Harbor:Admission and consultation 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 Policies 312 File:HUMC Policy 312.pdf and 370 File:HUMC Policy 370.pdf (Official Feb 2020). Any new agreements are so annotated below.

Admission Decisions

  • The ED Attending will determine the need for admission for all ED patients (AED, RME, PED) with input from consulting services
  • The ED Attending will determine appropriateness for OBS/CORE with input from UR
  • The ED attending has admitting privileges to all inpatient services; for cases with no specific guidelines, the ED Attending will use their best professional judgment in determining the admitting service
  • The ED Attending should document the rationale for admission, admitting service, and required level of care
    • A collaborative discussion should be had with the admitting service
    • After discussion with the admitting service, the ED provider will place the admission order which transfers care to the admitting service (unless there is a medical emergency)
      • 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
        • If there is disagreement about a admitting service, the ADMITTING ATTENDING NEEDS TO CALL THE ALTERNATE/MORE APPROPRIATE ADMITTING SERVICE ATTENDING
    • If the admitting service has not evaluated the patient and placed orders within 2 hours of the admission, the ED should place abbreviated admission orders ("holding orders" - activity, vitals, oxygen, IV)
  • Patients <18 will be admitted to Pediatrics; ages 18-20 will be admitted to Pediatrics at the discretion and capacity of the Peds service

Complicating Medical Conditions (CMC)

  • One or more potentially active acute medical conditions that the non-IM/FM service does not usually manage AND 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 (inpatient service & ED); elevation to division chief/department chair, then associate/CMO (Dr. Stein/Dr. Mahajan); chief residents cannot replace an attending for this discussion
      • Service specific, so it might vary by services
        • Consideration: Simply having stable co-morbidities that require continuation of home medications and therapies does NOT constitute a reason to deviate from the admission guidelines
        • Consideration: Significant co-morbidities that separately would require admission to a medicine service, consider admitting that patient to medicine with the surgical or specialty service on consult
      • If there is disagreement about a CMC, the ADMITTING ATTENDING NEEDS TO CALL THE ED ATTENDING
    • 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
  • 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
    • 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)
    • Endocrine: may be consulted to assist with blood sugar management
    • 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)

BOA

Mother & Baby workflow File:BOA Mother-Baby Workflow 7 14 20 (1).pdf


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 6-6-22.pdf

From DHS expected practice and agreed upon by Radiology, Acute Care Surgery, Breast Surgery, EM: DHS_Best_Practice_-_Mastitis-Breast_Abscess_3-11-21.pdf

  • First line is needle aspiration, does not matter the depth of the abscess with PO antibiotics
    • Coverage for staph/strep
    • Lactating mother: dicloxacillin (better safety profile for infant)
    • Diabetic: consider adding GNR coverage
    • MRSA risk factor or history: bactrim or clindamycin
    • If you feel comfortable doing the needle aspiration, then please do so, send wound culture, start PO antibiotics, and have patient follow up in Breast Surgery Clinic following Tuesday 9am @ N24. (Clerk messages the BSC staff for an appointment)
    • If you think the patient should go to Breast Diagnostic Center (BDC) for the needle aspiration, then order the needed studies and start PO antibiotics, and:
    • During business hours, call BDC to have them perform US and add on case. Save ED bed for patient to return to for discharge.
    • After hours, patient can to go BDC next business day. Message BDC to let them know patient is coming for urgent add on case.
    • If patient is septic and needs admission, admit to Trauma Surgery (to get to Breast Surgery). Surgery or ED provider can either do the needle aspiration or call in on-call radiology resident.
    • If failed needle aspiration, or overlying skin unhealthy, then 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
    • If Acute Care Surgery or the ED provider performed needle aspiration or I&D: Discharge with urgent follow up into Breast Surgery Clinic for DHS/MHLA patients
      • If DHS/MHLA patient, 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
        • 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 x68178.
  • If want BDC to perform needle aspiration
    • Initiate patient with PO abx
    • Breast Diagnostic Center (BDC) performs same day/next business day, OOP/DHS/MHLA all eligible. 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: Call BDC to add on case, x67406, p3386 Fellow, x68178 clerk
      • Afterhours: Next business day follow up 830a in BDC in B200. Message BDC to add on case.
      • After BDC – if DHS/MHLA, gets auto-f/u with Breast Surgery Clinic. If OOP, goes back to PCP for Breast Surgery referral.
  • Consider PCP to 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 3-9-22.pdf

