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 HUMC Policy 370 <INSERT POLICY PDF> (Official Feb 2020). Any new agreements are so annotated below.

Complicating Medical Conditions (CMC)

• One or more potentially active acute medical conditions that is likely to require ongoing management or active monitoring during the hospitalization; the decision of what constitutes a CMC is made by the ED Attending
• Any discussion for most appropriate admitting service given a CMC will occur at the attending level; elevation to division chief/department chair, then associate/CMO (Dr. Stein/Dr. Mahajan); chief residents cannot replace an attending for this discussion
  • Residents cannot overrule admission decisions made by the ED attending
  • Residents cannot discharge a patient from the ED who has been admitted to their service without an explicit discussion and agreement from their attending
  • If an admitting service attending feels the patient would be best cared for on another inpatient service, the admitting attending should speak to the attending of that service and a final decision should be accomplished and reported back to the ED attending within 30 minutes; if this does not occur, escalate to the associate/CMO who will make the decision
• ASSISTING SERVICES for SPECIFIC CMCs
  • Primary surgical admission requiring ICU care will have a consult to trauma/surgical critical care in the surgical ICU
  • C-team can be consulted for CHF as a complicating medical condition
  • Nephrology can be consulted to assist with HTN as a complicating medical condition

• DELETE … 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

• Aortic Aneurysms & Dissections
  • Thoracic (Type A or B) - admit to trauma surgery (or CTS if immediately available)
  • Abdominal Aneurysm
    • Expanding or ruptured to trauma (or vascular if immediately available)
    • Stable aneurysms can be admitted to other services based on reason for admission
  • Abdominal Dissection - trauma (or vascular if immediately available)

Brain Death

• Admit to the service who would have cared for the primary illness or injury
  • Trauma - trauma patient
  • Neurosurgery - ICH
  • IM/FM - medical/cardiac cause
  • Neuro - stroke
  • Peds/PICU - all peds
• Admitting service should notify organ donation agency

Breast abscess/mastitis

File:Breast Abscess Pathway 12-4-19 no lactation.pdf

From DHS expected practice and agreed upon by Radiology, Acute Care Surgery, Breast Surgery, EM: File:Breast Mastitis-Breast Abscess DHS Expected Practice.pdf

• Step 1:Obtain breast ultrasound - order "US Breast R/L" stat
  • During business hours 7a-330p: call Breast Diagnostic Center (BDC) x68244
  • Afterhours: patient can go to regular Radiology Ultrasound
• If no abscess, only phlegmon, treat with PO abx and obtain close follow up with PCP.
• Step 2:Superficial abscess <1cm from the skin, need I&D.
  • I&D can be done by either ED or Acute Care Surgery (ACS) / Breast surgery consult.
  • Send wound culture, place wick, d/c patient with PO abx
  • Percutaneous aspiration may also be appropriate for superficial abscess in a lactating patient to avoid milk duct fistula.
  • If concerns for sepsis (elev HR, WBC >15K or with left shift, etc.), and needs admission, contact Acute Care Surgery (ACS) / Breast Surgery for admission.
  • If ED provider performed I&D: Discharge with urgent follow up into Breast Surgery Clinic for DHS/MHLA patients
    • Tell patient go to clinic the following Tuesday at 9am in N24. ED clerk does NOT make an appointment.
    • Clerk to message clinic to schedule appointment via ORCHID communication:
      • Jessica Mendez NP
      • Melissa Burla NP
      • Dr. Christine Dauphine
      • Dr. Junko Ozao-Choy
      • If during the weekdays and daytime hours, Clerk/ED provider could call the clinic directly to have appt scheduled or for any questions x3476 x1821, x1822.

• Step 2:Deep abscess >1cm from the skin, or lactation abscess, needs needle aspiration
  • ED provider can perform - if simple abscess, no concern for malignancy, and attending feels comfortable
  • Send wound culture, d/c patient with PO abx, f/u as above in Breast Surgery Clinic.
    • If breastfeeding: 1st line dicloxacillin, consider lactation consultant, continue breastfeeding/pumping/manual expression
    • If concerns for sepsis (elev HR, WBC >15K or with left shift, etc.) and needs admission, contact ACS/Breast Surgery for admission, needs BDC needle aspiration ASAP. Surgery resident discuss with on-call Radiology resident, then Radiology perform procedure emergently
  • Breast Diagnostic Center (BDC) performs same day/next business day. If patient is going to BDC on the same day, save the patient's ED bed to return to after the procedure.
    • ED provider orders both “US Breast R/L” and “US Drainage Abscess or Cyst," as future order, for next business day or date/time discussed w/ BDC over the phone. Place in clinical info in “relevant history: location what o’clock and r/o abscess.” Do not need to fax form.
    • ED provider initiates PO antibiotics.
    • During 7a-330p: contact BDC to add on case x68244
    • Afterhours: Next business day follow up 830a in BDC in B200
    • Applies to DHS or MHLA or OOP
    • Once seen in BDC – gets auto-f/u with Breast Surgery Clinic

• Consider eConsult to Specialty Breast Services:
  • if palpable mass persists after 14-21 days, ultrasound and needle biopsy should be performed of solid components by radiology department
  • recurrent mastitis/abscess, or chronic granulomatous mastitis

Breast mass/malignancy

File:Breast Mass Pathway 12-4-19.pdf

• Highly suspicious symptoms for breast malignancy
  • Still needs imaging to diagnose, needs urgent BDC referral 2 wks
  • ED to message PCP or CCC, send back to MHLA clinic. PCP will work on getting patient to a BDC.
  • Once, seen in BDC, patient’s gets auto-f/u into Breast Surgery Clinic

• Newly diagnosed without obvious metastatic disease
  • If diagnosed from outside, patient must obtain outside records (CD and packet with path slides)
    • If they do not have BOTH imaging and path results, they must go to Breast Diagnostic Center first
  • ED provider messages empaneled PCP or CCC. PCP/CCC initiates e-consult to Breast Surgery Clinic
  • ED clerk does not make an appointment.

