Harbor:ED follow-up options: Difference between revisions
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===[[Urgent Specialty Follow-up for DHS or MHLA Patients]]===
===[[Urgent Specialty Follow-up for DHS or MHLA Patients]]===
*Within 2 weeks or less
*Within 2 weeks or less
 
*[[Direct book without consultant discussion]]
===[[Direct book without consultant discussion]]===


===[[NERF]]===
===[[NERF]]===

Revision as of 22:39, 15 October 2021

REFER TO

  • File:AED followup flowchart 8-23-21.pdf
  • File:PED followup flowchart 8-23-21.pdf
  • Outpatient Follow up is based on patient’s insurance network
  • Out of Plan (OOP), means the patient has Non-DHS insurance network, Private insurance, Other Medi-Cal HMOs, or could be out of County/Country.
  • DHS means LA County Department of Health Services network eligible
  • MHLA, MyHealthLA, are > 18yo, “uninsurable,” community clinic PCP that can e-consult to get subspecialty & inpatient care through DHS

Same/Next Day Specialty Clinic Follow up

  • Sending or discharging directly to specialty clinic

RESULTS/SYMPTOM FOLLOW-UP

OOP follow up options

DHS eligible patients

Urgent Specialty Follow-up for DHS or MHLA Patients

NERF

Patient wants to switch to Harbor

Instructions for clerk requesting/booking an appointment

Pediatrics CCS Follow up

CCC

  • Bridges DHS eligible patients to primary care until empaneled (still need to NERF)
  • Refer all DHS patients with substance use disorder (SUD) started on medication assisted treatment (MAT) to CCC for enrollment in Dr. Brown's addiction clinic

MAT/BUP/Opiate Withdrawal

Follow up In Other Clinics

For DHS eligible patients only: Clerk will book into appointment slot, or if unable, will place a request into the scheduling queue for Patient Access Center/Call Center to take over. Patients can also call PAC to schedule appointments (Rather than calling the clinic directly)

Anticoagulation (Coumadin) Clinic

  • Book without consultant approval
  • Book at 7d post initiation of anticoagulation
  • M-F 8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, S- Sun 8am-8pm Pager 9995

Breast Diagnostic Center (Radiology)

Breast Surgery Clinic

CARDIOLOGY

  • Daytime: Talk to CORE during the day, Afterhours: Talk to C-team Night fellow (listed on MedHub)
  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up. (Cards will message Mariedel Morales and Sheila Walters IC, the Cardiology clerks, to book).
  • For ZioPatch (holter monitor) - message empaneled PCP or CCC for cardiology
Stress Testing
  • OOP - refer back to in-network PCP for cardio workup
  • DHS empaneled - message PCP for further cardio workup or schedule for stress test
    • 1 - Ensure patient is ambulatory (walk 2 blocks); if not able to complete a treadmill stress test, consult cardiology to determine best option
    • 2 - Send COVID test via "AMB Coronavirus Covid-19" order
      • Select "nasopharyngeal" then modify order
        • Change order for future visit to "no"
        • Change collection priority to "STAT"
      • If the stress test appointment is more than a week in advance, DHS patients can be tested at N26 (the COVID test has to be resulted within 3-7 business days of the procedure)
        • Modify to: "future order"; "RN collect"; "anterior nares"
        • Call x67786 (N-26) with any questions about the COVID testing procedure
    • 3 - Place order for "CV Treadmill Stress Test"
      • Reason for procedure "Chest Pain"
      • Special Instructions "Schedule in 3-4 business days"
    • 4 - In DEPART section, click "Schedule Follow-up Appointment" so clerk makes appointment prior to patient DC
      • If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss
        • 1 - COVID symptoms
          • If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
          • If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
        • 2 - Cardiac Symptoms
          • The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
            • If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
            • If deemed low-risk, stress testing will be deferred to the PCP for follow up
  • DHS Eligible without assigned PCP
    • 1 - Ensure patient is ambulatory(walk 2 blocks); if not able to complete a treadmill stress test, consult cardiology to determine best option
    • 2 - Send COVID test via "AMB Pre-surgical/Procedure Coronavirus COVID-19 Screening" order
      • Select "nasopharyngeal" then modify order
        • Change order for future visit to "no"
        • Change collection priority to "STAT"
    • 3 - Place order for "CV Treadmill Stress Test"
      • Reason for procedure "Chest Pain"
      • Special Instructions "Schedule in 3-4 business days"
    • 4 - In DEPART section
      • ***CCC for NERF*** (get a PCP assigned)
      • Click "Schedule Follow-up Appointment" so clerk makes appointment prior to patient DC
    • If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss
      • 1 - COVID symptoms
        • If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
        • If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
      • 2 - Cardiac Symptoms
        • The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
          • If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
          • If deemed low-risk, stress testing will be deferred to CCC for follow up