  • Follow along below if patient is DHS or MHLA only (OOP must go back to their network)
  • All patients need mammogram, ultrasound, and biopsy done at Breast Diagnostic Center (BDC)
  • Localized breast cancer without mets --> Breast Surgery Clinic (BSC)
  • Metastatic breast cancer --> Oncology consult in ED for urgent follow-up, PCP follow up, or CCC+NERF if no established PCP
  • Highly suspicious symptoms for breast malignancy
    • If no tissue diagnoses, mammogram, or ultrasound done yet then, please start the process by:
    • Order both the 1) bilateral diagnostic mammogram and 2) unilateral ultrasound. Include details of:
      • 1) Chief complaint
      • 2) Relevant history (PMH or Fam Hx)
      • 3) Special instructions:
        • include right/left breast,
        • what o’clock location of mass,
        • distance from nipple in cm
    • ED to message PCP or CCC+NERF, or send back to MHLA clinic.
    • ED to message Har-BDC message pool to notify Breast Radiologists
    • Once, seen in BDC, patient’s gets auto-f/u into Breast Surgery Clinic
  • Newly diagnosed with tissue diagnosis from biopsy already, 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 will consult Med Onc for urgent f/u w/in 2 weeks. Clerk books 'oncology new' appointment type in time frame provided by Oncology.
    • If no tissue diagnoses, mammogram, or ultrasound done yet then, please start the process by:
    • Order both the 1) bilateral diagnostic mammogram and 2) unilateral ultrasound. Include details of:
      • 1) Chief complaint
      • 2) Relevant history (PMH or Fam Hx)
      • 3) Special instructions:
        • include right/left breast,
        • what o’clock location of mass,
        • distance from nipple in cm
    • ED to message Har-BDC message pool to notify Breast Radiologists
    • ED to message PCP or CCC+NERF, or send back to MHLA clinic.
    • 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

CHF

  • If estimated <2 midnight stay, place in Cardiology Observation Rapid Evaluation area (CORE) CORE
    • Admit any patients with anasarca (including abdominal or scrotal edema)
  • 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 Cardiology aka C-team if the above criteria are not met or the patient needs ICU care


Cellulitis, Abscess, NSTI

  • Cellulitis
    • IM/FM
    • 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
      • "Tooth Call" pager: 800-233-7231 x32831 (per ENT 10-2-16)
    • 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
    • Consider outpt IR
      • If unable to perform outpatient then admit to IM/FM
  • IM/FM (with vascular and nephrology) if requires more than IR
  • Less than 30 days post-op - trauma consult in the ED

Decubitus Ulcers

  • IM/FM if 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
    • Vascular Surgery (through Trauma Surgery afterhours) for phlegmasia
      • Phlegmasia alba dolens painful swollen white leg from early arterial compromise
      • Phlegmasia cerulea dolens = painful swollen cyanotic leg, bullae and necrosis from later arterial compromise
      • Heparin 80-100U/kg followed by infusion of 15-18U/kg/hr
    • If needs admission, IM/FM
    • <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
    • IM/FM
  • Dementia
    • Dr. Kronfeld, Director of Inpt Neuro, 7/2022
      • Typically, concern for gradual onset dementia does not warrant admission solely for workup
        • Discharge with neuro clinic follow-up if neurology recommends outpatient evaluation of the patient
        • May need to admission for placement if meets Interqual (otherwise, consult SW, PT, and involve ED AOD ASAP)
      • If rapidly progressive dementia, consider UDS, psych consult, LP, and inpatient admission/MRI
    • If admission is warranted:
      • Neuro - new onset or previously undiagnosed
      • IM/FM - new onset with one or more complicating medical condition

Diabetic Foot Infections

  • Trauma/ACS with planned transfer to limb salvage if being admitted solely for the DM foot infection (would otherwise be discharged)
    • 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

Confirmed with Dr. Putnam 7-15-2021

Disposition Problems

  • Patients with placement needs, see Harbor:Placement_patients for more detailed tips
    • Consult SW early, many resources only available during business hours
    • Offer family option of Harbor:Home_Health for PT/OT, home safety evals if can wait couple business days
    • If unable to safely discharge, then need to admit (DHS) or transfer (if OOP) for placement, via Interqual request
      • Admit to IM/FM for DHS patients that need long-term placement unless otherwise directed by UR
      • If unable to transfer to patient's OOP network or unable to authorization to admit to IM/FM then:
  • EXCEPTIONS:
    • Patient develops a complication from a medical or surgical problem and is already followed by that particular service in the outpatient setting should be admitted to that service
    • Problem is solely surgical without complicating medical condition, admit to that surgical service (eg, cannot care for self due to fracture, admit to ortho)

