Harbor:ED follow-up options

FOLLOW-UP

Summary

REFER TO ED follow up flow chart

DHS Patient with Empanelled Provider

  1. Instruct the patient to follow up with their empaneled provider
  2. Use the 'communicate' tool to send a message to the empaneled provider listed in the banner bar
  3. Write a brief message explaining why and when the patient needs follow up
  4. Their empaneled provider can initiate e-consults if applicable
  5. Starting Feb 2018, empaneled providers will automatically be notified of ED visits but you can still message them with any specific concerns

Urgent <2 Week Specialty Follow-up for DHS or MHLA Patients

Write the following items in the follow up field for clerk to book:

  1. Name of approving doctor
  2. Time frame (I.e., 2 days, 1 week, etc.)
  3. Reason for urgent follow up

Discharging Patients Direct to Specialty Clinic

  • In certain situations, patients can (and should) be discharged to a specialty clinic for same/next business day visit (Ophtho, ENT, Cast room, OMFS, etc.). This is considered a continuation of ED care to stabilize their presenting emergent medical condition. Once care is completed in the clinic, the patient should NOT be sent back to the ED.
  • This allows consultants to evaluate and treat patients in their clinic as opposed to coming to the ED
  • The patient CAN BE "OUT OF PLAN" FOR THIS SERVICE as is considered part of ED visit
  • Process/Troubleshooting:
  1. Get agreement from consultant
  2. Must be seen in 24 hours or next business day (if weekend)
  3. ED Care should be complete
  4. Must be during normal clinic operating hours and clinic must be open (Cast room is open until 11 pm 7 days a week)
  5. ED physician should note time and place for patient to follow-up on the ED discharge paperwork, and make sure patient takes paperwork with them to clinic
  6. ED Clerk schedules the visit as appropriate
  7. If any issues, consider attending involvement and/or contact Dr. Roger Lewis via cell.

Dir AED, Chair EM, Dir OPS 9/20/17

Follow up in CCC

REFER TO ED follow up flow chart

LAB/SYMPTOM FOLLOW-UP: any patient seen in the Adult ED, regardless of insurance or empanelment.

  • Be specific re: f/u time frame when filling out the form
  • CCC reviews requests in a few business days. No abnormal lab result review after hours or on weekends or holidays
  • If you think a patient needs an urgent face to face evaluation, have them go to the Urgent Care if DHS eligible.
  • CCC will only call patient if an abnormal result needs to be addressed. (Example: Urine culture shows antibiotic needs to be switched).
  • For pediatric patients, do not select PVCC/CCC, rather select PED

Bridge to PMD: only DHS patients discharged home, not empaneled on banner bar, not MHLA/OOP.

  • Only for DHS patients without other resources.
  • Only for patient's dispositioned HOME.
    • If unassigned MediCal, patient can go to Health Care Options office to get help choosing a PCP. Health Care Options is located at. Main Hospital PCDC 108, Window #8, Mon and Wed 8a-430p, x8101
    • If the patient was dispositioned to Obs/CORE/Psych ED/Admitted, they cannot go to CCC.
    • Don’t place the ‘ED Post Visit Plan’ form for CCC referral until you’ve decided the patient’s final disposition. If you place it too early, have to cancel or ‘place in error’ the referral form.
  • Need at least one Ambulatory Care Sensitive Condition (ACSC)
    • Chronic conditions which appropriate outpt care prevents inpt admission and/or complications.
    • Asthma, CHF, Cancer, CVA, ESRD, CF, DM, HIV/AIDS, IBD, Heart Dz, HTN, HL, Neuromuscular dz, Psych d/o, CKD, RA, Sz d/o, Substance abuse d/o, Specified debilitating conditions
    • CCC will work to transition to primary care via NERF submission
    • If they want to switch to Harbor UCLA or have problems with their health plan, they can call their own insurance plan. For MHLA patients, they can also contact MHLA directly and request the change if eligible.
    • If they are Out of Country/County, and now reside in LA County, they can go to Registration PCDC Rm 108, 1st floor main hospital, ext 8101 to change their address by bringing any mail or DMV record.

E-consult for non-urgent specialty referral - DHS patient discharged home, not empaneled, not MHLA

  • Only non-urgent/not time-sensitive. If request for specialty visit <2wks, do not use CCC. Instead, call specialty consultant to schedule appt prior to d/c
    • Appointment Service Center contacts patient to schedule the appointment around 2 weeks just to start arranging follow up.
    • If e-consult submitted already, patient can call ASC themselves to schedule their appointment 855-521-1718.
  • Need BMI and smoking status in chart for patients who are being referred for elective cholecystectomy or hernia repair. Elective cholecystectomy requires formal RUQ US prior to clinic evaluating patient. Consider obtaining formal RUQ US if appropriate. (Otherwise, could add several months delay to referral process).
  • If outside records available, ask ED clerk to copy and upload to ORCHID

