Harbor:ED follow-up options

REFER TO

  • File:AED followup flowchart 8-23-21.pdf
  • File:PED followup flowchart 8-23-21.pdf
  • 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.
  • MHLA, MyHealthLA, are > 18yo, “uninsurable,” community clinic PCP that can e-consult to get subspecialty & inpatient care through DHS
  • 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. During business hours, can also send patient to Patient Relations Office in Rm 1-B-1.

Same/Next Day Specialty Clinic Follow up

  • Sending or discharging directly to specialty clinic

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

OOP follow up options

DHS eligible patients

Urgent Specialty Follow-up for DHS or MHLA Patients

  • Within 4 weeks or less
  • Place the "ED Request for Specialty Appointment" order
    • As of 7/25/23, no longer done by clerks
    • 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.

NERF

Patient wants to switch to Harbor

Instructions for clerk requesting/booking an appointment

Pediatrics CCS Follow up

CCC

  • Bridges DHS eligible patients to primary care until empaneled (still need to NERF)
  • 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

MAT/BUP/Opiate Withdrawal

Follow up In Other Clinics

For DHS eligible patients only: Clerk will book into appointment slot, or if unable, will place a request into the scheduling queue for Patient Access Center/Call Center to take over. Patients can also call PAC to schedule appointments (Rather than calling the clinic directly)


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

Anticoagulation (Coumadin) Clinic

  • ED Request for Specialty Appointment: ANTICOAGULATION (Return)
    • Book without consultant approval
    • Patient must be an established patient in the anticoagulation clinic seen in the last 12 months
    • Request the specific date for 7 days post initiation of anticoagulation
  • M-F 8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, Sat-Sun 8am-8pm Pager 9995

Breast Diagnostic Center (Radiology)

Breast Surgery Clinic

  • 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 Breast/Surg Onc (x9397)
    • 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.
  • e-Consult via PCP
    • If the patient needs urgent follow-up <2 weeks for DHS patient, consider consult to breast surgery resident (through Trauma surgery) from the ED
  • Only for Breast Abscess in DHS patients s/p bedside I&D, recurrent breast abscess/mastitis, as per https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis
  • Only for Breast Mass in DHS patient with imaging and tissue biopsy results already done https://www.wikem.org/wiki/Harbor:Operations_manual#Breast_mass.2Fmalignancy
    • Otherwise, they need referral to the Breast Diagnostic Center (BDC) first for imaging
    • Patients with metastatic disease - consult (Medical) Oncology from the ED
  • If the patient was previously 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: Breast Surgery-Clerical

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.
    • If you are instructed to call the MAC to make an appointment (this is NOT a transfer), send Dr. Wu an email of the patient’s info, date/time, or use the QR code to submit an admin issue.
  • For OOP patients, they can go to Torrance Memorial

CARDIOLOGY

  • Daytime: Talk to CORE during the day, Afterhours: Talk to C-team Night fellow (listed on MedHub)
  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up. (Cards will message Mariedel Morales and Sheila Walters IC, the Cardiology clerks, to book).
  • For ZioPatch (holter monitor) - message empaneled PCP or CCC for cardiology
  • 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-Cardiology: Anticoagulation-Clerical
    • HAR-OP-Cardiology: General Cardiology-Clerical
    • HAR-OP-Cardiology: HFDMP-Clerical
Stress Testing

COLORECTAL Surgery (CRS)

  • 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)
    • 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.
  • Coming Soon: ED Request for Specialty Appointment order in Orchid
    • ONLY if proven colorectal cancer; if unproven cancer, use CCC for EWC
      • Book <2 weeks: HAR Colorectal Surgery New (ok to overbook)
    • Any other colorectal (non-malignancy) issues, book <4 weeks

DERM

  • 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-Dermatology-Clerical

ENT

  • 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: Otolaryngology-Clerical

Expedited Work-up Clinic (EWC)

GYN

  • 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-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

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

  • 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”)
  • 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

  1. 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
  2. If they are from a county close by - consider referring them to their home county. Call 2-1-1 social services hotline.
  3. 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

See Also

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