Template:Harbor Admission Guidelines

Admission and Consultation Rules

The following guidelines for specific medical disorders are intended to expedite care of ED patients. They have been reviewed and agreed upon by all Departments and Divisions that provide consultation to the Adult ED.

The detailed guidelines can be found in decommissioned hospital policy 312 [Link Coming Here] which remain the agreed upon criteria until such time that new agreements are reached by individual departments with all stakeholders. New agreements are so annotated below.

Surgical or Subspecialty Patients with Medical Co-morbidities

• If patients have a condition listed in the admission guidelines that direct their admission to a non-medicine service (ie, surgical or subspecialty) but have another significant co-morbidity that separately would require admission to a medicine service, consider admitting that patient to medicine with the surgical or specialty service on consult
  • Examples include: hip fracture with DKA
  • Simply having stable co-morbidities that require continuation of home medications and therapies does not constitute a reason to deviate from the admission guidelines

• Note: the following service can assist in management of patients with concomitant medical conditions
  • Geriatrics may be consulted 24/7 and is available to assist in the care of patients greater than 65 years old (will go as low as 60 for ortho patients)
  • Diabetes: endocrine may be consulted to assist with blood sugar management
  • Hypertension: nephrology may be consulted to assist with blood pressure control; if the patient needs cardiac clearance as well, cardiology can perform this function and help manage hypertension
  • Pre-operative Clearance: If >65, consult geriatrics; otherwise, third-call can assist in providing this service

Aortic Aneurysms

• Traumatic thoracic aortic injury: Admit to Trauma Surgery
• Non-traumatic thoracic aortic dissections:
  • Type A, or with complication (hypotension, aortic insufficiency, vascular occlusion, tamponade): Cardiothoracc Surgery
  • Type B: Medicine, with CT Surgery consultation
• Abdominal aortic aneurysm: Trauma surgery, or vascular surgery if immediately available

Brain Death

• Admit to the service who would have cared for the primary illness or injury
• Admitting service should notify organ donation agency

Burns

• Transfer to a hospital with a burn unit, if admission is required
• Trauma surgery to provide consultation and admission if burn unit bed unavailable

Cellulitis(Non-maxillofacial)

• Admit to medicine with the following exceptions
  • Upper extremity (hand to the antecubital fossa): Hand call (plastic surgery or ortho)
  • Necrotizing fasciitis or requiring surgery in 24 hours: Trauma Surgery

Dialysis fistula/graft problem (e.g. bleeding or thrombosed)

• Fistula/grafts that do NOT need to go immediately to the operating room: admit to medicine (with inpatient vascular surgery consultation)
  • For example, the patient in whom there was some bleeding, but trauma surgery or EM was able to place a suture in the ED and achieved hemostasis – if this patient needs further evaluation via vascular duplex or interventional radiology, this patient would get admitted to medicine with consults to vascular and renal.
• Fistulas/grafts that warrant immediate operative intervention: admit to Trauma (then transferred to Vascular the next day)
  • For example, TTA patient
• Patients recently post-op for their fistula should always have an urgent surgical consultation in the ED

Decubitus Ulcers

• Wound care primary indication for admission: Plastic Surgery
• Placement, management of medical problems: Medicine

Deep venous thrombosis

• Women, suspected DVT< 6wk postpartum: OB
• Women, followed by gyn-onc, OR < 6wk post-op by gyn-onc: Gynecology
• Post-operative DVT, < 6wk post-op: Surgical service who performed operation
• All other DVTs: Medicine

Delirium/Dementia

• Acute delirium: Medicine
• Established dementia: Medicine
• New onset or previously undiagnosed dementia: Neurology

GI Bleeding

• Upper gastrointestinal bleeding: Medicine, with trauma consultation if patient is unstable
• Lower gastrointestinal bleeding: Trauma Surgery, with appropriate consultation as needed for unstable medical conditions

Hand Injuries

• Open and closed fractures of the forearm and hand: Orthopedics
• Soft tissue injuries of hand up to AC fossa: Hand call (ortho or plastics)

Intracranial mass lesions

• Solitary lesion with no other significant medical problem: Neurology (note, HIV positive or suspected HIV infection does not constitute significant medical problem)
• Non-hemorrhagic intracranial mass lesion with urgent or emergent medical problem: Medicine
• Solitary intracranial lesion at risk of herniation: Neurosurgery

