Harbor:ED follow-up options: Difference between revisions

Revision as of 18:01, 1 March 2022

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.
MHLA, MyHealthLA, are > 18yo, “uninsurable,” community clinic PCP that can e-consult to get subspecialty & inpatient care through DHS
DHS means LA County Department of Health Services network eligible
- Insurance codes eligible for DHS [Insurance Codes]

Same/Next Day Specialty Clinic Follow up

Sending or discharging directly to specialty clinic

RESULTS/SYMPTOM FOLLOW-UP

OOP, MHLA, DHS can all have phone follow up for results (labs or imaging), symptoms checks
Adults results/symptom phone follow up
Peds results/symptom phone follow up
Follow-up of outpatient labs/imaging
- Any imaging/labs requested by a consultant in the ED that will NOT be resulted during the patient's stay in the ED should be ordered by the consultant making the request.
- Follow-up of outpatient tests can be either performed by the consultant OR by the CCC

DHS eligible patients

DHS-Eligible patient needing Primary Care

Urgent Specialty Follow-up for DHS or MHLA Patients

Within 2 weeks or less
Direct book without consultant discussion

Patient wants to switch to Harbor

Instructions for clerk requesting/booking an appointment

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

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)

DHS Patients Lost to Follow-up

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange for routine follow-up for the patient:

- HAR-OP-Anesthesiology: Pain Management-Clerical
- HAR-OP-Cardiology: Anticoagulation-Clerical
- HAR-OP-Cardiology: General Cardiology-Clerical
- HAR-OP-Cardiology: HFDMP-Clerical
- HAR-OP-Cardiology: Pulmonary Hypertension-Clerical
- HAR-OP-Dermatology-Clerical
- HAR-OP-Endocrine: Diabetes-Clerical
- HAR-OP-Endocrine: General-Clerical
- HAR-OP-Endocrine: Pituitary-Clerical
- HAR-OP-Endocrine: Thyroid-Clerical
- HAR-OP-Endocrinology: Diabetes Specialty-Clerical
- HAR-OP-Endocrinology: General Endocrinology-Clerical
- HAR-OP-Gastroenterology-Clerical
- HAR-OP-Hematology/Oncology-Clerical
- HAR-OP-Infectious Disease-Clerical
- HAR-OP-Neurology-Clerical
- HAR-OP-OB/Gyn: Gyn Oncology-Clerical
- HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical
- HAR-OP-OB/Gyn: Reproductive Endo/Infertility-Clerical
- HAR-OP-OB/Gyn: UroGyn-Clerical
- HAR-OP-OB/Gyn: Women's Health-Clerical
- HAR-OP-Pulmonology-Clerical
- HAR-OP-Renal: General Nephrology-Clerical
- HAR-OP-Renal: Renal Hypertension-Clerical
- HAR-OP-Renal: Renal Transplant - Clerical
- HAR-OP-Rheumatology-Clerical
- HAR-OP-Surgery: Bariatric Surgery-Clerical
- HAR-OP-Surgery: Breast Surgery-Clerical
- HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
- HAR-OP-Surgery: Colorectal Surgery-Clerical
- HAR-OP-Surgery: Dentistry-Clerical
- HAR-OP-Surgery: Neurosurgery-Clerical
- HAR-OP-Surgery: Ophthalmology-Clerical
- HAR-OP-Surgery: Oral and Maxillofacial Surgery-Clerical
- HAR-OP-Surgery: Orthopedic Surgery-Clerical
- HAR-OP-Surgery: Otolaryngology-Clerical
- HAR-OP-Surgery: Plastic Surgery-Clerical
- HAR-OP-Surgery: Surgical Oncology-Clerical
- HAR-OP-Surgery: Trauma Surgery-Clerical
- HAR-OP-Surgery: Urology-Clerical
- HAR-OP-Surgery: Vascular Surgery-Clerical

