Harbor:ED follow-up options

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.
DHS means LA County Department of Health Services network eligible
Patient Relations Representatives (PRR) in ED 7 days a week;
- Call Registration for PRR who can help empanel into DHS or change empanelment/network in real time. For any questions, send the patient to Window 6 in the AWR.
File:AED followup flowchart 8-23-21.pdf - note: using DC to specialty order, not clerk scheduling
File:PED followup flowchart 8-23-21.pdf - note: using DC to specialty order, not clerk scheduling

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 (Lab Follow-up - HAR)
Peds results/symptom phone follow up (Peds - HAR/USC)
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

Same/Next Day Specialty Clinic Follow up

Sending or discharging directly to specialty clinic
ED Extension Appointments
Please utilize the ED to Specialty Clinic Referral Guidelines

CCC

Bridges DHS eligible patients to primary care until empaneled
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

DHS eligible patients

DHS-Eligible patient needing Primary Care

OOP follow up options

Urgent Specialty Follow-up for DHS

Within 4 weeks or less
Place the "ED Request for Specialty Appointment" order (7/23/2023)
- If no approval is needed per the ED to Specialty Clinic Referral Guidance document, write your name (ordering provider) in the approving provider field.
- When specialty approval is required per the document, place the approving specialty provider’s name in the field.
After a conversation with a consulting specialist, their specific recommendation supersedes any timeframe listed in the ED to Specialty Clinic Referral Guidance document.

Pediatrics CCS Follow up

MAT/BUP/Opiate Withdrawal

NERF

This periodically changes, but there is currently limited space with the exception of Geriatrics, HIV, and OB care

Patient wants to switch to Harbor

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

Clinics not included in ED to Specialty Care Order (2023)

ED to Specialty Clinic Referral Guidelines

BURN CENTER CLINIC

For DHS eligible patients that need Burn Center follow up at LAC+USC, please call over 24/7 to their Burn Unit Front Desk 323-409-7991 to get an appointment w/in 2-5d depending on your assessment of their acuity.
- Inform the clerk there that you’d like to book a patient into the Burn Eval and Treatment area, which is in 5D in the Inpatient Tower (NOT their A5D Clinic).
- Patients can also call if they have questions about their appointment logistics or want to change their appointment time.
- This is NOT a transfer, so you should NOT call MAC to make an appointment
For OOP patients, they can go to Torrance Memorial

Stress Testing

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

Limb Salvage

Opting out of automatic 30-day automatic f/up consult

Weekdays 7a - 5p
- If the patient seems stable for outpatient follow-up:
  - Page limb salvage p0847
  - After discussion with on-call resident/NP, initiate a TEAMS Chat with: ED attending, ED resident, LS on-call res/NP, LS on-call Attending and send a picture of the involved foot
  - The limb salvage team may respond with appropriate outpatient f/up timeframe or may notify you they will come see the patient in the ED if they feel it is necessary

Afterhours (5p - 7a weekdays, weekends, holidays)
- Consult trauma if the patient needs surgical evaluation; trauma will liaise with limb salvage attending
  - Do NOT consult surgery for appointment
- For appointment only, can directly contact limb salvage OR defer to PCP for e-consult to podiatry (at MLK) if appropriate (several weeks to f/up)
  - 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

A. Wu, MD - ED Director of Ops & A. Miller, DPM - Director of Limb Salvage, Co-Chair of DHS Podiatry Workgroup 3/30/22

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

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

Ophtho Alphabet soup:

AAU: acute anterior uveitis
AFT: artificial tears
AGV: Ahmed glaucoma valve
ARMD or AMD: age-related macular degeneration
DR: diabetic retinopathy
BRAO: branch retinal artery occlusion
BRVO: branch retinal vein occlusion
BULB: bilateral upper lid blepharoplasty
BVS: borderline visually significant
C/D: cup-to-disc ratio
CEIOL: cataract extraction with insertion of intraocular lens
CME: cystoid macular edema
CRAO: central retinal artery occlusion
CRVO: central retinal vein occlusion
CSME: clinically significant macular edema
CS: cortical spoking (cataract)
CSR: central serous retinopathy
DES: dry eye syndrome
DME: diabetic macular edema
DWC: dense white cataract
ED: epithelial defect
EL: endolaser
ERM: epiretinal membrane
FML: focal macular laser
GS: glaucoma suspect
HST: horseshoe tear
HVF: Humphrey visual field
K: cornea
LH/WC/AFTs: lid hygiene, warm compresses, artificial tears
LPI: laser peripheral iridotomy
MMCR: Muller's muscle conjunctival resection
MP: membrane peel
NCVH: non-clearing vitreous hemorrhage
NPDR: non-proliferative diabetic retinopathy
NS: nuclear sclerosis (cataract)
NTG: normal tension glaucoma
NVG: neovascular glaucoma
NVS: not visually significant
OD: right eye
OHTN: ocular hypertension
OS: left eye
OU: both eyes
POAG: primary open angle glaucoma
PCO: posterior capsular opacity (aka, secondary cataract)
PDR: proliferative diabetic retinopathy
PKP: penetrating keratoplasty (aka corneal transplant)
PPV: pars plana vitrectomy
PRP: pan retinal photocoagulation
PSC: posterior subcapsular cataract
PTG: pterygium
PVD: posterior vitreous detachment
RRD: rhegmatogenous retinal detachment
RT: retinal tear
SB: scleral buckle
SRD: serous retinal detachment
Trab: trabeculectomy
TRD: tractional retinal detachment
VA: visual acuity
VH: vitreous hemorrhage
VS: visually significant
XT: exotropia
YAG cap: YAG capsulotomy