GI Bleeding

  • IM/FM: all patients with GI bleeding who require admission, including post-endoscopy
    • GI should evaluate immediately if patient hemodynamically unstable or requiring massive transfusion; admit to MICU with Trauma / ACS consultation.
  • Admit to Surgery only if established surgical patient that has GI bleeding potentially related to a surgical procedure

(Chair IM, Chief Trauma 5-8-20)

Gyn

  • DRAFT
    • D&C's
      • Indications for vacuum aspiration: r/o ectopic, incomplete miscarriage (no FHTs), active miscarriage
        • Gyn Clinic:
          • Patients who can be reasonably managed on an outpt basis should have D&C in gyn clinic
          • Patients requesting termination of pregnancy can be seen at ROC clinic on Wednesdays
        • ED D&C indications:
          • Patients experiencing symptoms that would generally necessitate taking to the OR solely for a D&C but are stable
          • Patients who have extenuating barriers to clinic follow-up
            • OB can perform paracervical block in the ED (no procedural sedation)
            • Patients generally need to be monitored for 30 min post D&C
              • Gyn to provide pictorial for appropriate amount of post-procedural bleeding and will re-eval pt if there is concern from the ED provider or RN
              • NB/JL - need written policy ... same population as clinic; do in clinic during clinic hours; standard work in clinic; no sedation
        • OR:
          • Any patient with massive hemorrhage, hemodynamic instability, or expected prolonged recovery period

Hand Injuries & Infections

  • Fractures of hand and forearm: Ortho
    • EXCEPTION - isolated distal phalanx fractures: Hand call (plastics & ortho)
    • Trauma patient need clearance by Trauma Surgery prior to admission
  • Soft tissue injuries or infection up to elbow WITHOUT fracture: Hand call (plastics & ortho)


Hip Fractures

  • Suggested pre-op workup (UCSF Guideline):
    • XR hip, pelvis, femur
    • CBC, Chem 10, INR, Vitamin D, T&S
    • CXR & EKG if history of heart or lung problems

HUMC Policy 370 https://lacounty.sharepoint.com/sites/DHS/Harbor_PP/Forms/AllItems.aspx?q=370&id=%2Fsites%2FDHS%2FHarbor%5FPP%2FHarbor%2DUCLA%20Medical%20Center%20Policies%20and%20Procedures%2F370%2DAdmission%20Medical%20Service%20and%20Transfer%20Guidelines%2Epdf&parent=%2Fsites%2FDHS%2FHarbor%5FPP&parentview=7


Intracranial mass lesions

  • Non-hemorrhagic intracranial masses
    • Neuro with NS consult: new solitary lesion without hemorrhage
    • IM/FM with NS consult: non-hemorrhagic mass WITH complicating medical condition OR likely metastatic disease
    • Patients with known mass will be admitted to the service that manages them on outpt basis (eg, IM with oncology for glioma, Neuro for MS)
  • Neurosurgery: hemorrhagic mass OR non-hemorrhagic at risk of herniation (>5mm midline shift) regardless of complicating medical conditions


Lower back pain

  • Admit IM/FM pain control with no neuro deficits
    • Could consider NS consult
  • Neurosurgery: LBP with acute weakness, bowel/bladder incontinence, or requiring surgical intervention

Maxillofacial trauma

  • Trauma: any maxillofacial traumatic injuries requiring admission
  • Face Call: isolated non-traumatic maxillofacial diagnoses requiring surgical intervention
  • Optho: isolated glob injury (eg, globe rupture)


Meningitis

  • IM/FM
    • Neuro can be consulted for diagnostic and management assistance


Neurosurgery

  • Consult NS on any patient presenting within 30 days of surgery regardless of reason for visit (Dr. Dhall, NS CHair, 4/1/22)


NSTEMI

  • C-team: if appears to be secondary to ACS or CHF
  • IM/FM: if appears to be secondary to non-cardiovascular cause (eg, sepsis)
  • Trauma: if appears to be secondary to a traumatic injury (eg, cardiac contusion after a motor vehicle accident) and NOT the etiology of the trauma (eg, cardiac syncope leading to a motor vehicle accident)
    • Determination of the most likely cause of the NSTEMI will be made by the ED Attending

Optic Neuritis

  • Admit to Neurology if requiring inpatient admission and alternate ophthalmologic condition is not suspected