- HAR-OP-Pediatrics: Allergy/Asthma-Clerical
- HAR-OP-Pediatrics : Cardiology - Clerical
- HAR-OP-Pediatrics : Child Development - Clerical
- HAR-OP-Pediatrics : Craniofacial - Clerical
- HAR-OP-Pediatrics : Diabetes - Clerical
- HAR-OP-Pediatrics : Endocrinology - Clerical
- HAR-OP-Pediatrics : Failure to Thrive - Clerical
- HAR-OP-Pediatrics : Gastroenterology - Clerical
- HAR-OP-Pediatrics : Hematology - Clerical
- HAR-OP-Pediatrics : High Risk Infant - Clerical
- HAR-OP-Pediatrics : Immunology - Clerical
- HAR-OP-Pediatrics : Infectious Disease - Clerical
- HAR-OP-Pediatrics : Medical Genetics - Clerical
- HAR-OP-Pediatrics : Nephrology - Clerical
- HAR-OP-Pediatrics : Neurology - Clerical
- HAR-OP-Pediatrics : Nursery - Clerical
- HAR-OP-Pediatrics : Oncology - Clerical
- HAR-OP-Pediatrics : Rheumatology - Clerical
- HAR-OP-Pediatrics : Surgery - Clerical

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)

Follow the breast abscess or breast mass pathways below.
BDC is a Radiology Imaging Center for mammograms and ultrasounds. NOT the same as Breast Surgery Clinic
- Breast Abscess - needing ultrasound guided needle aspiration as per https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis
- Breast Mass - need imaging and biopsy of mass/malignancy as per https://www.wikem.org/wiki/Harbor:Admission_and_consultation_guidelines#Breast_mass.2Fmalignancy

Breast Surgery Clinic

needs e-Consult via PCP
If urgent needs follow up <2 weeks for DHS patient, consider consult to breast surgery resident (through Trauma surgery) from the ED
Only for Breast Abscess in DHS patients s/p bedside I&D, recurrent breast abscess/mastitis, as per https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis
Only for Breast Mass in DHS patient with imaging and tissue biopsy results already done https://www.wikem.org/wiki/Harbor:Operations_manual#Breast_mass.2Fmalignancy
- Otherwise, they need referral to the Breast Diagnostic Center (BDC) first
- Not for patients with metastatic disease, must see medical oncology first - consult in ED before discharge for an urgent appt

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Breast Surgery-Clerical

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
If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Cardiology: Anticoagulation-Clerical
- HAR-OP-Cardiology: General Cardiology-Clerical
- HAR-OP-Cardiology: HFDMP-Clerical

Stress Testing

DERM

Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Dermatology-Clerical

ENT

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

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Otolaryngology-Clerical

Expedited Work-up Clinic (EWC)

GYN

Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-OB/Gyn: Gyn Oncology-Clerical
- HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical
- HAR-OP-OB/Gyn: Reproductive Endo/Infertility-Clerical
- HAR-OP-OB/Gyn: UroGyn-Clerical
- HAR-OP-OB/Gyn: Women's Health-Clerical

Gyn UCC

Book without consultant approval
3-4d f/up for ALL DHS PID patients (cervical motion tenderness or adnexal tenderness, empirically treated)
If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical

Interventional Radiology

[Urgent Outpatient IR]

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)

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Renal: General Nephrology-Clerical
- HAR-OP-Renal: Renal Hypertension-Clerical
- HAR-OP-Renal: Renal Transplant - Clerical

Neurosurgery

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

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Neurosurgery-Clerical

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 desired pregnancy w/out anticipated complications: discharge patient with OB clinic intake phone number (424-306-7200) so they can schedule appointment. OB intake is a medical assistant appt, NOT a provider
For patients with needing serial beta HCGs, patient should follow with Gyn UCC w/in 2-4 days
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

