I am seeking some help regarding finding criteria for discharge or step-down from ICU to a non-critical care unit. I have hit up the usual suspects for nursing research, but I haven't found what I'm looking for yet. In brief, a family friend is hospitalized in an ICU and was recently transferred from a large hospital to a smaller one. The staff at the smaller hospital is telling his family that he'll probably be moved to a regular semi-private room on a non-critical care unit within a few days. He does have a trach, no speaking valve, and while he is conscious at times he is not able to perform intentional movements as would be needed to operate a call bell. He has been off a vent for 1 week, and needs suction several times per day. (Also has vac dressing, PICC, and a PEG).
While I've never worked in an ICU I have worked in a step-down unit with constant visual contact with up to 8 patients, and a med-surg floor focused on trauma and neuro. I would never have imagined taking a patient who could not speak or signal for help and putting them into a normal closed room, but that seems to be what his family is being told.
I know hospitals and ICUs differ, but there must be a set of guidelines or criteria for moving a patient from ICU to step-down, or from ICU straight to a med-surg floor.
I no longer work in a hospital so I don't have access to the in-house guidelines that I used to.
Any help in terms of finding articles or even a sample set of guidelines would be most helpful. He was all ready to be moved earlier today when his wife told the charge nurse that she was not happy with the prospect of her husband being on a med-surg floor, so he's in place for another day.
Thanks very much.
Jun 30, '10
In my area of the country, this patient would be sent off to an LTACH, (long
term acute care hospital). The pt ratio is 4:1 and the main goal is to wean
the pt off of the trach. What is the ratio of the med/surg floor they want
to send your friend?
I am sorry I don't have any evidence based practice to post. How the decision
is usually made is a doctor decides the pt does not need the high level of
care an ICU provides.
In your friend's case, he needs frequent visits from a respiratory therapist,
a wound care nurse to change his wound vac, and continuous O2 monitoring.
If he needed hemodynamic monitoring and was on titratable drips to keep
him alive, he would stay in ICU. In other words, what services does the ICU
provide that he wouldn't get elsewhere?
Your friend needs a Passey-Muir valve to speak. He also needs a pillow call
light that he can operate by moving his head.
I am sorry that I can not provide advice that he should stay in ICU. Look
into LTACH care. Nation wide LTACHs are Kindred, Select Specialty, and
Promise. These places specialize in that type of pt.
Jun 30, '10
He does not need an ICU bed at all. He needs proper measures any accredited hospital can provide, like mentioned above (pillow call light). Infrequent suctioning doesn't merit you an ICU stay. I worked med-surg for many years with patients who came from nursing homes completely contracted and trach'd who weren't even able to use a call bell at all.
This is common practice, sorry to say.
ICU stays also cost a heck of a lot more, so if he's footing the bill like many folks are nowadays, he'll be thankful later.
Jun 30, '10
As a longtime charge nurse in a SICU (and have been in the past in other ICU specialties) this type of patient does NOT meet the criteria for an ICU bed. You have to be just about dead these days to keep a bed in the ICU. And yes, there are criteria. The facility should have a written policy on what patients go where with what tubes, lines, meds, and therapies. Often times the staff nurses aren't aware of this sort of thing because it's a management issue primarily, but yes, there are references for patient placement (I know my NM has a big book on patient placement from her MSN program) and most utilization management departments have some sort of program or formula they buy into to figure out who goes where (ours are called "qual standards" - short for qualification. Don't know if that is a manual, program, or what.) This is big, big business so you BET there are policies. No hospital these days is going to keep patients in the ICU for much longer than they absolutely need to if the standards are telling them to get them out.
As far as the patient goes, is he fragile? Yes. Does he need to be looked at regularly? Yes. Is he unstable? No. Here, (midwest) that is placement material, but not in an LTACH. As far as an LTACH, if this patient is trached but OFF ventilator support, in my area, they wouldn't qualify for that level of care. We use LTACHs here mostly for long term vent weaning. Here, that patient would move out to the floor for a little while, they would make sure he was stable, and then .... off to a skilled nursing rehab. The trach would probably get removed at some point during his rehab stay.
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