ICU/HAU transfers

  • We ONLY see ICU/HAU patients once a bed becomes available (Senior checks this on the phone before accepting the consult)
  • The process for seeing ICU/HAU transfers is as follows:
    • CTU Sr receives a call from the ICU/HAU resident, CA, or staff, who confirm a bed is available for the patient on the CTU ward.
    • CTU Sr goes to triage the patient within 30 minutes
      • Assess medical suitability for ward
    • CTU Sr and CTU Ward charge RN communicate again to confirm bed available and patient is appropriate for ward from medical and nursing perspective. Once this is done, enter communication order “ok to transfer to CTU”
    • If patient suitable for medical ward, and bed still available: CTU Sr to co-sign Transfer Orders a(completed by ICU Housestaff) and place bed transfer request order
  • Assigning Housestaff to see the patient:
    • Medical students should NOT see ICU/HAU transfers
    • Ideally pick Housestaff from the home team where the bed is available
  • Consult may be completed by Housestaff once patient has already moved to CTU Ward

CCU transfers

  • We DO see CCU patients even if there is NO bed available on CTU
  • When CTU Sr gets consult: ask CCU charge RN and CTU Ward charge RN if there is a bed available
    • Bed available: try to assign Housestaff from that team
    • No bed available: assign based on Housestaff availability and medical complexity. Patient will go under CTU Purple team while still in CCU (also the case if they need to stay in CCU for cardiac monitoring).

Exception to Transfer and Modified Assignments

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Exception to transfer

  • The goal of the Exception to Transfer policy is to allow CTU to care for patients who may be unstable on initial presentation, but who are expected to improve within a few hours of appropriate management.
  • These patients often need a short amount of additional time in a critical care setting (ie. ED) before they are ready to be transferred to the inpatient wards in a 4-5 : 1 nursing assignment.
  • Common reasons for Exception to Transfer include:
    • Patients in respiratory distress needing BiPAP
    • Patients needing very frequent bloodwork, such as initial DKA management or severe hyponatremia
    • Patients with unstable (high or low) blood pressure, expected to improve within a few hours of appropriate therapy
    • Patients requiring cardiac monitoring due to:
      • Unstable arrhythmias
      • Severe electrolyte abnormalities
      • Possible ACS (cardiology should be involved)
  • For patients in whom level of consciousness, hemodynamics, or respiratory status is a major concern who may urgently need a higher level of care → HAU/ICU should be consulted up-front
  • For patients who are NOT expected to have a reasonable chance of improvement over a 4 hour window, HAU/ICU should be consulted up-front (exception to transfer should NOT be used as a delay tactic).
  • VGH now has a formal Exception to Transfer form that MUST be completed and discussed with the ED Charge Nurse. This form emphasizes timely re-assessment and promotes open communication between ED and CTU, with the goal of providing patients with appropriate levels of care and also optimizing patient flow out of the ED.
  • Patients who are made Exception to Transfer MUST be re-assessed frequently, and, if not improving, HAU/ICU should be consulted expediently. If the patient is NOT appropriate for the ward at the 4 hour window, HAU/ICU should be strongly considered.
  • If there is any conflict around patients being made Exception to Transfer, CTU staff should be called immediately (regardless of time)
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Modified Assignments

  • VGH does NOT have medicine “step-down” units
  • We have the capacity to make a limited number of modified nursing assignments (lower patient:nurse ratio) to accommodate patients who require more intensive nursing care.
  • Examples include:
    • Frequent (q hourly) glucometer checks
    • Frequent suctioning
    • Frequent monitoring/vital sign checks (for patients who are improving and don’t need HAU; truly unstable patients should be cared for in a more monitored setting)
  • The decision as to which patients require modified assignments is made by nursing staff (ED Charge RN and unit Charge RN).
  • The role of the CTU senior is to flag possible modified assignments to be assessed by the respective Charge nurses. Please ensure that the bed request is updated if a patient’s condition changes.