VGH CTU - On-call guidance

• We admit a broad range of multi-system consults from the ED
• We do NOT admit:
  • Subacute strokes (hospitalists and neurology both admit strokes)
  • Fractures (including non-operative)
  • Surgical patients -> medicine consults or IMPACT can see and follow. If urgent surgery and periop consult requested -> CA if available
  • Patients on home mechanical ventilators go to Resp. We DO take patients with tracheostomies
  • Pregnant people over 20 weeks gestational age (MFM has a 24 hour call service)
  • Leukemia patients (direct to BMT)
• Subspecialty admissions
  • Refer to current cross-coverage guidelines for details
  • CTU admits almost all patients with multisystem problems.
  • GI: Stable GI bleeds (not on anticoagulation), simple pancreatitis, stable cholangitis, inflammatory bowel disease, new TPN starts
  • Eating Disorders: Admitted under CTU, but need to consult SPH Eating Disorders on first day (via SPH Switchboard (604) 806-9090 or PHC on call application)
  • Resp: Resp admits vented patients, some asthma, ILD, isolated pneumothorax, pulmonary hypertension, pre-lung transplant workup. They admit ALL lung transplants
  • Nephro: we admit many patients with Renal issues. If patient is on dialysis (HD/PD) you need to let Nephro know. Nephro admits renal transplants under 3 months ago
  • The rest of consults seen by cross coverage will be admitted under CTU and reviewed by CTU staff as well as subspecialty staff – it is cross coverage responsibility to add their patient to the list and attend CTU handover in the morning if they have admitted XC patients to CTU.
• FYI we have a HIV service run by Dr. Reynolds. Please consider involving them for all patients on HAARTs, new HIV diagnosis and HAART initiations.

• Triaging
  • All patients should be triaged in a timely fashion, particularly if they sound unstable.
  • ICU transfers should be triaged within 30 minutes (see below)
    • Consults received after 5am should be triaged for the day team to see as a holdover, unless patient unstable.
  • Housestaff Assignment
    • Unstable patients
      • Sick patients are seen by the most appropriate housestaff, regardless of team colour
      • Consider Exception to Transfer (see below)
    • Stable patients
      • Special circumstances
        • Geriatric patients (>70) -> Green/Yellow
        • EtOH or substance abuse/withdrawal; aggressive patients -> Blue, Orange, or Red
        • Bouncebacks (in the current block only) -> back to home team
      • Other cases -> consider medical complexity, housestaff availability, equal distribution between housestaff

ICU - Daytime

• Team destination determined by bed allocation (eg T10C destination will go to Red) and the ICU transfer is seen by the ward team during the day, reviewed with their own staff (ED intake team not involved). On the weekends, ED daytime CA sees ICU transfers unless ED triage is unreasonably busy.

ICU - Overnight

• CTU Sr receives consult from the ICU/HAU resident, CA, or staff, who confirms a bed is available for the patient on the CTU ward
  • CTU is not involved until there is a confirmed ward bed – this must be confirmed with the ICU and ward charge RNs
• CTU Sr goes to triage the patient within 30 minutes to assess medical suitability for ward
• Communicate with bedside RN and ICU charge RN to review that patient is appropriate for ward from medical and nursing perspective – If there are concerns with stability for the ward, must speak with the ICU team member who called the consult (ok to involve your staff if it is unclear)
• In Cerner:
  1. Order “Bed Transfer Request” in Cerner
  2. Sign the transfer reconciliation (should be planned by ICU): Fully review the orders and ensure that ICU orders (eg IV insulin sliding scale, electrolyte replacement protocols) are discontinued. Double check that unneeded CVCs, art lines are ordered to be discontinued
• Residents are assigned to see the patient, ideally the resident from the home team where the bed is available. Medical students are not allowed to see ICU transfers.
  1. In Cerner: Discontinue ICU admission powerplan and replace with CTU admission powerplan (can keep elements that the ICU bedside RN requests when you are discontinuing the ICU powerplan)

CCU Transfers

• These patients are seen regardless of bed availability. If there is a bed available, try to assign Housestaff from that team. If no bed available, the patient will be assigned to CTU Purple/other non-teaching while still in the CCU (also in the case where they need to stay in CCU for monitoring).

Exception to Transfer and Modified Assignments

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)

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.

Exception to Transfer and Modified Assignments

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)

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.

• Clinical associates are Internal Medicine residents (PGY3) or fellows who are hired to cover the ward 1800-0600. Handover is called in to the CA covering your team at 1800.
• Check CA schedule to see if there is coverage on your night. CA1 covers red/blue/green/yellow, CA2 covers non-teaching teams (orange/pink/purple/black/plaid/mocha). CAs also cover patients admitted by the daytime ED triage team - admits going to T10/11 covered by CA #1 and admits going to T14/off-service covered by CA #2.
  • If there is no CA coverage: overnight residents take first call for ward issues for patients on their own team, XC Sr covers the remaining teams
  • In surge conditions, CA 1 or 2 may be asked to help with ED consults. Inform the LMR in the morning to ensure that these consults are reviewed early so the CA finishes their shift at 0800.

• Admissions
  • Admit in Cerner (admit to inpatient order) under the CTU ED Triage staff (daytime hours) or under the CTU attending on call (overnight)
  • Avoid “batching” admissions – this delays patient flow out of Emerg and has important implications with regards to funding.
  • In the Situational Awareness/Team Communication section of Provider View, please enter “Please contact (your name) (your cellphone #) directly for issues overnight until (date and time your shift finishes)” and check off “available to all”. This will greatly alleviate the call burden to the CTU Sr and enhance your own learning managing the case. 
  • Day team (or very astute on-call housestaff) will enter “change attending to” order in the morning to ensure correct MRP is listed – reduces confusion, less misdirected phone calls.
  • Morning handover
    • Occurs at 7:40am in T14F conference room, 7 days a week.
  • CA handover
    • CA will start calling team phones to handover at 7:30am