transfer Process:
i. Patients will be reviewed by nursing and the medical director or their designees on a daily basis for
appropriateness for IMC level of care.
ii. The Nursing Coordinator will be notified of any transfer by the Care Team Leader prior to the actual
transfer.
iii. A Health Link transfer order must be submitted to transfer the patient from IMC status indicating the
service, level of care and attending physician.
iv. Patients with transfer orders will be physically transferred out of the unit as soon as an appropriate
transfer bed is available.
a. A Health Link transfer order must be submitted to transfer the patient from IMC status
indicating the service, level of care and attending physician.
b. Order reconciliation, including medication reconciliation, must be completed by the
primary service at the time the patient is transferred from IMC status.
v. 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 may be given
to the receiving nurse either at the time of transfer or by phone prior to the patient’s transfer.
F. Discharge:
G. Patients may be discharged to home or an appropriate care facility directly from the IMC. When direct
discharge from the IMC is appropriate, it will be completed according to UW Health Clinical Policy #2.1.25,
Discharge Planning Process
H. Conflict Resolution:
i. Conflicts which arise regarding the admission and discharge of patients and priorities, which cannot
be adequately resolved by the parties involved, should be promptly referred to the Trauma Medical
Director or their designee. The decisions of the Trauma Medical Director may be appealed to the
Senior VP of Medical Affairs.

IV. COORDINATION

Author: Nurse Manager, Trauma/Surgical IMC



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission and Discharge Criteria for the IMC Status in the F4/4 Trauma/Surgical IMC
Policy Number: 2.1.31

Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Trauma Program Manager-RN; CNS, Trauma/Surgical IMC; Trauma Medical Director
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: August 21, 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

- UW Health Clinical Policy #2.1.25, Discharge Planning Process
- McKesson Health Solutions, LLC. (2009). InterQual Level of Care Criteria. Newton, MA: McKesson
Corporation and/or one of its subsidiaries.
- American College of Critical Care Medicine. Guidelines on Admission and Discharge for Adult Intermediate
Care Units (1998) Mar; 26(3): 607-610

VII. REVIEW DETAILS
Version: Revision
Last Full Review: October 20, 2017
Next Revision Due: October 2020
Formerly Known as: UWHC policy #7.05