DOM Admission Service Guidance

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1 Acute Care for the Elderly (ACE) Who to Call Who to admit Admission exclusion criteria Ideal Admission Location 1. Age > 75 with indication for general medicine admission (i.e. no medical or surgical specialty service management required, and not a Family Medicine patient) 2. Age > 75 with advanced acute and/or chronic illness who refuse aggressive care (e.g. no ICU, no surgery) for symptom management ACE admission pager Shock or respiratory failure requiring initial step down or ICU support (pressors, mechanical ventilation) 2. Cardiac condition requiring Cardiology or CCU support a. Acute MI, high risk chest pain based on TIMI score, requiring cardiac intervention and monitoring b. Any unstable dysrhythmia c. Any dysrhythmia requiring continuous IV medications d. Acute cardiac problem or exacerbation of chronic cardiac problem requiring hospital admission 3. Patients with active cancer diagnoses (on treatment or having symptoms) or a suspected new cancer diagnosis should be admitted to Oncology Hospitalist regardless of age. 4. Patients followed by the UCH Gynecologic Oncology service except for those receiving experimental chemotherapy through the Phase 1 clinic, should go to the GynOnc team 5. Patients followed in clinic by Hepatology are admitted by Hepatology Inpatient Service regardless of age 6. Acute or impending surgical condition requiring Surgical Service support 7. Neurologic condition requiring Neurology support b. Status epilepticus/uncontrolled seizure activity 8. Other medical problem requiring specialty management that cannot be appropriately provided on a general medical inpatient unit by medical nursing staff 9. Patients followed by the Family Medicine clinic are admitted by Family Medicine Inpatient Service regardless of age 10. All hip fracture patients. If trauma is isolated to hip fracture, patients who are floor status should be admitted to orthopedic surgery with medical consultation. BMT/Heme BMT/HEME should be notified 1. Heme Malignancy with Heme/BMT specific 1. Septic shock requiring ICU Support

2 Cardiology/CCU immediately of ALL BMT/HEME Malignancy patients presenting to the ED Pager Call Cardiology resident with all admissions with the exception of STEMIs which are called to the cath lab activation attending or cardiology intervention attending listed in Amion Pager: complication a. New diagnosis of a Heme/Malignancy (leukemia, lymphoma, multiple myeloma, etc.) b. Relapse or progression of Heme Malignancy c. Fever/Sepsis/Infectious complications d. Complications of Graft vs Host Disease (Non solid tumor) 1. Suspected or confirmed ACS (from ED per chest pain pathway; from cath lab or floors) 2. EP patients 3. Serious arrhythmia including new onset atrial fibrillation, cardiac arrest, and complete heart block. 4. Patients requiring Cardiac ICU monitoring (e.g. cardiogenic shock) 5. New onset or decompensated CHF 6. Syncope pf presumed cardiac etiology 7. Pericarditis and pericardial tamponade 8. All patients pre and post-cardiac interventions 2. Cardiac dysrhythmia/condition requiring Cardiology or CCU support a. Acute MI requiring cardiac intervention an monitoring b. Any unstable dysrhythmia c. Any dysrhythmia requiring continuous IV medications d. Acute cardiac problem or exacerbation of chronic cardiac problem requiring hospital admission 3. Acute or impending surgical condition requiring Surgical Service support 4. Pulmonary decompensation requiring Pulmonary Medicine/ICU support 5. Neurologic condition requiring Neurology support b. Status epilepticus/ uncontrolled seizure activity 6. Other medical problem requiring specialty management that cannot be appropriately provided on oncology patient until by oncology nursing staff Low risk chest pain patients should be admitted to the CDU per pathway (these include patients with a TIMI Score < 2, negative cardiac enzymes, no EKG changes, and that are chest pain free with stable vital signs.) Note: Call ACHD pager after initial ECG is obtained on all patients identified as having congenital heart disease and followed at UCH

3 Congestive Heart Failure (CHF) Cystic Fibrosis Call the CHF fellow or on call Cards resident. CHF admits from 7a-5p Monday-Friday and 7a-12p on the weekend. At other times, admissions will be worked up by the general cardiology team on call. Call CF service regarding any patient with the diagnosis of cystic fibrosis presenting to ED 1. All heart transplant patients 2. All CHF patients seen in the Heart Failure Clinic except those with a non-cardiac related admitting diagnosis (who will go to the floor teams with a CHF consult) Admit to CF service Electrophysiology On Call EP attending Admit to cardiology GI (not hepatology) 1. For therapeutic endoscopy patients presenting to the ED (Dr. Shah, Fukami, Brauer, Yen, Wani and Amateau) call therapeutic endoscopy service PA first (during business hours) 2. For all other GI consults call GI fellow For therapeutic endoscopy patients post procedure or transferred, admit to HMS. For hepatology patients, see below. For all other GI patients, Admit to Medicine ( ) or ACE ( ) if age> 75, if nonsurgical disease Hemophilia Call Sally Stabler Admit to Medicine ( ) 1. New onset CHF goes to general cardiology (or to medicine?) 2. CHF patients seen in the Heart Failure Clinic except those with a noncardiac related admitting diagnosis (who will go to the floor teams with a CHF consult) Hepatology Call the Hepatology fellow (or attending) before disposition ID 1. Call Body Fluid Exposure questions to ID Attending (per ED Body Fluid Exposure Pathway) 2. Established ID Clinic 1. All patients followed in hepatology clinic with a primary hepatology indication for admission 2. Outside hospital transfers for liver transplant evaluation 1. Hepatology clinic patients with a non-hepatology related indication for admission 2. Post liver transplant patients generally go to surgery with hepatology consult