ORTHO

Starts 5/1/23
Make sure you're signed off on splinting Splinting Guide with Videos
File:Ortho consult criteria_Harbor_Final.pdf

Book: depends on injury, see below, with or without 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

Diagnoses Where Orthopedics SHOULD Be Consulted While Patient is in the ED
- Consult after XR or other appropriate workup is complete. A single scout film may be the appropriate initial imaging for polytrauma patients with obvious open fracture.
- Incarcerated or non-DHS patients with a diagnosis not found on the “refer to primary care list” may benefit from an orthopedic consult (call orthopedics to review if unsure) to optimize their pre-discharge care and specify timeframe for f/up
- Always ask/consult if unsure!
  - General:
    - Acute hardware infection
    - Amputation (including subtotal amputation with dysvascular distal part)
    - Chronic osteomyelitis (not related to diabetic foot infection [admission guideline])
    - Compartment syndrome in extremity with fracture
    - Crush injury to the extremity (other than distal tuft)
    - Irreducible fracture or dislocation
    - Laceration or fracture with tendinous or neurovascular injury or symptoms
    - Open fracture of an extremity or impending open fracture (eg, a fracture resulting in skin tenting)
    - Open joint, acute foreign body in joint (consult ortho prior to challenge when high suspicion)
    - Septic joint (ED to perform arthrocentesis outside region of erythema/cellulitis and consult if results are concerning for infection or if unable to aspirate)
    - Any pediatric fractures requiring procedural sedation or surgery
  - Clavicle
    - Clavicle fracture with >5mm displacement
    - AC joint dislocations, types 4-6
  - Arm/forearm
    - Proximal humerus fracture with displacement
    - Humeral shaft fracture with displacement
    - Any displaced elbow fracture (radial head/neck, distal humerus, olecranon, coronoid)
    - Radius, Ulna, or both bone forearm fracture
    - Distal radius fracture with displacement
  - Wrist/Hand
    - Scaphoid fracture with displacement
    - Acute lunate or perilunate dislocation
    - Flexor tenosynovitis
    - Flexor tendon (palmar hand) injuries
    - Metacarpal fractures with angulation or malrotation or involving multiple MCs
    - Any clenched fist injury, (aka: fight bite)
    - Pressure injection injuries
    - Hand/finger abscesses (excluding paronychia and felon)
    - Reduced DIP/PIP/MCP/CMC dislocations
    - Displaced Phalangeal fractures (other than distal tuft)
    - Nailbed injury with underlying distal phalanx fracture aka Seymour fracture (excluding tuft)
  - Pelvis/thigh/knee
    - Any pelvic fracture
    - All hip and knee dislocations
    - Any femur fracture
    - Patella fractures
    - Acute patellar or quadriceps tendon rupture
    - Multi-ligamentous knee injury (i.e. dislocated knee s/p spontaneous relocation)
  - Leg/ankle
    - Any tibial plateau fracture (please discuss case with ortho prior to ordering any CT)
    - Any tibial shaft fracture
    - Pilon (distal tibia articular impaction) fractures
    - Ankle fractures with displacement (call orthopedics to review XR if unsure)
  - Foot
    - Calcaneus fractures
    - Talus fractures
    - Subtalar dislocations
    - Lisfranc injuries (including 1st and 2nd metatarsal base fractures)
    - Navicular / Cuboid / Cuneiform fractures

