Template:Harbor Admission Guidelines

Admission and Consultation Guidelines

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.

  • Aortic Aneurysms
  • Brain Death
    • Admit to the service who would have cared for the primary illness or injury
    • Admitting service should notify organ donation agency
  • Burns
    • Transfer to a hospital with a burn unit, if admission is required
    • Trauma surgery to provide consultation and admission if burn unit bed unavailable
  • Cellulitis(Non-maxillofacial)
    • Admit to medicine with the following exceptions
      • Upper extremity (hand to the antecubital fossa): Hand call (plastic surgery or ortho)
      • Necrotizing fasciitis or requiring surgery in 24 hours: Trauma Surgery
  • Clotted dialysis graft: Admit medicine, with inpatient vascular surgery consultation
  • Decubitus Ulcers
    • Wound care primary indication for admission: Plastic Surgery
    • Placement, management of medical problems: Medicine
  • Deep venous thrombosis
    • Women, suspected DVT < 6wk postpartum: OB
    • Women, followed by gyn-onc, < 6wk post-op by gyn-onc: Gynecology
    • Post-operative DVT, < 6wk post-op: Surgical service who performed operation
    • All other DVTs: Medicine
  • Delirium/Dementia
    • Acute delirium: Medicine
    • Established dementia: Medicine
    • New onset or previously undiagnosed dementia: Neurology
  • GI Bleeding:
  • Hand Injuries:
    • Open and closed fractures of the forearm and hand: Orthopedics
    • Soft tissue injuries of hand up to AC fossa: Hand call (ortho or plastics)
  • Intracranial mass lesions:
    • Solitary lesion with no other significant medical problem: Neurology (note, HIV positive or suspected HIV infection does not constitute significant medical problem)
    • Non-hemorrhagic intracranial mass lesion with urgent or emergent medical problem: Medicine
    • Solitary intracranial lesion at risk of herniation: Neurosurgery
  • Lower back pain:
    • With neurologic deficit (motor, sensory or reflex): Neurosurgery
    • Without neurologic deficit: Orthopedics
  • Maxillofacial trauma:
    • Soft tissue and bony injury: Face call
    • Orbital floor fx with ocular injury: Ophthalmology
  • Maxillofacial injections
    • Infections involving orbit: Ophthalmology
    • Dental infection or odontogenic abscess: OMFS
    • Infection of sinuses, complicated dental infection with facial and/or neck extension: Head and Neck Surgery
    • Other maxillofacial infections: Face Call
  • Meningitis
    • Even MRN: Medicine
    • Odd MRN: Neurology
    • Significant medical problem not including positive HIV: Medicine
  • Osteomyelitis requiring admission:
    • Even MRN or with urgent/emergent medical problems: Medicine
    • Odd MRN or requiring surgical management: Orthopedics
  • Painless Jaundice:
    • Medicine
  • Pancreatitis:
    • Effective 3/31/16, the following change in this practice will be implemented as approved by the Chairs of IM, Surgery, and EM:
    • Patients seen in the Emergency Department with pancreatitis who require admission to the hospital will undergo a right upper quadrant ultrasound by either a certified emergency medicine provider or in Radiology to determine the presence of gallstones. For ultrasound images acquired by emergency medicine physicians, the adequacy of the images to determine the presence or absence of gallstones will be determined by the emergency medicine attending physician;
    • Patients who are found to have gallstones and pancreatitis requiring hospital admission will be admitted to the Trauma/Acute Care Surgery service; and
    • Patients who have pancreatitis requiring hospital admission who do not have gallstones will be admitted to the Internal Medicine service.
  • Pyelonephritis:
    • Pregnant women: Obstetrics
    • Pyelo with nephrolithiasis or other urinary tract obstruction: Urology
  • Septic Arthritis:
    • Involving the shoulder or hips, unless concurrent medical condition requiring urgent/emergent intervention: Orthopedics
    • All other joints: Medicine
  • Spinal Injuries
    • With neurologic deficit: Neurosurgery
    • Without neurologic deficit: Orthopedics
  • Stroke:
    • Nontraumatic intracranial hemorrhage requiring surgical intervention: Neurosurgery
    • Traumatic intracranial hemorrhage: Neurosurgery consultation, generally Trauma Surgery admission
    • Stroke and requiring urgent/emergent medical therapy: Medicine
    • All other strokes admitted to Neurology
  • Thyroid Masses
    • Refer to endocrinology
  • Trauma patients:
    • Can admit to subspecialty service when only one organ system involved, at discretion of Trauma Surgery

Direct Admission after Hours

  • All patients going to Gold must be evaluated in the ED with an ED Chart completed
  • Patients may directly placed in CORE by cardiology without ED evaluation
  • Any inpatient direct admissions presenting before 8pm: admitting physician directly contacts Bed Control for Ward Beds (x2185) or Patient Flow (x3434) for Tele/PCU beds
  • If after 8pm: Admitting physician completes "Clinic/Emergency/Urgent Admission Request Form" (can be obtained from registration in ED or Bed Control)
    • Admitting physician provides a copy of the request to ER Registration x2075/2076/2078 and they create a pre-admit FIN UR Financially clears patient
      • Admitting physician provides a copy of the request to Bed Control/informs location of patient to release bed (ER)
      • ER Registration informs Physician/UR if patient is non-DHS
        • If patient is DHS, admitting physician inputs the admitting order on the pre-admit FIN UR calls to obtain authorization Informs Bed Control of approval
        • Informs Physician/Bed Control of denial; if denied, decision must be made whether this is urgent and needs to be seen in ED and transferred to in-network hospital or stable for outpatient treatment
    • ER Physician will document the patient's presence in AWR/ED as a Pre-arrival with name and patient location (AWR or room #) with brief note with admitting service and physician to contact for questions (pager #)
      • If patient is stable, should wait in AWR until upstairs bed is available
      • If needs to be watched for any reason, they can be placed in internal WR (RME 7, 8, 12) until upstairs bed is ready
      • If the patient is in any way unstable or requires immediate intervention or cardiac monitoring, they should be registered and seen as an ED patient and the admitting team should be notified of the change in patient status as soon as possible
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