Template:Harbor Admission 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 8-18-20.pdf

From DHS expected practice and agreed upon by Radiology, Acute Care Surgery, Breast Surgery, EM: File:Breast Mastitis-Breast Abscess DHS Expected Practice.pdf

  • Step 1:Obtain breast ultrasound - order "US Breast R/L" stat
    • During business hours 7a-330p: call Breast Diagnostic Center (BDC) x68178
    • Afterhours: patient can go to regular Radiology Ultrasound
  • If no abscess, only phlegmon, treat with PO abx and obtain close follow up with PCP.
  • Step 2:Superficial abscess <1cm from the skin, need I&D.
    • I&D can be done by either ED or Acute Care Surgery (ACS) / Breast surgery consult.
    • Send wound culture, place wick, d/c patient with PO abx
    • Percutaneous aspiration may also be appropriate for superficial abscess in a lactating patient to avoid milk duct fistula.
    • If concerns for sepsis (elev HR, WBC >15K or with left shift, etc.), and needs admission, contact Acute Care Surgery (ACS) / Breast Surgery for admission.
    • If Acute Care Surgery or the ED provider performed 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
        • Melissa Burla NP
        • Dr. Christine Dauphine
        • Dr. Junko Ozao-Choy
        • If during the weekdays and daytime hours, Clerk/ED provider could call the clinic directly to have appt scheduled or for any questions x68178.
  • Step 2:Deep abscess >1cm from the skin, or lactation abscess, needs needle aspiration
    • ED provider can perform - if simple abscess, no concern for malignancy, and attending feels comfortable
    • Send wound culture, d/c patient with PO abx, f/u as above in Breast Surgery Clinic.
      • If breastfeeding: 1st line dicloxacillin, consider lactation consultant, continue breastfeeding/pumping/manual expression
      • If concerns for sepsis (elev HR, WBC >15K or with left shift, etc.) and needs admission, contact ACS/Breast Surgery for admission, needs BDC needle aspiration ASAP. Surgery resident discuss with on-call Radiology resident, then Radiology perform procedure emergently
    • Breast Diagnostic Center (BDC) performs same day/next business day, 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: contact BDC to add on case x68178
      • Afterhours: Next business day follow up 830a in BDC in B200
      • After BDC – if DHS/MHLA, gets auto-f/u with Breast Surgery Clinic. If OOP, goes back to PCP for Breast Surgery referral.
  • Consider eConsult to Specialty Breast Services:
    • if palpable mass persists after 14-21 days, ultrasound and needle biopsy should be performed of solid components by radiology department
    • recurrent mastitis/abscess, or chronic granulomatous mastitis

Breast mass/malignancy

File:Breast Mass Pathway 10-5-20.pdf

  • Highly suspicious symptoms for breast malignancy
    • Still needs imaging to diagnose, needs urgent BDC referral 2 wks
    • ED to message PCP or CCC, send back to MHLA clinic. PCP will work on getting patient to a BDC.
    • Once, seen in BDC, patient’s gets auto-f/u into Breast Surgery Clinic
  • Newly diagnosed without obvious metastatic disease
    • If diagnosed from outside, patient must obtain outside records (CD and packet with path slides)
      • If they do not have BOTH imaging and path results, they must go to Breast Diagnostic Center first
    • ED provider messages empaneled PCP or CCC. PCP/CCC initiates e-consult to Breast Surgery Clinic
    • ED clerk does not make an appointment.