- - Diagnoses which can be stabilized by ED and REFERRED TO ORTHO Fracture Clinic in 2 weeks unless otherwise specified
    - Establishing follow up after outside hospital orthopedic procedure
    - Any fracture with radiographic healing (eg, callus formation)
    - Chronic foreign body in joint
    - Fractured non-unions or malunions
    - Symptomatic orthopedic hardware
  - Shoulder/arm
    - Isolated scapular body fracture
    - Non-displaced/minimally displaced (<5mm midshaft clavicle fracture)
    - AC joint dislocation, types 1-3 (DESCRIBE TYPES 1,2,3)
    - Rotator cuff tear confirmed on MRI (Ortho Sports Clinic, NOT fracture clinic)
    - Nondisplaced proximal humerus fracture (DEGREE OF ANGULATION - sling vs sarmiento?)
  - Elbow/forearm
    - Elbow and shoulder dislocations with no associated fracture that have appropriate imaging confirming reduction** (perfect lateral for the elbow, axillary, Velpeau, or CT for the shoulder). call orthopedics to review XR if unsure
    - Nondisplaced Radial head/neck fracture (splint then Ortho Fracture Clinic - WHY IS THIS LISTED - WHOLE SECTION TO FX CLINIC)
    - Nondisplaced distal radius fracture (splint then Ortho Hand Clinic, NOT Fracture Clinic)
  - Wrist/Hand
    - Occult scaphoid fracture (Ortho Hand clinic, NOT Ortho Fracture Clinic)
    - Non-displaced phalangeal and metacarpal fracture (intrinsic plus splint then refer to clinic; boxer's fractures ok to put into soft dressing then refer to hand clinic - BUDDY TAPE?)
    - Extensor tendon (dorsal hand) injuries (splint then refer to Ortho Hand Clinic in <7 days, NOT Ortho Fracture Clinic)
    - Distal phalanx fracture without nailbed injury (excluding tuft - Ortho Hand clinic, NOT Ortho Fracture Clinic)
    - Distal phalanx fracture with subungual hematoma (Ortho Hand Clinic, NOT Ortho Fracture Clinic)
    - Nailbed injury WITH tuft fracture or without underlying distal phalanx fracture, after ED repair (Ortho Hand Clinic, NOT Ortho Fracture Clinic) ABX IF OPEN?
  - Lower extremity
    - Patellar dislocation s/p relocation (if DHS Empaneled --> Ortho Sports Clinic)
    - Single knee ligament injuries (eg, isolated ACL rupture, meniscal injuries confirmed on outpt MRI - ED MRI not indicated; if DHS Empaneled --> Ortho Sports Clinic)
    - Ankle fractures without displacement subluxation or dislocation (call orthopedics to review XR if unsure)
    - Achilles tendon rupture
    - Fracture of 1st-5th metatarsal shafts

- - Diagnoses which can be stabilized by ED and referred to Primary Care (NO ORTHO CONSULT NEEDED)
    - Arthritis (osteoarthritis of knee or hip OR inflammatory arthritis [consider rheumatology referral])
    - Cellulitis
    - Chronic pain
    - Toes:
      - Closed minimally displaced distal phalanx fracture can be treated with buddy tape & hard sole shoe
      - Closed fractures of the lesser (2nd-5th) toe phalanges
    - Deep foreign body in extremity without neurovascular symptoms, fracture, or joint involvement
    - Gunshot wound to extremity without fracture, tendinous, or neurovascular injury (DHS-empaneled patients may be referred to Ortho Joint Reconstruction Clinic)
    - Shoulder impingement
    - Sprains, strains, or contusions (no fracture or joint space widening on radiographs)
    - Tendonitis

PEDIATRIC ORTHO

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):
- 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

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

STI Testing

HAR Positive Care Clinic
DHS empaneled patients only 18 y/o and above with high-risk behavior (multiple partners, recurrent STI, etc)
- M-F 8a-4:40p
- x64350 to schedule appt
- can Orchid message Claudia Murray, RN and Vanessa Salguero (clerk) after hours; include reason for referral (eg: “referral for HIV/STI testing in a patient with multiple partners”)
  - PrEP - Orchid message Tiffany Hogan (navigator)
Offers:
- HIV/STI testing
- HIV Pre Exposure Prophylaxis (PrEP)

SURGERY

Please consult the appropriate surgical service on any patient presenting to the ED within the 30-day post-operative period, even if for something seemingly unrelated to the surgery.
- During the daytime (7a-7p), you should always directly call CRS (x0044), Bariatric/MIS (x0802), Pediatric (x6105), Breast/Surg Onc (x9397), and Vascular (x0503 – note the new pager number).
- After hours (7p – 7a), these teams are covered by trauma.
- If you inadvertently call trauma for these services during the daytime, they have been instructed to have you directly page the appropriate service.

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