Drs. Chappell, Shah, & Pillutla 8/19/2020

DERM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

ENT

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Expedited Work-up Clinic (EWC)

GYN

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Gyn UCC

  • Book without consultant approval
  • 3-4d f/up for ALL DHS PID patients (cervical motion tenderness or adnexal tenderness, empirically treated)

Interventional Radiology

  1. REDIRECT [[1]]

Nephrology Clinic

  • For non-dialysis patients only: Don’t need Nephrology fellow approval per Sharon Adler, MD, Chief, Division of Nephrology and Hypertension, 7/28/17)
    • 3 slots a week specifically earmarked for ED use for Thursday morning Nephrology clinic (GN, diabetes, other CKD)
    • 2 “Discharge” slots for the Friday afternoon Hypertension (complex/resistant HTN, HTN with CKD, stones, PCKD, SLE)

Neurosurgery

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Limb Salvage

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • Clerk books directly into HAR Surg VASC -> Podiatry New

OB

  • For new pregnancy: discharge patient with OB clinic intake phone number (424-306-7200) so they can schedule appointment
  • For patients considering pregnancy termination or interested in discussing options: discharge patient with general Gyn clinic phone number (424-306-4061), they can request appointment with ROC (reproductive options clinic)

ONCOLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up.
  • Newly diagnosed, metastatic cancer - discuss with oncology fellow p7862

OPHTHO

  • Book without consultant approval for next day follow up for orbital wall fractures w/o orbital injury concerns, ok per Dr. Prasad, Division Chief
  • All other cases: Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

ORTHO

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
    • ADULT:
      • Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks
      • Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week
      • Humerus:
        • Proximal: non-displaced; sling, ortho in 1 week
        • Shaft: non-displaced; sugar tong/sling, ortho 1 week
      • Radius:
        • Non-displaced distal or shaft; volar splint, ortho 2 weeks
        • Non-displaced head with good ROM: sling, ortho in 2 weeks
      • Ulna: non-displaced; volar splint, ortho 2 weeks
      • Occult Scaphoid: thumb spica splint, ortho in 3 weeks
      • Metacarpal: non-displaced shaft and neck
        • MCP 4&5: Ulnar gutter splint, ortho 3 weeks
        • MCP 2&3: Radial gutter splint, ortho 3 weeks
      • PIP/DIP dislocations: simple, no fracture; buddy tape with padding between digits/splint, ortho 1 week
      • Hand: Distal Phalanx - buddy tape/alumiform splint, ortho in 3 weeks
      • Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks
      • Foot: non-displaced phalanx fracture - buddy tape, ortho in 2 weeks
      • Chronic or non-healing fracture: CCC for e-consult (call ortho if needs closer follow-up)
    • PEDIATRIC
      • Radius, ulna, fibula, clavicle, tibia fractures
        • < 5mm displaced and < 15 degrees angulation
        • Pain controlled by oral meds
        • Normal neurovascular status
        • 5 years and older
      • Proximal humerus fractures with minimal displacement – place in sling
      • Elbow trauma with elevated posterior fat pad, no visible fracture
      • Foreign bodies not in bone or joint space
      • Salter Harris 1 fractures that are not displaced
      • Distal phalanx fractures not involving joint space
      • Tuft fractures