Dr. Kronfeld (Director Inpatient Neuro) 2/9/2022


Osteomyelitis requiring admission

  • Hand Call: hand and forearm
  • Ortho: all other extremity osteo
  • Trauma/ACS/Limb Salvage: underlying a DM foot infection
  • NS: osteo of the spine WITH acute weakness, numbness, or bowel/bladder incontinence
  • IM/FM: all other osteo locations (including spine without neuro deficit)

Painless Jaundice

  • Consider Expedited Work-up Clinic if stable for outpatient evaluation
    • Message PCP if DHS empaneled
    • Clerk can schedule Directly into EWC
    • CCC if clerk unable to schedule directly (no slots)
  • IM/FM if requiring admission

Pancreatitis

  • Trauma/ACS: if gallstones present on ultrasound
    • Bedside US requires: gallbaldder wall thickness, comment on pericholecystic fluid, comment on gallstones, and diameter of the common bile duct or common hepatic duct
    • If all 4 items are not present, formal US should be obtained
  • Pancreatitis without gallstones, admit to IM/FM

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, or cardiac arrest with high suspicion of PE considering thrombolytics, Page Harbor:PE_Response_Team (PE response team) Fellow p9956 or Cerner autopage PRIOR TO THROMBOLYTICS if one or more criteria are present (if no return call, auto-page pulm):
  • 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
  • For cardiac arrest due to PE, activate PERT
    • tPA: 50 mg pushed IV/IO (any line, peripheral preferred)
    • May get ECMO; if so, can give tPA at lower doses of 0.6 mg/kg IBW to max of 50 mg as a push, then rest of dose over 2 hours to decrease bleeding risk with cannulation
    • Continue CPR for at least 15-60 minutes following tPA
  • For massive/high-risk PE with hypotension, activate PERT
    • SBP <90 mmHg or decrease in systolic blood pressure of ≥40 mmHg from known baseline for at least 15 min OR need for pressors without alternate etiology of shock.
    • Heparin should be started immediately upon suspicion of hemodynamically significant PE, with unfractionated heparin dosed with 80 U/kg load followed by 18U/kg/h.
      • Heparin should be held when tPA arrives at bedside
    • tPA
      • Dosing: 100 mg over 2 hours
        • Half-dose alteplase (50mg over 2 hours) should be considered in patients without strict contraindications to tPA but at higher risk for ICH or major bleed, age>65, body weight <50kg, frailty, post-CPR, cancer with metastases, pregnant patients, or patients with other relative contraindications to full-dose thrombolysis. PERT will help in the determination of dosing.
      • Absolute contraindications for thrombolytic therapy
        • Hemorrhagic CVA
        • Ischemic CVA within 3 months of presentation
        • Structural CV disease or neoplasm
        • Recent CNS Surgery
        • Recent head trauma with fracture or brain injury
        • Active bleeding (except menses) or known bleeding diathesis
      • Relative contraindications for thrombolytic therapy
        • Ischemic CVA over 3 months prior to presentation
        • Major non-CNS surgery within 3 weeks
        • Recent puncture of non-compressible vessel
        • Pregnancy or first postpartum week
        • Prolonged CPR (>10m)
        • Age >75 years
        • Dementia
        • Hx chronic, severe, poorly controlled htn
        • SBP >180 or DBP >110
        • Oral anticoagulants
        • Internal bleeding within last 2-4 weeks
        • Platelets <100
      • Cautions
        • Arterial Lines; not contraindicated, but bleeding anticipated
        • Venous access
          • Ensure two large-bore IV’s if planning on systemic lytics in order to resuscitate patient rapidly if they develop any bleeding complications
          • Central Line Placement
            • If needed for pressors or other support IV access, then place before lytics if possible
            • Femoral preferred
            • Lytics not a contraindication (but use compressible site)
        • Echo NOT required prior to lytics; PERT will call if needed
    • Catheter based interventions by either IR or interventional Cards when tPA contraindicated, or patient has deteriorated after tPA
      • PERT will coordinate if indicated
  • Submassive / intermediate high-risk PE, activate PERT
    • evidence of RV dysfunction
      • RV dysfunction noted on CTPA or bedside US (e.g. RV/LV > 0.9, RV hypokinesis)
      • BNP > 100 pg/mL
      • troponin > 0.028 ng/mL
    • heparin or tPA?
      • Unfractionated heparin 80-100U/kg followed by infusion of 15-18U/kg/hr or enoxaparin 1 mg/kg q 12 hours subcutaneously. If you are concerned that the patient may deteriorate and require advanced intervention, start UFH drip over LMWH.
      • tPA: patient deteriorates from hypotension not thought to be due to any other cause, progressive hemodynamic instability, severe hypoxemia, severe or worsening RV dysfunction
        • These patients should already be admitted and be managed by an inpatient service. PERT should be notified about this clinical change to help with this management decision.
  • Low risk PE
    • Treat with anticoagulation EXCEPT if isolated subsegmental PE, then obtain BLE ultrasounds to assess for the presence of a DVT. Treatment would be offered only if a DVT is found in this clinical scenario
    • Unfractionated heparin 80-100U/kg followed by infusion of 15-18U/kg/hr or enoxaparin 1mg/kg q 12 hours (rarely indicated)
    • DOACs:
      • If renal function is > 30ml/min, a DOAC can be considered as a treatment option for this patient population.
      • Be sure to check for drug-drug interactions with this class of oral anticoagulants before prescribing them and be sure the patient is able to get them through our pharmacy or their local pharmacy.
      • Consider giving first dose in the ED before discharge.
        • Rivaroxaban: 15 mg po bid x 21 days f/b 20 mg daily
        • Apixaban: 10 mg bid x 7 days f/b 5 mg bid
  • Prevention in patients with COVID needing hospitalization in non-ICU setting
    • Enoxaparin 30 mg SQ bid if meet criteria below**
      • For non-critically ill patients with COVID (defined as requiring hospitalization and low-flow oxygen), obtain a D-dimmer.
      • NIH recommends the following anticoagulation management in the absence of a confirmed VTE event
        • Use therapeutic-dose heparin in hospitalized, nonpregnant, non-critical adults requiring low-flow O2 with D-dimer above upper limit of normal, when no contraindications are present.
        • Continue for 14 days or until hospital discharge.
      • NOTE: Therapeutic-dose heparin is NOT recommended in critical COVID cases defined as patient requiring HFNC, PAP therapy, or mechanical ventilatory support.


