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Admission and Discharge Criteria for ICU Status on the Cardiothoracic Surgery and Transplant Unit (Acuity Adaptable Unit) (2.1.35)

Admission and Discharge Criteria for ICU Status on the Cardiothoracic Surgery and Transplant Unit (Acuity Adaptable Unit) (2.1.35) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.35


UW HEALTH CLINICAL POLICY 1
Policy Title: Admission & Discharge Criteria for ICU Status on the Cardiothoracic
Surgery and Transplant Unit (Acuity Adaptable Unit)
Policy Number: 2.1.35
Category: UW Health
Type: Inpatient
Effective Date: October 20, 2017

I. PURPOSE

To ensure the appropriate utilization of the Intensive Care status beds located on the Cardiothoracic Surgery
and Transplant Unit.

II. DEFINITIONS

ICU – Intensive Care Unit
IMC – Intermediate Care
TLC – Trauma Life Center
AAU – Acuity Adaptable Unit

III. POLICY ELEMENTS
A. The ICU beds located on the Cardiothoracic Surgery and Transplant Unit predominantly serve critically ill
adult patients who have recently undergone major cardiothoracic surgical procedures or for critical illness
related to heart and lung transplantation. The patient in ICU status demonstrates actual or potential acute or
chronic life-threatening symptoms and/or injury. These patients require frequent or constant nursing
observation and nursing intervention, with active or stand-by life support systems, sophisticated monitoring
equipment and support services. The predominant ICU status patient populations on this unit include
Cardiac Surgery, Thoracic Surgery, Ventricular Assist Device, Heart Transplant, and Lung Transplant
patients who may demonstrate or develop instability in terms of hemodynamic and/or respiratory status,
metabolic and/or endocrine status. These states of instability may exist or be induced by the surgical
intervention itself, a surgically related underlying disease process, and/or an unrelated underlying disease
process.
B. Typical post-operative patient populations include:
i. Cardiac Surgery: coronary bypass, valve repair or replacements, aneurysms, atrial septal
defect/ventricular septal defect (ASD/VSD), heart transplants, lung transplants, adult congenital
patients post surgery, extracorporeal membrane oxygenation patients (ECMO), and patients with
temporary/implantable Ventricular Assist Devices (VADs).
ii. Thoracic Surgery: thoracotomy, lobectomy, pneumonectomy, esophagogastrectomy,
mediastinoscopy, open lung biopsy and lung decortication.
C. As census permits, the unit serves patients as overflow from other services, as appropriate in the event that
beds are not available in the ICU that would usually manage those patients. In these cases, admission to
ICU status on the Cardiothoracic Surgery and Transplant Unit will follow the admission and discharge
policies in place for the ICU that would usually manage those patients.
D. Admission to ICU status may not be appropriate for patients with advanced malignancy or other terminal
disease, for whom death is imminent and anticipated. Particular thought should be given to the admission of
patients for whom a "No CPR" order has been written. While such patients may be admitted to ICU status on
this unit for specific monitoring or intervention, the potential benefits to be accrued should be carefully
considered before admission.
E. Priority for admission to the Cardiothoracic Surgery and Transplant Unit are the following:
i. Cardiac surgery adult open-heart cases, VADs, and heart and lung transplantation patients.
ii. Patients in acute/chronic rejection who require intensive monitoring following heart or lung
transplantation.
iii. Thoracic surgery patients.
F. The Cardiothoracic Surgery and Transplant Unit is a HEPA filtered unit. Transplant patients and patients
with VADs are preferentially placed on a HEPA unit.





UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge Criteria for ICU Status on the Cardiothoracic Surgery and Transplant Unit
(Acuity Adaptable Unit)
Policy Number: 2.1.35