How to submit CCC referral

  • Fill out ‘ED Post Visit Plan’ in the Depart Process. Select ‘PVCC/CCC – Har’ and fill out the form to put patient on their tracking list. Make sure there is a correct phone number.
  • Forgot to do the form, patient off the tracking board?
    • Highlight your patient on the “HAR Look Up” track
    • Click ‘Modify Event’ on the toolbar.
    • Then, manually request BOTH:
      • ‘Post Visit PVCC’ for adult patients or ‘Post Visit Peds’ for peds patients,
      • ‘Post Visit Follow Up’ event to put the patient on the follow up track.
      • If you placed the form by accident, cancel the PVCC form or place ‘in error’ notification. Example, if patient doesn’t get discharged from ED, need to cancel PVCC form if placed earlier.
  • Finish your ED Provider Note. CCC can’t do anything until you’ve finished your note!

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 x1220 to take over. Patients can also call 310-222-1200 to schedule appointments (Rather than calling the clinic directly).

Anticoagulation (Coumadin) Clinic

  • Book without consultant approval
  • M-F 8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, S- Sun 8am-8pm Pager 9995

Breast Diagnostic Center (Radiology)

https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis

Breast Surgery Clinic

  • needs e-Consult via PCP
  • If patient does not have PCP, consider CCC (if patient qualifies) to start eConsult process
  • For patients with diagnosed breast cancer, recurrent breast abscess/mastitis, persistent palpable masses (also need biopsy by Radiology's Breast Diagnostic Center as above)
  • If urgent needs follow up <2 weeks for DHS patient, consider consult to breast surgery resident (through Trauma surgery) from the ED

CARDIOLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • Daytime: Talk to CORE during the day, Afterhours: Talk to C-team Night fellow (listed on MedHub)

DERM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

ENT

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Expedited Work-up Clinic (EWC)

  • Book without consultant approval
  • HAR CCC Rm 4
  • Ideal candidates are those patients that would be admitted in the absence of EWC, and do not have a primary care provider. Patients must have reliable contact information to attend this clinic.
  • Clinic available every Monday PM in the CCC rm 4.
  • Katrina Pasion, RNI, is the EWC care coordinator. Please address any questions to her via ORCHID communication, Outlook email kpasion@dhs.lacounty.gov, or 310-222-2859.
  • Clinical criteria:
  1. New onset ascites: New diagnosis and first presentation of ascites. Requires paracentesis performed in ED to rule out infection, SAAG >1.1, transaminases < 3x normal, rapid HIV, CBC, lipase, CMP. No referral for therapeutic paracentesis alone, No evidence of pancreatitis or biliary obstruction.
  2. Anemia (Hgb< 8g/dL on initial presentation): Requires CBC, peripheral smear, CMP, rapid HIV, ECG, CXR, type and screen No evidence of pancytopenia, HIV, leukemia, active GI/GU bleeding, or evidence of hemolysis. Patients with suspected gynecologic etiology should be referred to the GYN service. Post transfusion CBC required.
  3. Weight loss, unexplained >10% within 1 month or >15% in 6 months: Requires CBC, CMP, ECG, CXR, rapid HIV. Patients with prior imaging must have actual images or be instructed to retrieve images prior to clinic appointment.
  4. Undiagnosed mass (excluding primary breast /brain masses): Requires results or radiographic imaging to confirm presence of mass. Patients with prior imaging must have actual images or be instructed to retrieve imaging prior to clinic appointment.
  5. New onset pleural effusion: Requires thoracentesis, CMP, CBC, serum amylase, LDH, and pleural fluid analysis (predominant lymphocytic effusion or high suspicion for Tuberculosis must be admitted). Chest CT only if immediately clinically indicated (ie. suspicion for pulmonary embolism).
  • Patient is stable (T< 38.3c, HR<100, RR <24, BP >110/50, BP <180/110, pulse ox >92% on room air, oriented x 4)
  • Able to be seen in 2-10 business days without significant risk
  • No ACTIVE co-morbidities (ie infection, CAD, CHF, stroke, metastatic cancer, renal failure, dyspnea).
  • Patient has RELIABLE contact information.

GYN

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Gyn UCC

  • Book without consultant approval
  • 3-4d f/up for ALL DHS PID patients (cervical motion tenderness or adnexal tenderness, empirically treated)

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)

Neurosurgery

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

ONCOLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

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

ORTHO

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

PEDIATRICS

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

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

PLASTIC SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

PULMONARY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

RHEUM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

UROLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

72 HRS STRESS TEST

Place order in ORCHID for "CV Treadmill Stress Test"

  • If test is abnormal, cardiology follow up automatically generated by HEART station.
  • If test is normal, no notification occurs, other than typical follow up. If you want someone to follow up on the result, consider messaging empaneled PCP or refer to CCC.
  • Outpatient P-MIBI Nuclear stress has to be arranged by CORE

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

Authors:

Ross Donaldson