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Ophthalmology-Clerical

ORTHO

Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Orthopedic Surgery-Clerical

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

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Pediatrics: Allergy/Asthma-Clerical
- HAR-OP-Pediatrics : Cardiology - Clerical
- HAR-OP-Pediatrics : Child Development - Clerical
- HAR-OP-Pediatrics : Craniofacial - Clerical
- HAR-OP-Pediatrics : Diabetes - Clerical
- HAR-OP-Pediatrics : Endocrinology - Clerical
- HAR-OP-Pediatrics : Failure to Thrive - Clerical
- HAR-OP-Pediatrics : Gastroenterology - Clerical
- HAR-OP-Pediatrics : Hematology - Clerical
- HAR-OP-Pediatrics : High Risk Infant - Clerical
- HAR-OP-Pediatrics : Immunology - Clerical
- HAR-OP-Pediatrics : Infectious Disease - Clerical
- HAR-OP-Pediatrics : Medical Genetics - Clerical
- HAR-OP-Pediatrics : Nephrology - Clerical
- HAR-OP-Pediatrics : Neurology - Clerical
- HAR-OP-Pediatrics : Nursery - Clerical
- HAR-OP-Pediatrics : Oncology - Clerical
- HAR-OP-Pediatrics : Rheumatology - Clerical
- HAR-OP-Pediatrics : Surgery - Clerical

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

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Pediatrics : Cardiology - Clerical

PLASTIC SURGERY

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

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Plastic Surgery-Clerical

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
If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Rheumatology-Clerical

SURGERY

Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Bariatric Surgery-Clerical
- HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
- HAR-OP-Surgery: Colorectal Surgery-Clerical
- HAR-OP-Surgery: Plastic Surgery-Clerical
- HAR-OP-Surgery: Surgical Oncology-Clerical
- HAR-OP-Surgery: Trauma Surgery-Clerical
- HAR-OP-Surgery: Vascular Surgery-Clerical

UROLOGY

Nephrolithiasis
- OK for clerk to book per Dr. Blumberg within 7-10d without calling urology consultant if meet below criteria
  - New Dx Nephrolithiasis
    - BMP, UA, consider CT for size/location/hydro (US if pregnant), have patients strain urine
  - Established Nephrolithiasis
    - BMP, UA, bedside US for hydro
CALL urology consult for patients with UTI (infected stone), h/o DM, solitary kidney, pregnancy
PCP follow-up if not already established, then can NERF when appropriate.
PCP for non-obstructive <5mm stones
- Ureteral stent or percutaneous nephrostomy tube pain without concern for infection, otherwise uncomplicated course, follow-up in urology clinic in 7 days
  - Send Urine culture

Acute urinary retention
- OK to book in Urology Clinic in 10-14 days WITHOUT consult approval per Dr. Blumberg if near baseline Cr, no significant electrolyte derangements, no evidence of post-obstructive diuresis, pain is controlled, and tolerating PO's
- Place foley, send UA, BMP; do NOT sent PSA (falsely elevated with acute retention)
  - If <200ml output, remove catheter
  - If >400ml out, maintain catheter
  - Monitor for post obstructive diuresis. If >200ml/hr for 2 hours (not counting the initial output), consider further observation and IVF resusc
  - Discharge with tamsulosin 0.4 mg daily

All other Urologic conditions: book with consultant approval - write name of approving doctor, time frame, and reason for follow up

Epididymitis/orchitis just needs PCP f/up

If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
- HAR-OP-Surgery: Urology-Clerical

Per Dr. Blumberg (Urology) & Dr. Wu 2/8/22

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

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
If they are from a county close by - consider referring them to their home county. Call 2-1-1 social services hotline.
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

@@ Line 365: / Line 365: @@
 *'''Acute urinary retention'''
-** '''OK to book in Urology Clinic in 10-14 dyas WITHOUT consult approval per Dr. Blumberg''' if near baseline Cr, no significant electrolyte derangements, no evidence of post-obstructive diuresis, pain is controlled, and tolerating PO's
+** '''OK to book in Urology Clinic in 10-14 days WITHOUT consult approval per Dr. Blumberg''' if near baseline Cr, no significant electrolyte derangements, no evidence of post-obstructive diuresis, pain is controlled, and tolerating PO's
 ** Place foley, send UA, BMP;  do NOT sent PSA (falsely elevated with acute retention)
 *** If <200ml output, remove catheter