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Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » ICU Admission or Transfer

Release Notes:
Data Element
Version 2015A

Data Element Name: ICU Admission or Transfer
Collected For: CAH-04, PICU-03, PN-3a,
Definition:Documentation that the patient was admitted or transferred to the intensive care unit (ICU) at this hospital. The definition of an ICU for the purpose of the measures noted above is that used by the CDC in the NHSN Patient Safety Project. An intensive care unit can be defined as a nursing care area that provides intensive observation, diagnosis, and therapeutic procedures for adults and/or children who are critically ill. An ICU excludes nursing areas that provide step-down, intermediate care or telemetry only and specialty care areas.
Suggested Data Collection Question:Was the patient admitted or transferred to the intensive care unit (ICU) during this hospitalization?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1    (Yes)   The patient was admitted or transferred to the ICU during this hospitalization (at this hospital within the first 24 hours following arrival at this hospital for PN).

2   (No)   The patient was not admitted or transferred to an ICU during this hospitalization (at this hospital within the first 24 hours following arrival at this hospital for PN).

3   (UTD)   Unable to determine from medical record documentation if the patient was admitted or transferred to ICU during this hospitalization (at this hospital within the first 24 hours following arrival at this hospital for PN).

Notes for Abstraction:
  • Direct admits, admissions via the emergency department, or transfers from lower levels of in-patient care are included.
  • Do not use clinical judgment based on the type of care administered to the patient. The level of intensive care MUST be documented.
  • PCU is not an inclusion for ICU, unless it is identified as a Pulmonary Care Unit, which can be considered synonymous with Respiratory Care Unit.
  • If there is an order for ICU, but the patient was not moved to an ICU because the patient’s condition changed and did not require an ICU level of care, select value "“2”." However, if the patient is not moved to an ICU unit due to lack of a bed, select value "“1”."

PN:
The patient was admitted or transferred to the intensive care unit (ICU) at this hospital within the first 24 hours following arrival at this hospital.
  • In order to select value "1”" (yes) for this data element there must be a physician order for admission or transfer to an ICU AND documentation that the patient was transferred or admitted to the ICU within 24 hours following hospital arrival.
  • The 24-hour timeframe relates to the time from hospital arrival to arrival in the ICU unit, not the time of the physician order to admit or transfer to the ICU.
  • If documentation reflects ICU graphic sheets or ICU nursing notes and there is no physician order for ICU, select value "“2"” (No).
  • If other pneumonia related reasons for transfer or admission, such as septic shock, respiratory distress or failure, hypotension, tachypnea, hypoxemia or the need for a ventilator are documented, select value "“1."”
  • If the patient was transferred or admitted to the ICU at this hospital within the first 24 hours after arrival to the hospital for reasons other than complications due to pneumonia, select value "“2"” to this question (i.e., a patient presents to the ED with pneumonia and shortly after arrival has a GI bleed or cardiac arrhythmia or the ICU may be the only place with monitored beds).
  • If there is no other documented reason why the patient was transferred/admitted to the ICU at this hospital, assume it was for complications due to pneumonia.

VTE:
The patient was admitted or transferred to the ICU anytime during this hospitalization regardless of the patient location select value "“1"” (yes).
Suggested Data Sources:

ONLY ACCEPTABLE SOURCE (required)
  • Physician orders

PN ONLY Suggested data sources to support admission or transfer to ICU
  • Emergency Department record
  • ICU Nursing admission assessment
  • ICU Nursing notes
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None
  • ED, OR, or procedure units as inpatient units.
  • Intermediate care unit (IMCU)
    • Step-down unit : a post critical care unit for patients that are hemodynamically stable who can benefit from close supervision and monitoring such as frequent pulmonary toilet, vital signs, and/or neurological and neurovascular checks.
    • Inpatient units with telemetry monitoring that are not intensive care units.
  • Post coronary care unit (PCCU)
  • Specialty care units (hospital locations specializing in the following types of care)
    • Bone marrow transplant
    • Solid organ transplant
    • Inpatient acute dialysis
    • Hematology/Oncology
    • Long term acute care

ICU Admission or Transfer
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
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