  • Obvious metastatic breast cancer
    • ED provider will message empaneled PCP or CCC.
    • BDC w/in 1 wk – Need biopsy to prove is breast source (results usually in 2d)
    • ED will consult Med Onc for urgent f/u w/in 2 weeks. Clerk books 'oncology new' appointment type in time frame provided by Oncology.
    • 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 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 C-team if the above criteria are not met or the patient needs ICU care


Cellulitis, Abscess, NSTI

  • Cellulitis
    • OBS <2 midnights
    • IM/FM >2 midnights
    • 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
    • Sunday to Thursday - OBS
    • Friday & Saturday - IM/FM
    • Less than 30 days post-op - trauma consult in the ED
  • IM/FM (with vascular and nephrology) if requires more than IR

Decubitus Ulcers

  • OBS if <2 midnights and does 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/PE
    • Trauma/ACS (or vascular) for phlegmasia
    • OBS if <2 midnights; IM/FM if >2 midnights
    • <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
    • OBS <2 midnights
    • IM/FM >2 midnights
  • Dementia
    • Neuro - new onset or previously undiagnosed
    • IM/FM - new onset with one or more complicating medical condition
    • OBS - established dementia requiring placement (unless directed by UR for admission [IM/FM])

Diabetic Foot Infections

  • Trauma/ACS with planned transfer to limb salvage
    • 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

Disposition Problems

  • OBS for long-term placement unless otherwise directed by UR (then admitted to IM/FM)
  • EXCEPTIONS:
    • Patient develops a complication from a medical or surgical problem and is already followed by that p[articular 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)

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

  • Low Energy Mechanism (ground level fall)
    • Age >/=65: Admit to IM/FM with Ortho & Anesthesia consults
      • Courtesy consult to Anesthesia (23335 daytime, 23337 after 6p) for fascia iliaca block (should not delay admission process)
      • Any ED faculty comfortable placing a fascia iliaca block may perform it PRIOR to Ortho evaluation of the patient
    • <65 without ACTIVE medical issues (medical co-morbidities requiring active management): Admit to Ortho with Anesthesia consult
    • <65 with active complicating medical conditions: Trauma has right of refusal; if cleared by Trauma, admit to IM/FM; Anesthesia consult regardless of admitting service
  • High energy mechanism or distal femur fracture: Trauma with Ortho & Anesthesia consults
  • 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

  • OBS: for pain control with no neuro deficits
    • If they fail the obs period, admit to IM/FM with 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


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

OBS - BC

  • All placement patients unless otherwise instructed by UR


Osteomyelitis requiring admission

  • Hand Call: hand and forearm
  • Ortho: all other extremity osteo
  • Trauma/ACS/Limb Salvage: underlying a DM foot infection
  • Spine Call (Ortho or 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
    • OBS: expected LOS <2 midnights
    • IM/FM: expected LOS >2 midnights

Pulmonary Embolus

  • Confirmed PE or DVT with symptoms suggestive of PE but unable to obtain CTPA
    • Start anticoagulation and consider pulmonary consult if contraindications to anticoagulation or other clinical concerns
    • For (sub)massive PE considering thrombolytics, Page PERT (PE response team) Fellow p9956 PRIOR TO THROMBOLYTICS if one or more criteria are present (if no return call, auto-page pulm):
      • Elevated troponin
      • RV dysfunction noted on CTPA or bedside US (e.g. RV/LV > 0.9)
      • HR > 110 bpm
      • SBP < 100 mmHg
      • PaO2 < 60 mmHg
      • SaO2 < 90%
    • For patients with massive PE or who are rapidly deteriorating due to known or suspected PE where thrombolytics are felt to be indicated emergently by the Attending Emergency Physician, do not delay administration in order to obtain consultation
      • If the patient is admitted, make reasonable attempts to include the admitting team in any decision about emergent thrombolytics

Drs. Wu/Vintch 5/28/19, Dr. Peterson 6/21/19

Pyelonephritis

  • Men and non-pregnant women
    • OBS if expected <2 midnights
    • IM/FM if >2 midnights
  • 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

Re-implant

  • Discuss with HUMC Ortho
  • Consider HIPAABridge for USC specialist to view the image
  • USC cannot refuse an ELTC transfer - if they evaluate and feel it is non-surgical, they may transfer back
    • MAC for ELTC transfer
      • 911 on the rare occasion you cannot get a timely MAC transfer and life or limb are in jeopardy due to time sensitive matter

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

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

DRAFT - final version pending

  • Page Trauma/ACS
  • During daytime hours, directly page the specialty service if you need a more rapid decision

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