4 Lung Transplant patients to the ID Attending 3. Other ED patients with questions about infectious issues or patients with planned hospitalization consult ID Fellow Contact: Lung Transplant Attending on-call on arrival to the ED. If not answering within 5 minutes, contact the Lung Transplant Coordinator on-call Lung transplant recipients > 90 days post-transplant who were transplanted at UCH or are followed at UCH should be admitted to the lung transplant service. To the 6th floor transplant unit or if they have a respiratory infection admit to 9 th floor pulmonary unit. 1. Patients transplanted at other institutions that we do not follow or have never seen should be admitted to the appropriate medical or surgical service with a Lung Transplant Consult (Lung Transplant Attending oncall). 2. Admit to CT Surgery if < 90 days post-transplant. Medicine/ Hospitalist Services 1. For medical consultation call: For Medicine Admission Call: Indication for general medicine admission generally means no medical or surgical specialty service management required, < age 75, and not a Family Medicine patient 2. Medicine admits all hematology, GI, renal patients as above 3. Shock or respiratory failure requiring initial step down or ICU support (pressors, mechanical ventilation) 4. Cardiac condition requiring Cardiology or CCU support a. Acute MI, high risk chest pain based on TIMI score, requiring cardiac intervention and monitoring b. Any unstable dysrhythmia c. Any dysrhythmia requiring continuous IV medications d. Acute cardiac problem or exacerbation of chronic cardiac problem requiring hospital admission 5. Patients followed in clinic by Oncology actively being treated for cancer are admitted by the Oncology Inpatient Service regardless of age 6. Patients followed in clinic by Hepatology are admitted by Hepatology Inpatient Service regardless of age 7. Acute or impending surgical condition requiring Surgical Service support 8. Neurologic condition requiring Neurology support b. Status epilepticus/uncontrolled seizure activity

5 MICU Oncology Pulmonary Hypertension Call MICU fellow on call for questions regarding MICU bed availability and appropriateness Oncology Hospitalist should be notified of admissions. 24/7 pager is Call Pulmonary Hypertension attending physician on call with any patient known to pulmonary hypertension 9. Other medical problem requiring specialty management that cannot be appropriately provided on a general medical inpatient unit by medical nursing staff 10. Patients followed by the Family Medicine clinic are admitted by Family Medicine Inpatient Service regardless of age 11. All hip fracture patients. If trauma is isolated to hip fracture, patients who are floor status should be admitted to orthopedic surgery with medical consultation. See level of care document for guidance (link) 1. End of life; 2. Goals of care not consistent with ICU level of care (e.g. DNI for respiratory failure) 3. Primary cardiac condition; admit to CCU 4. Primary surgical condition; admit to SICU 5. Primary neurologic condition, admit to Neuro ICU All medical patients with active cancer diagnoses, defined as either: -Undergoing cancer-directed therapy (chemo or radiation) -Actively followed at UCH or at another cancer center -Have symptoms due to cancer Patients with suspected new cancer diagnoses (e.g. new mass on imaging) All ages (no ACE age cutoff) Admit to Pulmonary Hypertension Service, unless requiring admission to the MICU 1. Patients without active cancer diagnosis, e.g. history of cancer but followed by oncology for surveillance only and no cancer-related symptoms. 2. Patients with hematologic malignancy are admitted to the BMT service 3. Shock or pulmonary decompensation requiring ICU 4. Cardiac conditions requiring cardiology/ccu 5. Acute or impending surgical condition requiring Surgical Service support 6. Neurologic condition requiring Neurology support b. Status epilepticus/uncontrolled seizure activity 7. Neuro-oncology patients with primary brain tumors unless there are no cancer-related acute issues and the primary problem is medical (e.g. DVT/PE, pneumonia). Otherwise, these patients go to the Neurology service. 11 th floor Oncology 9 th Floor Pulmonary Unit, unless requiring admission to

6 program presenting to ED Renal 1. For acute renal disease (acute kidney injury, electrolyte abnormalities, etc.) call Renal Fellow 2. For chronic dialysis patients with for unrelated acute illness call end-stage renal disease service Renal Transplant 1. Call the Transplant Surgery fellow on call before disposition if < 90 days from transplant 2. Call the Renal Transplant fellow or attending on call before disposition if > 90 days from transplant 1. If primary diagnosis of acute renal disease, admit to Medicine ( ) or ACE ( ) if age> For other primary diagnoses, admit to appropriate service 1. Admit to Transplant Surgery if < 90 days from transplant 2. Admit to Medicine service with Renal Transplant consult if > 90 days from transplant ( ) or ACE ( ) if age> 75. Sickle Cell Call Kathy Hassel Admit to Medicine ( ) MICU or Step Down

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