Template:Harbor Admission Guidelines

Revision as of 22:08, 8 November 2019 by Kwilhelm (talk | contribs) (Cardiology)

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 File:312-Adult Emergency Department Consultation and Admission Guidelines.pdf which remain the agreed upon criteria until such time that new agreements are reached by individual departments with all stakeholders (per Dr. Mahajan, CMO 12/18/18). 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

Brain Death

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

Breast abscess/mastitis

File:Breast Abscess Pathway 6-10-19.pdf

From DHS expected practice and agreed upon by Radiology, Acute Care Surgery, Breast Surgery, EM:

  • 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 expedited follow up into Breast Surgery Clinic for DHS/MHLA patients
      • Tell patient go to clinic the following Tuesday at 9am in N24
      • 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, 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 tp 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 11.7.18.pdf

  • Highly suspicious symptoms for breast malignancy
    • Still needs imaging to diagnose, needs urgent BDC referral 2 wks (Currently, have backlog at Harbor BDC, will send onto MLK or other DHS Breast Imaging Center.)
    • 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 sends ORCHID communication message to Breast Surgery Clinic team for follow up to help expedite scheduling
      • Jessica Mendez NP
      • Melissa Burla NP
      • Dr. Christine Dauphine
      • Junko Ozao-Choy
  • Obvious metastatic breast cancer
    • 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
    • ED provider will message empaneled PCP or CCC.
    • No Breast Surgery Clinic needed at this point.


  • Transfer to burn unit, if admission needed
  • Burn unit not available - admit to Trauma


  • 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


  • If estimated <2 midnight stay, place in CORE
    • Any patients with anasarca (including abdominal or scrotal edema) should be admitted
  • If estimated >2 midnight stay:
    • Admit to IM/FM (tele/PCU) if all of the following are met:
      • Low suspicion for ACS (as determined by ED attending)
      • HR < 110
      • BP > 110
      • Creatinine <2.0 (unless ESRD on HD)
      • No BiPAP required at any time in the ED
    • Admit to C-team if the above criteria are not met or the patient needs ICU care


  • 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

  • Do NOT need to go immediately to the operating room: admit to medicine (with inpatient vascular surgery consultation)
  • Need immediate operative intervention: admit to Trauma (are transferred to vascular next day)
  • Recently post-op for their fistula: urgent surgical consultation in the ED

Putnam/Kaji email 8/5/16

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


  • 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
    • 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


  • 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


  • 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


  • 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


  • 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