IV. PROCEDURE

Patient assignment and mechanisms for admission and discharge.
A. Admission procedure to ICU beds on the Cardiothoracic Surgery and Transplant Unit:
i. Admission Process:
a. Identification of patient's need for post-operative intensive care management is made by
the responsible cardiothoracic Graduate Medical Education (GME) trainee in conjunction
with attending physician and guidelines set forth in UW Health clinical policy #2.1.27,
Triage of Critically Ill Patients. In situations requiring immediate transfer, the responsible
attending staff must be notified by the resident as soon as possible after transfer.
b. Patients may be directly admitted to ICU status on the Cardiothoracic Surgery and
Transplant Unit from referring hospitals and via Med Flight with cardiothoracic attending
acceptance.
c. Requests for transfer to ICU status may be made by the Graduate Medical Education
(GME) trainee or attending physician caring for a patient. Requests for admission may be
made through the Nursing Coordinator and/or the Access Center.
d. Prior to, or immediately following the actual transfer of the patient, a transfer note will be
placed in the Progress Notes by the Graduate Medical Education (GME) trainee or
attending staff initiating the transfer.
e. A physician is to write orders promptly upon the patient's arrival or upon changing an
existing patient’s status to ICU level.
f. The Medical Director of the Cardiothoracic Surgery and Transplant Unit or his/her
designee will be consulted if questions arise regarding the admission.
g. Patients may be received from the Operating Rooms, Post Anesthesia Care Unit (PACU),
the Emergency Department, and other patient care units. However patient's admission to
the Cardiothoracic Surgery and Transplant Unit will not occur until bed space availability is
confirmed through the Nursing Coordinator and the unit Care Team Leader.
h. Bed needs for post-operative patients should be anticipated and discussed with the
Nursing Coordinator and Care Team Leader. While anticipation of bed needs is
necessary, bed space in a particular ICU cannot be reserved or guaranteed.
ii. Assignment of Patients: Transfers into the Cardiothoracic Surgery and Transplant Unit may remain
on the service of origin or be transferred to a more appropriate service by the attending
physician(s).
a. The transferring staff physician and service responsible for the patient's care will clearly
document in the orders the physician and service responsible for care during the patient's
stay.
b. The primary service may initiate a consultation to another service that could best meet the
current patient care needs. Decisions for orders and treatment may then occur within both
services as designated.
c. The assignment process will follow the admission and discharge policy in place for the
ICU that would usually manage these patients at the ICU or IMC level. (For example,
patients usually admitted to TLC for ICU care would follow the TLC policy for ICU
admissions).
iii. Admission Criteria to ICU status on the Cardiothoracic Surgery and Transplant Unit:
a. Priority I:
1. Hemodynamic status requires assistance by such mechanisms as a Ventricular
Assist Device, Intra-aortic Balloon Pump or ECMO. If there is already an ECMO
patient on the Cardiothoracic Surgery and Transplant Unit and another patient
needs to be placed on the circuit or is admitted with ECMO, that patient will likely
be admitted to the Cardiothoracic Surgery Transplant Unit regardless of clinical
service, to facilitate staffing for the ECMO specialists.
2. Immediately following successful cardiopulmonary resuscitation.
3. Hemodynamic status requires continuous assessment for critical blood loss or
fluid shifts from the vascular space and/or replacement with blood, blood
component infusions, or volume, i.e., chest tube output >50ml/hr.



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge Criteria for ICU Status on the Cardiothoracic Surgery and Transplant Unit
(Acuity Adaptable Unit)
Policy Number: 2.1.35

