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Admission Guidelines - Subspecialty Services(Updated 7/21/2014)General principles - if a patient falls within the guidelines for admission to a subspecialty service, the patient should go to that service. If a patient does not fall into these guidelines, only then should the patient go to general medicine. Observation cases should preferentially go to the hospitalist service. The goal, to prevent capping, is to place all subspecialty patients on subspecialty teams as much as possible. Under unusual circumstances (i.e. all general medical teams capped), the subspecialty services may be asked to admit general medical patients in order to facilitate patient flow. Additionally, a team may be asked to go over their cap in extenuating circumstances such as a “code yellow” if approved by the chief medicine residents.ID Service Admission Guidelines (Menino)Team Cap of 16 patientsDaily admission cap of 5 patients including transfersIf the team caps at 16 patients at any point during the day, it will remain capped until 7pm, regardless of discharges.All internal medicine patients with HIV/AIDS should primarily be admitted to the ID service regardless of their chief complaint, unless they are dialysis patients, actively undergoing chemotherapy treatment, or have an active cardiac issue. Concern for any of the following diagnoses should warrant admission to the ID service, unless the patient is on dialysis, actively undergoing chemotherapy treatment, or have an active cardiac issue:HIV/AIDS Sepsis (not septic shock, not fever alone)Endocarditis – if prosthetic valve, admit to cardiologyCentral venous catheter infection – if dialysis, admit to renalNonsurgical abscessMeningitis Encephalitis Peritonitis – if on dialysis, admit to renalCholangitis Infectious colitis Osteomyelitis Septic arthritis Head and neck infection Ocular and periorbital infection Malaria Tuberculosis – including rule out TB Syphilis Febrile rash illness Positive blood culture Complicated pneumonia Patient’s with the following chief complaints or likely diagnoses should not preferentially go to the ID service, unless Medicine is capped: Uncomplicated cellulitis Fever alone Simple pneumonia Uncomplicated viral illnessThe ID service will admit general medicine patients if medicine is capped. Overnight, if the ID team census is 8 or fewer, 2 patients will be admitted to the ID service. The HAC senior nightfloat can reassign patients to or away from the ID team after evaluating the patient if needed and will notify admitting by 6am. Geriatric Service Admission Guidelines (Menino)Team Cap of 16 patientsDaily admission cap of 5 patients including transfers* If the team caps at 16 patients at any point during the day, it will remain capped until 7pm, regardless of discharges.*Patients admitted by the NP do not count to the daily cap, but count towards the team cap.Any patient in the Home Care practice or the Geriatric Ambulatory Practice whose primary care physician is a faculty member or fellow in the Section of Geriatrics.Any long-term care nursing home patient whose primary care physician is a faculty member or fellow in the Section of Geriatrics. Any patient at a nursing home for rehabilitation whose primary care physician is a faculty member or a fellow in the Section of Geriatrics. Any patient admitted with a hip fracture whose primary care physician is a faculty member or a fellow in the Section of Geriatrics. Any patient admitted with cardiac problems not requiring immediate specialist cardiac care (such as CCU, EP intervention, care of MI) whose primary care physician is a faculty member or a fellow in the Section of Geriatrics. Any patient with a BMC PCP 80 years old or older, if the Geriatrics Inpatient Service is not at risk of being capped. Any patient aged 70 or older without any PCP (i.e. unassigned).If the patient is at a nursing home for rehabilitation and a geriatrics physician is following the patient, and the patient originally came from a PCP not affiliated with BMC, the patient should be admitted to the Geriatric Inpatient Service. If the patient is at a nursing home for rehabilitation and a geriatrics physician is following the patient, but the patient was followed by a non-geriatrics BMC provider, that patient should be admitted to a general medicine team. Although BU Geriatrics patients should be admitted to the Geriatrics team, there will be times when this is not possible (i.e. team is capped). If this occurs, the patient should be cared for by the team to which they were admitted. Interservice transfers are at the discretion of the Geriatrics and primary team attending, and should not be systematic. Hematology-Oncology Inpatient Service Admission Guidelines (7E at East Newton)Team cap of 18 patientsDaily admission cap of 5 patients including transfersIf team caps at 18 patients at any point during the day, it will remain capped until 7pm, regardless of discharges.The highest priority for admission to the ENC 7E Heme-Onc Inpatient Team are heme-onc patients with active hematologic/oncologic management issues, ongoing chemotherapy, or patients undergoing bone marrow (stem cell) transplantation. Every attempt should be made to admit these patients to the heme-onc service. If the service is capped, transfer of less active patients to a general medicine team should be considered. The second priority for admission should be heme-onc patients requiring chronic medical care, palliative care, end-of-life care, and other non-acute care. In general, heme-onc patients with active medical problems unrelated to their hematologic/oncologic illness that are outside of the scope of expertise of the Heme-Onc subspecialty attending staff should be admitted to a general medicine service. Examples of such problems might include suspicion of acute MI, DKA, CHF exacerbation. The heme-onc consult team should be notified of their admission and asked to consult if their care is impacted by their underlying heme-onc