Drs. Wu/Vintch/Claudius 2-1-22

Pyelonephritis

  • Men and non-pregnant women, admit to IM/FM
  • Urology: pyelonephritis associated with nephrolithiasis, urinary stents, obstructive uropathy, or nephrostomies
    • If they have a Complicating Medical Condition, they will be admitted to Internal Medicine/Family Medicine with consultation by Urology
  • OB/Gyn: pregnant women with pyelonephritis
    • If they have a Complicating Medical Condition, they will be admitted to Internal Medicine/Family Medicine with consultation by OB/Gyn

Re-implant

Harbor:Replantation_Patients

ROSC

  • C-team: presumed cardiac etiology of cardiac arrest
  • MICU: presumed non-cardiac etiology of cardiac arrest
  • The presumed etiology will be determined by the ED Attending physician. Initiate TTM, consider CT head, with post ROSC care

Septic Arthritis

  • Orthopedics unless the patient has systemic sepsis or complicating medical conditions
  • IM/FM with ortho consult if CMC or sepsis

Spinal Injuries

  • Trauma/ACS: All cervical, thoracic, or lumbar injuries

Stroke

  • Neurology: All strokes EXCEPT:
    • IM/FM with neurology if complicating medical condition
    • Trauma/ACS: traumatic ICH (if cleared by surgery, admit to Neurosurgery)
    • Neurosurgery: aneurysmal SAH or massive hemorrhage (>5mm midline shift, intraventricular extension, GCS<8) even if no immediate operative intervention planned
    • Neurology admit with NS consult: non-aneurysmal SAH or non-massive ICH (<5mm midline shift, no intraventricular extension, GCS>8)

See Harbor:Code stroke

Surgical Specialty Consults

  • ALL surgical admissions (acute care or trauma) go to the "Surgery - Trauma" service
  • For surgical subspecialty consults:
    • Page Trauma/ACS
    • During daytime hours, you can directly page the specialty service if you need a more rapid decision, especially if already known to specialty service

Thyroid Masses

  • Refer to endocrinology

Trauma patients

  • Trauma/ACS: will admit all multi-system trauma including fractures and must clear any TTA1 or TTA2 patients prior to admission to other services
  • Hip Fractures: see Hip Fractures guideline
  • Ortho: isolated traumatic fractures once cleared by trauma

Vaginal Bleeding

  • Gyn: symptomatic anemia from vaginal bleeding requiring extended stay OR greater than 2U pRBC transfusion

See Also

References


See Also

References