4. Hemodynamic and respiratory status requires complex monitoring equipment to
provide information regarding multiple parameters (i.e., physiologic pressure
monitoring, cardiac output).
5. Respiratory status requiring assisted mechanical ventilation or respiratory
support by a secured airway.
6. Circulatory status requires addition of vasoactive drug infusions, increasing
amounts, and/or frequent titration.
7. Respiratory support requiring ventilation, Nitric Oxide, epoprostenol and/or
Heliox.
b. Priority II:
1. Hemodynamic IV drip status requiring continuous monitoring or cardioversion for
existing life-threatening arrhythmias, i.e., Ventricular Tachycardia,
Supraventricular Tachycardia.
2. Hemodynamic status requires continuous monitoring due to the administration of
concentrated intravenous electrolyte replacements.
3. Respiratory status requires continuous pulmonary care to prevent and/or treat
increasing respiratory failure/insufficiency.
4. Critical management of labile endocrine status (i.e., hypoglycemic/hyperglycemic
crisis).
5. Requirement for emergent or recurrent procedures at intervals less than every
two (2) hours for prolonged duration.
6. Vasoactive drug infusions that require titration no more than once every four (4)
hours.
IV. MECHANISM AND CRITERIA FOR TRANSFER OR DISCHARGE
A. The needs for continued care of each patient in ICU status will be assessed daily by the Care Team Leader,
nurse caring for patient, case manager, Graduate Medical Education trainee, and attending physician or
physician responsible for the care of the patient to establish whether or not further stay in ICU status may be
beneficial to the patient. The decision for change to intermediate or general care status shall in general be
made in conjunction with Graduate Medical Education trainee and attending physician responsible for care
of the patient in consultation with the Care Team Leader and the nurse caring for the patient. When there
are disagreements within the cardiothoracic surgery service about the suitability for transfer or status
change, the Medical Director of the Cardiothoracic Surgery and Transplant Unit or his/her designee shall
have the final authority concerning discharge. Disagreements arising out of overall ICU bed shortages within
UW Health will be resolved according to the Triage for Critically Ill Patients policy (UW Health Clinical Policy
2.1.27). All decisions in such cases shall be clearly documented in the chart by a physician.
B. In general, status change or transfer criteria would include:
i. Resolution of the underlying problem(s) which necessitated admission, to the extent that ICU
monitoring and management are not required. This implies that cardiovascular, pulmonary, and
central nervous system functions have stabilized and can be monitored and managed with the
capabilities available in the unit to which the patient is being discharged.
ii. Reduction of the acuity of the underlying problem(s) which necessitated admission, such that ICU
monitoring management available in the unit to which the patient is being discharged is sufficient
for proper care of the patient.
iii. Special circumstances may prompt discharge from ICU status despite the absence of either of the
above criteria. These will usually be the result of intensive consultation between the attending
physician responsible for the care of the patient, nursing staff, the patient and/or the patient's
family, and others. These criteria are not intended to either guide or restrict the application of
judgment and compassion in assessing the suitability of continued intensive care for a specific
patient in the unit.
C. In the unusual event that all patients continue to need ICU level care and the admission of another patient is
required, transfer to another ICU can be referred to the Medical Director of unit or designee and Nursing
Coordinator.
D. Complete transfer orders and a transfer summary must be written by the primary service prior to a patient's
transfer to another unit.



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge Criteria for ICU Status on the Cardiothoracic Surgery and Transplant Unit
(Acuity Adaptable Unit)
Policy Number: 2.1.35

E. The receiving unit will be contacted prior to transfer and arrangements made for transfer of the patient.
Reports on patient's hospitalization and current condition will be given to the receiving nurse by the
transferring nurse either in person or via telephone. A nurse accompanies all patients during transfers.
F. If possible, transfer of patients should be made to the unit of the primary service.
G. The Nursing Coordinator will be notified of any transfer by the Care Team Leader prior to actual transfer.
H. ICU status will generally end after extubation and discontinuation of frequent monitoring of cardiac output
and hemodynamic parameters.
I. Stable patients may be transferred to the Pulmonary stepdown area while still ventilated according to D6/5
IMC criteria. They may also be transferred to intermediate status in accordance with admission criteria for
intermediate status on the Cardiothoracic Surgery and Transplant Unit. Decisions are based on individual
review and admission/discharge guidelines.
V. DISCHARGE

Patients are rarely discharged directly to home from ICU status on the Cardiothoracic Surgery and
Transplant Unit. UW Health Clinical Policy #2.1.25, Discharge Planning Process, will be followed in
accordance with discharge teaching and referral to appropriate agencies for home care in these cases.

VI. CONFLICT RESOLUTION

Conflicts which arise regarding the admission, transfer and/or discharge of patients and placement priorities
that cannot be adequately resolved by the parties involved should be promptly referred to the Medical
Director, Cardiothoracic Surgery and Transplant Unit for resolution.

VII. COORDINATION

Author: Manager, Cardiothoracic Surgery and Transplant Unit
Senior Management Sponsor:SVP/Chief Nurse Executive
Reviewers: CNS, Cardiac Surgery; CNS, Thoracic Surgery; Director, Heart, Vascular and Thoracic Care
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: September 18, 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.

VIII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

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

IX. REFERENCES

UW Health Clinical Policy #2.1.27, Triage of Critically Ill Patients
UW Health Clinical Policy #2.1.25, Discharge Planning Process

X. REVIEW DETAILS
Version: Revision
Last Full Review: October 20, 2017
Next Revision Due: October 2020
Formerly Known as: UWHC policy #7.19