• Obvious metastatic breast cancer
  • ED provider will message empaneled PCP or CCC.
  • BDC w/in 1 wk – Need biopsy to prove is breast source (results usually in 2d)
  • ED will consult Med Onc for urgent f/u w/in 2 weeks. Clerk books 'oncology new' appointment type in time frame provided by Oncology.
  • No Breast Surgery Clinic needed at this point.

Burns

• Transfer to burn center AFTER trauma evaluation if meet ABA burn center referral criteria

1. Partial thickness burns greater than 10% total body surface area (TBSA)
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
3. Third degree burns in any age group
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality
8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols
9. Burned children in hospitals without qualified personnel or equipment for the care of children
10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

• LAC-USC cannot refuse transfers

Cardiology

REVIEW

• Cardiology consults and admissions:
  • For quick questions during business hours, CORE fellow p1035 (follow up, CORE vs Cteam admission, etc.)
  • For Admits, contact Third call p6534
  • For anything else (potential STEMI, not sure what a patient has, not sure what the rhythm is, discharge coordination when CORE isn’t here, etc.) --> Fellow consult pager - p6493
    • Any issues reaching on-call fellow, 1) check MedHub and call the on-call fellow, or 2) call the CCU, or 3) consider contacting attending

Cellulitis, Abscess, NSTI

• Cellulitis
  • OBS <2 midnights
  • IM/FM >2 midnights
  • EXCEPTION: Hand Call (plastic surgery or ortho) - upper extremity cellulitis (hand to AC, or proximal to AC if primarily below) or deep space hand
• Soft tissue abscess
  • Trauma - all except face, neck, mouth, or distal arms; even if drained in the ED
  • Spine call - epidural abscess
• NSTI - trauma surgery
• Maxillofacial cellulitis or abscess
  • Optho - periorbital/orbital
  • OMFS - odontogenic infection or facial cellulitis secondary to dental
  • ENT - dental infection with facial cellulitis AND neck extension WITH risk of rapid loss of airway, deep space neck infection, or sinus infection
  • Face call - all other maxillofacial infections

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

• Trauma (or vascular if immediately available) if needs immediate operative intervention (uncontrolled bleeding)
• Require IR
  • Sunday to Thursday - OBS
  • Friday & Saturday - IM/FM
  • Less than 30 days post-op - trauma consult in the ED
• IM/FM (with vascular and nephrology) if requires more than IR

Decubitus Ulcers

• OBS if <2 midnights and does NOT need surgical debridement
• If requires admission primarily for wound care of decubitus ulcers, admit to Trauma/ACS regardless of the need for surgical intervention
• IM/FM - if requires admission for other medical issues but also has decubitus ulcers

Deep venous thrombosis

• DVT/PE
  • Trauma/ACS (or vascular) for phlegmasia
  • OBS if <2 midnights; IM/FM if >2 midnights
  • <30-day post-op, admit to surgical service who performed the operation
  • OB/Gyn - pregnant, <6-weeks post-partum, due to gyn malignancy

Delirium/Dementia

• Acute delirium
  • OBS <2 midnights
  • IM/FM >2 midnights
• Dementia
  • Neuro - new onset or previously undiagnosed
  • IM/FM - new onset with one or more complicating medical condition
  • OBS - established dementia requiring placement (unless directed by UR for admission [IM/FM])

Diabetic Foot Infections

• Trauma/ACS with planned transfer to limb salvage
  • Hold antibiotics until surgery evaluation unless the patient is septic or has rapidly progressing infection
  • Consult Trauma/ACS or Limb Salvage if being admitted for another primary medical condition but also has a diabetic foot infection

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
  • Starting 6/17/19
    • Admit to Medicine unless needs immediate surgical intervention. Observation OK if < 2 midnights.

 6/11/19 - Drs. Daar, Putnam, Lewis

Hand Injuries

• Fractures present: Always Ortho
• Up to AC fossa: Hand call

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

OBS - BC

• All placement patients unless otherwise instructed by UR

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.

Pulmonary Embolus

• Confirmed PE or DVT with symptoms suggestive of PE but unable to obtain CTPA
  • Start anticoagulation and consider pulmonary consult if contraindications to anticoagulation or other clinical concerns
  • For (sub)massive PE considering thrombolytics, Page PERT (PE response team) Fellow p9956 PRIOR TO THROMBOLYTICS if one or more criteria are present (if no return call, auto-page pulm):
    • Elevated troponin
    • RV dysfunction noted on CTPA or bedside US (e.g. RV/LV > 0.9)
    • HR > 110 bpm
    • SBP < 100 mmHg
    • PaO2 < 60 mmHg
    • SaO2 < 90%
  • For patients with massive PE or who are rapidly deteriorating due to known or suspected PE where thrombolytics are felt to be indicated emergently by the Attending Emergency Physician, do not delay administration in order to obtain consultation
    • If the patient is admitted, make reasonable attempts to include the admitting team in any decision about emergent thrombolytics

Drs. Wu/Vintch 5/28/19, Dr. Peterson 6/21/19

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)

See Also

• Harbor:Main