Location & Clock Management in CCS

Location Management Rules

Patient location dictates available monitoring tools and intervention speed.

stateDiagram-v2
    [*] --> Office: Stable Presentation
    [*] --> ED: Acute / Emergency

    Office --> ED: Patient Unstable / Acute Deterioration
    ED --> ICU: Pressors, Intubation, Sepsis, Severe DKA, STEMI
    ED --> Ward: Hemodynamically Stable, Requires IV Meds / Observation
    ED --> Home: Discharged with Outpatient Rx & Follow-up

    ICU --> Ward: Step-Down when Stable
    Ward --> Home: Discharge when Afebrile, Ambulating, Tolerating Oral Intake

Location Transfer Triggers

Clinical Situation	Current Location	Correct Transfer Target
Abnormal vitals in clinic (BP 80/50, HR 130, SpO2 88%)	Office	Emergency Department
STEMI / Malignant Arrhythmia / Cardiogenic Shock	ED / Ward	Intensive Care Unit (ICU)
Intubated patient / Mechanical ventilation	ED	Intensive Care Unit (ICU)
Pneumonia on room air, tolerating fluids, vitals normal	ED	Home (Outpatient oral antibiotics)
Pneumonia with hypoxia requiring O2 and IV Ceftriaxone	ED	Inpatient General Ward

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Clock Advancement Strategy

Advancing time improperly is the primary cause of lost points in CCS:

1. “Call me with results” vs “Advance to next available result”:
   • Always choose “Call me with results” or select specific times when checking lab intervals.
2. Never advance time by days for an acute inpatient:
   • In the ED or ICU, advance in increments of 15 to 30 minutes (or “until next result”) to check vitals response to fluids and meds.
3. Always re-evaluate the patient (Order: “Interval History and Physical Exam”):
   • After giving major medications (e.g. nebulizers for asthma, IV fluids for dehydration, nitroglycerin for chest pain), advance the clock 15–30 minutes, then re-examine to document improvement.