Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Postoperative ICU Admit or Transfer

Release Notes:
Data Element
Version 2020B

Name:Postoperative ICU Admit or Transfer
Collected For: THKR-IP-2, THKR-OP-2
Definition:Documentation that the patient was admitted or transferred to an intensive care unit (ICU) postoperatively on the day of surgery or the day of discharge from the PACU (if different from the day of surgery). 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.
Question:Was the patient admitted or transferred to an intensive care unit (ICU) postoperatively on the day of surgery or the day of discharge from the PACU (if different from the day of surgery)?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)   The patient was admitted or transferred to an ICU postoperatively on the day of surgery or the day of discharge from the PACU (if different from the day of surgery).

N (No)   The patient was not admitted or transferred to an ICU postoperatively on the day of surgery or the day of discharge from the PACU (if different from the day of surgery), or unable to determine from medical record documentation.
Notes for Abstraction:
  • In order to select “Yes” for this data element there must be a Physician/APN/PA order for admit or transfer to an ICU. Documentation of ICU admit or transfer can be found in the physician orders or in the secondary data sources.
  • When the physician orders do not have a clear admit or transfer to the ICU, additional information listed in the secondary data sources, such as protocol to transfer to ICU, can be used to support the order to transfer to the ICU.
    Example:
    • Patient has a code blue on the medical floor the day of discharge from the PACU. The code blue sheet states transfer from medical bed to ICU bed when stabilized. The code blue sheet is signed and dated. Hospital protocol indicates that all code blue patients are transferred to ICU. Select “Yes.”
  • Do not use clinical judgment based on the type of care administered to the patient. The level of intensive care MUST be documented.
  • PCU can represent Progressive Care Unit. 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 “No.” However, if the patient is not moved to an ICU unit due to lack of a bed, select “Yes”.
  • For patients who are admitted to Observation status and then transferred to full admission to ICU, a physician order must be present to select “Yes.”
    Example:
    • Medical record documentation reflects that the patient was admitted to observation postoperatively on 04-05-20xx. Later in the day, on 04-05-20xx the physician writes an order to admit to ICU. Select “Yes.”
  • If the patient was transferred to the ICU immediately after surgery without going to the PACU, select "Yes".
  • If the patient is transferred to an ICU unit at another facility postoperatively on the day of surgery or the day of discharge from the PACU (if different from the day of surgery), select "Yes".

Suggested Data Sources: Priority Data Source (required):
  • Physician/APN/PA orders

Secondary Data Souces for the Physician/APN/PA order:
  • Code Blue/Rapid Response Team (RRT) Sheet
  • Order to transfer
  • Protocol to transfer to ICU
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)
  • PCU if not identified to represent Pulmonary Care Unit
  • 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

Postoperative ICU Admit or Transfer
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Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

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