  • Call Orthopedics for the following fractures
    • Displaced radius, humerus, ulna, tibia, fibula fractures
      • >5mm displaced or >15 degrees of angulation all ages
    • All elbow and femur fractures (unless only posterior fat pad)
    • Open fractures or concern for
    • Fractures entering a joint space or concern for
    • Suspected septic joint
    • Fractures with suspected neurologic or vascular injury or pain not controlled by oral pain meds
    • Excessive swelling or ecchymosis suggesting risk for compartment syndrome
    • Scaphoid fractures
    • All fractures in children less than 5 years
    • Any fracture > or = to 10 days that may need reduction
    • Anytime unsure of what to do or if fracture not included on any of this protocol


  • Peds Specifics
    • OK to Splint; DHS Eligible
      • Call ortho and ask for approval to book in clinic the next Tuesday for Pediatric fracture clinic.
      • Ortho does not have to see the patient or write a consultation
    • OK to splint; OOP (these will not qualify for CCS)
      • D/c patient with copies of films
      • Specific instructions to family to call and get ortho referral
      • Hand-out available with options for families (PMD, Shriner’s, Orthopedic institute)
    • Patients Seen at OH splinted and referred to Harbor; Call ortho if:
      • DHS eligible or empaneled
      • Believe urgent/emergent intervention needed
      • Needs a reduction
      • Patient having difficulty getting into empaneled orthopedist (can give hand-out of other options).
        • Ortho attempts to get CCS and if not able helps get care
          • Ortho and CCS (California Children’s Services)
            • Ortho has hired Anna Contreras ( Daisy) to help get CCS for many of the OOP ortho patients
            • If patient is OOP and ortho requests to see them after they splint or cast send a communication to Anna Contreras through Cerner and she gets back to families within 1 business day.
            • Instructions on each computer in PED doc box
            • If the patient doesn’t qualify for CCS, they will help the family get into their orthopedist

PEDIATRICS

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Adolescent Clinic

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Cardiology

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

PLASTIC SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

PULMONARY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


PROCEDURE CLINIC

  • For patient needing recurrent paracentesis
  • From Dr. Anshu Abhat:
  • only available for patients who are empaneled to Harbor-UCLA Internal Medicine or Geriatrics clinic.
  • If an ED provider thinks a patient could benefit from procedure clinic, they should include this in the ER note/documentation (ideal) or message the empaneled provider. Referrals to procedure clinic should only come from PCP's (not from ER providers).

RHEUM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

UROLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

72 HRS STRESS TEST

Place order in ORCHID for "CV Treadmill Stress Test"

  • If test is abnormal, cardiology follow up automatically generated by HEART station.
  • If test is normal, no notification occurs, other than typical follow up. If you want someone to follow up on the result, consider messaging empaneled PCP or refer to CCC.
  • Outpatient P-MIBI Nuclear stress has to be arranged by CORE

FOLLOW-UP FOR OUT-OF-COUNTY/OUT-OF-COUNTRY (OOC) PATIENTS

Per DHS Policy 516.1, Out of County/Country Patients who need an urgent follow-up for an emergency medical condition may be provided such follow-up at Harbor

  1. Emergent Conditions:
    1. Places health in serious jeopardy
    2. Threatens serious impairment to bodily functions
    3. Threatens serious dysfunction to any organ or body part
  2. If they are from a county close by - consider referring them to their home county. Call 2-1-1 social services hotline.
  3. Do not arrange follow-up for NON-EMERGENT/URGENT issues
  • If patient is no longer Out of Country/County, they can go to Registration Rm 108, 1st floor main hospital), ext 8101 to change their address.

Dir AED, Dir OPS, DHS Policy 516.1 9/25/17

See Also

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