disease. If there are any questions about the suitability of admission to the heme-onc service, please page the heme-onc fellow or attending on service or Drs. Gignac or Seldin.Triage ProtocolsED to floor: patients brought in to the ED for evaluation from outside or from clinic. Following the guidelines above, the ED staff will determine the appropriate service for admission and notify admitting. For admissions to the heme-onc team, admitting will text page the resident and heme-onc fellow (ghost pager 0598: Hematology & Oncology Admissions). The resident is responsible for taking report from the ED physician and discussing the admission with the fellow. There is a 30 min hold time in the ED from the time of bed assignment. If there are any concerns about the evaluation or disposition of the patient, the fellow or attending should speak with the ED physician directly. Patients Usually Requiring Heme-Onc Team Management Patient requiring inpatient treatment for their heme-onc disease, e.g. acute leukemia. Patients with direct side-effects of treatment Fever and neutropeniaChemo-specific side effects including nausea, vomiting, diarrhea, dehydration, mucositisChemo-induced pancytopeniaTumor lysis syndrome Other oncologic emergencies Transfusion reactions or immunotherapy reactions Patients on clinical trials or protocols requiring specific evaluation and treatment of disease or complications.Patients undergoing bone marrow stem cell transplant. Patients requiring an inpatient heme-onc diagnostic evaluation that is deemed most appropriate for the heme-onc service by a heme-onc attending. Patients with complications from their disease that are deemed best managed on the heme-onc service by the admitting attending. Patients requiring management of cancer-related pain. Patients Usually Appropriate for Management on a General Medical or Hospitalist Team Patients with a history of a heme-onc disorder that is not considered active requiring admission for an unrelated problem. Patients with an active heme-onc disorder requiring admission for a general medical problem felt to be better served by medicine (as above).Patients admitted from home, hospice, rehab, or a nursing home with an exacerbation of disease for which no specific heme-onc intervention can be offered when the heme onc team is nearing cap.Patients with amyloidosis admitted for management of a cardiac or renal complication of their disease not undergoing active treatment should be admitted to the respective inpatient subspecialty service in preference to the heme-onc service. The Amyloid Fellow who has attending privileges should be consulted (2013-2014, Dr. Julie Fu).Patients with benign hematologic conditions (e.g pancytopenia of unclear etiology) when the heme-onc team is nearing their cap. Patients with cancer who do not require inpatient heme-onc treatment when the heme-onc team is nearing their cap. Patients requiring chronic medical care who do not require direct subspecialty management (e.g. chemotherapy) when the team is nearing the cap. Patients requiring palliative care only when the heme-onc team is nearing cap.Patients with sickle cell anemia. The sickle cell attending on call (not the heme-onc consult fellow) should be notified of all sickle cell admissions, since they guide protocol-based algorithms for pain management for these patients. Renal Service Admission Guidelines (6West at East Newton)Team cap of 16 patients*Daily admission cap of 5 new patients including transfersIf team caps at 16 patients at any point during the day, it will remain capped until 7pm, regardless of discharges.** Exceptions: Patients on peritoneal dialysis or s/p renal transplant, may be admitted to the renal service when the team census is between 16-20. The team census may never exceed 20 patients. Any patient on chronic dialysis (hemo or peritoneal) admitted for a medical issue (does not include ICU or surgical). Any patient recently started on dialysis who currently is at a rehab facility, though never started at an outpatient unit (these used to stay on the consult service). All renal biopsies. Patients being admitted by a Renal attending to initiate dialysis (Stage V CKD patients from clinic). General Cardiology Service Admission Guidelines (7North at East Newton)Team cap of 16 patients*Daily admission cap of 5 new patients + 2 unit transfersIf team caps at 16 patients at any point during the day, it will remain capped until 7pm, regardless of discharges.*Any admissions beyond the team caps must be approved by the medicine chief residents in discussion with the attending.*Exceptions: Patients may still be transferred to the general cardiology team from outside hospitals up to a team cap of 20 patients. Patients with the following diagnoses may be appropriate for admission to the inpatient cardiology service/CCU floor team: Patients with a BMC cardiologist, who are presenting with a cardiac diagnosis ACS that does not require the CCU or IMCU TIMI score > 3 (age >65 yrs, > 3 cardiac risk factors, > 2 episodes of angina in 24 hrs, known CAD, aspirin use in past 7 days, ST deviation, elevated cardiac biomarkers) Elevated troponin Surgical or percutaneous revascularization within the last year. Rapid atrial fibrillation that is not controlled in the ED (patients with chronic or new onset afib that is controlled can be managed on the medical service with cardiology consult as needed)Endocarditis not requiring unit admission Symptomatic but hemodynamically stable valvular heart disease Some patients with ICD discharges that require telemetry admission Cardiac amyloid patients admitted with HF, bradyarrhythmias, or tachyarrhythmia Large pericardial effusion, without tamponade Pericarditis requiring admission Patients recently discharged from the cardiology service who are readmitted with cardiac problems. Patients with other symptomatic arrhythmias (e.g., WPW, AVNRT, NSVT) especially if presenting with syncope. ................
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