Where to Admit Patients

Policies,

These guidelines are to be used in determining the most appropriate service to which a patient shall be admitted.  Clinical circumstances may, on occasion, require the responsible ED attending to make an admission decision that overrides these guidelines.

Patients with the following primary diagnoses are to be admitted to the Surgery Service.

(Surgery Admissions  memo – original signed document- update July 2016)

  • Lower GI Bleeds
  • Pancreatitis with gallstones or if the patient requires an ICU admission.
  • Diverticulitis (with or without abscess)
  • Appendicitis
  • Bowel obstruction (large or small bowel)
  • Bowel perforation.
  • Cholecystitis (including acalculous cholecystitis)
  • Cholangitits/choledocholithiasis
  • Liver abscess
  • Post-operative complication (including DVT) within 30 days of surgery goes to service that operated on the patient.
  • Animal bites (except to upper extremity distal to the elbow, which goes to the service covering hand)
  • Frostbite/ burns (except to upper extremity distal to the elbow, which goes to the service covering hand)
  • Incarcerated Hernia
  • Spontaneous primary pneumothorax. (This excludes those patients with underlying pulmonary disease as the probable cause of the pneumothorax, such as COPD, TB, PCP or other HIV-related disease)
  • Perirectal abscess that requires admission.  Many can be operated on as ambulatory surgery case.
  • Cellulitis
    • Alternates with medical service
    • Hand service admission if cellulitis involves area below elbow
    • ***preferable on surgical service if patient is critically ill; as this suggests necrotizing fasciitis***

Trauma Admissions

Trauma Admissions memo – original signed document – update July 2016

All patients with traumatic injuries requiring admission MUST go to the trauma service or another surgical sub-speciality service.  The only possible rare exception would be if the traumatic injury can be unequivocally attributed to an acute cardiac evat or the patient is at high risk of acute cardiac dysrhythmia/ischemia as determined by the ED attending. Patients with serious medical conditions (i.e alcohol withdrawal, acute kidney injury, electrolyte abnormalities, DKA) with a traumatic injury cannot go to medicine and must be admitted to the appropriate surgical service.  These patients can be placed in the SICU or step-down unite for management of their medical issues.

A traumatic injury that will be managed non-operatively is not a reason for a medical admission.

Red Trauma:  Automatic admission to the Trauma Service unless:

***The ED attending agrees that the patient can be discharged and the senior/chief resident writes at progress note indicating that their plan for discharge and appropriate follow-up.  The progress note MUST include the name of the surgical attending with whom the case and disposition was discussed.

Yellow/Gree Trauma: 

  • More than one organ system injury: Trauma Service.
  • Syncope with significant trauma**:  Trauma Service.
  • Syncope with isolated intracranial bleed**: Neurosurgery Service or Trauma Service (If there is an argument as to which service, the patient should go to Trauma)
  • Isolated facial trauma not requiring ICU: Service covering facial trauma.
  • Isolated genitourinary trauma: Trauma Service
  • Isolated upper extremity fracture: Orthopedic Service ***New***
    • (DO NOT ADMIT TO MEDICINE)
  • Isolated lower extremity fracture: Orthopedic Service.
  • Pelvic Fracture:
    • Hemodynamically unstable and/or accompanied by significant blood loss:
      • Trauma Service. Otherwise, Orthopedic Service.
    • Hemodynamically stable
      • Orthopedic Service
  • Altered mental status (or post-concussive syndrome) after mechanism of trauma except for syncope (i.e. pedestrian struck, assault, motor vehicle crash):
    • Trauma service, even if trauma work up is negative.
  • Rib fractures: Trauma Service
  • Isolated vertebral fractures after trauma: Neurosurgery

 

 

Neurology/Neurosurgery Admissions

  • TIA goes to neurology (Only if unstable atrial fibrillation should these patients go to medicine)
  • Spontaneous Intra-parenchymal hemorrhage (ICH)-admit to neurology, do not call neurosurgery. Neurology will consult neurosurgery as appropriate. If these patients require operative intervention or EVD, they will go to the STICU under neurosurgery
  • Spontaneous SAH-neurosurgery

Cellulitis

  • Cellulitis below elbow-Service covering hand
  • Cellulitis in other locations-alternates between surgery/medicine.
    • Provider must call bedboard to see which service is next up.

GI Bleeds

  • Upper GI bleeds go to medicine