Lower back pain

• With neurologic deficit (motor, sensory or reflex): Neurosurgery
• Without neurologic deficit: Orthopedics

Maxillofacial trauma

• Soft tissue and bony injury: Face call
• Orbital floor fx with ocular injury: Ophthalmology

Maxillofacial infections

• Infections involving orbit: Ophthalmology
• Dental infection or odontogenic abscess: OMFS
  • "Tooth Call" pager: 800-233-7231 x32831 (per ENT 10-2-16)
• Infection of sinuses, complicated dental infection with facial and/or neck extension: Head and Neck Surgery
• Other maxillofacial infections: Face Call

Meningitis

• Even MRN: Medicine
• Odd MRN: Neurology
• Significant medical problem not including positive HIV: Medicine

Osteomyelitis requiring admission

• Even MRN or with urgent/emergent medical problems: Medicine
• Odd MRN or requiring surgical management: Orthopedics

Painless Jaundice

• Medicine

Pancreatitis

• Effective 3/31/16, the following change in this practice will be implemented as approved by the Chairs of IM, Surgery, and EM:
• Patients seen in the Emergency Department with pancreatitis who require admission to the hospital will undergo a right upper quadrant ultrasound by either a certified emergency medicine provider or in Radiology to determine the presence of gallstones. For ultrasound images acquired by emergency medicine physicians, the adequacy of the images to determine the presence or absence of gallstones will be determined by the emergency medicine attending physician;
• Patients who are found to have gallstones and pancreatitis requiring hospital admission will be admitted to the Trauma/Acute Care Surgery service; and
• Patients who have pancreatitis requiring hospital admission who do not have gallstones will be admitted to the Internal Medicine service.

Pyelonephritis

• Pregnant women: Obstetrics
• Pyelo with nephrolithiasis or other urinary tract obstruction: Urology

ROSC (Approved by the Chairs of IM and EM 5/1/16)

1. Patients whose cardiac arrest was of a presumed cardiac etiology, who obtain a sustained ROSC, will be admitted to the C-team;
2. Patients whose cardiac arrest was of a presumed non-cardiac etiology, who obtain a sustained ROSC, will be admitted to Medical Intensive Care Unit team; and
3. The presumed etiology will be determined by the ED Attending physician supervising the ED care of the patient.

Septic Arthritis

• Involving the shoulder or hips, unless concurrent medical condition requiring urgent/emergent intervention: Orthopedics
• All other joints: Medicine

Spinal Injuries

• Spine call rotates between Neurosurgery and Ortho Spine.
  • When Ortho Spine is on call, they would like the Ortho resident p0345 to be called for the following indications: boney and structural spine problems, such as trauma, infection, degenerative, stenosis, disk, and boney tumors and diskitis /osteomyelitis for patients aged 18 and up with or without neurologic deficit.
  • Neurosurgery will continue to see intradural pathologies and pediatric patients under the age 18. For patients with head trauma for which a neurosurgical consult is being obtained, it may be best for them to also be the consulting service for concomitant spine pathology, to ease the coordination of care.

• How to know who is on call:
  • Spine call has been added onto the ED Call List made the clerks each morning, please look there to see which service is on call for spine emergencies.
  • You can also look on intranet page ‘Call Schedule’ link which takes you to MedHub (new amion) – if the Orthopedic Surgery Spine Call section is blank, that means Neurosurgery is on call. If there are names listed, then that means Ortho Spine is on call.

A.Wu, Dir AED 10/28/16

Stroke

• Nontraumatic intracranial hemorrhage requiring surgical intervention: Neurosurgery
• Traumatic intracranial hemorrhage: Neurosurgery consultation, generally Trauma Surgery admission
• Stroke and requiring urgent/emergent medical therapy: Medicine
• All other strokes admitted to Neurology

See Harbor:Code stroke

Thyroid Masses

• Refer to endocrinology

Trauma patients

• Can admit to subspecialty service when only one organ system involved, at discretion of Trauma Surgery

Vaginal Bleeding

• If symptomatic anemia from vaginal bleeding and requires extended stay and greater than 2U pRBC's, admit to Gyn (not obs)