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Medicine/Orthopedics/ED Inter-Service AgreementAdmissionsPatients with an acute fracture (including non-operative fractures and patients whose indication for admission is pain control secondary to an acute fracture) will be admitted to orthopedics, UNLESS the patient has one of the following medical conditions, in which case they will be admitted to a medical service:,,,,Acute chest pain or EKG/enzyme evidence of ischemia (including troponin above upper limit of normal)Dyspnea, or signs/symptoms of pulmonary edema, or >2 liter new O2 requirementDecompensated Heart FailureUncontrolled arrhythmia or new arrhythmia with persistent/recurrent HR >110DKA Severe valve diseaseEF <30% on most recent ECHOSepsis or any complicated active infections (e.g. diverticulitis or pneumonia but not bronchitis or uncomplicated UTI) Acute kidney injury Persistent/Recurrent systolic BP >180 or diastolic >100 Persistent/Recurrent systolic BP < 90 despite appropriate fluid challenge (ICU consult recommended)Any signs of active internal bleedingAcute alcohol intoxication with significant behavioral disturbance or acute alcohol withdrawal.Decompensated liver disease including any of: hepatic encephalopathy, INR >1.7, new onset jaundice.Focal central neurologic changes including stroke and TIA (admit to neurology)Patients currently on hospice or requiring comfort care who will be managed nonoperativelyPatients in need of vulnerable adult or elder abuse evaluation Hip Fracture ProtocolIdentification of an incident hip fracture in an ED patient activates the hip fracture protocol and paging of the hip fracture team (orthopedics, medicine, and anesthesia).The surgical co-management (SCM) hospitalist provides medicine support for hip fracture protocol patients from 7am – 5pm and the general medicine residents provide support from 5pm – 7am. PAMF provides 24 hour medicine support for PAMF patients.ConsultsSurgical Co-Management Hospitalist/Nocturnist/Medicine Resident Consult RoleIf the SCM hospitalist is consulted on a patient admitted to the orthopedic service, they will see the patient within 3 hours (if called STAT within 1 hour).For patients followed by the SCM hospitalist service, the SCM hospitalist will be paged directly regarding medical issues from 8 AM-5 PM. After 5PM, the 1st page for medical issues is to the orthopedic resident, who after evaluating the patient may then contact the on-call SCM hospitalist (p24311). The SCM hospitalist may contact the in house nocturnist (N1; p12012) to perform bedside evaluation/treatment as necessary. If acute medical issues will require frequent monitoring/treatment decisions than a transfer request should be considered (see below Transfer Requests). The consulted SCM hospitalist will write daily notes and orders for evaluation and management of medical issues (e.g., labs, medications, etc.). Notes will include full risk stratification for intra-operative intervention and will recommend additional consults when appropriate.For non-emergent medical issues that develop overnight (7pm – 7am) in patients known to the SCM hospitalist, the on call SCM hospitalist will contact the in house nocturnist to perform evaluation/treatment. If non-emergent acute medical issues will require frequent monitoring/treatment decisions than a transfer request should be considered (see below Transfer Requests). For non-emergent after hours (5pm – 7 am) consults on patients not followed by the SCM hospitalist, the orthopedic resident should contact the on-call medicine consult resident (p27111) who then staffs the consult with the on-call SCM hospitalist.For emergent medical issues, the ICU fellow should be contacted directly.Orthopedics Consult RoleIf orthopedics is consulted on a patient admitted to a medical service, they will see the patient within 5 hours (if called STAT as soon as possible).Orthopedic consults will write daily notes and will write orders pertaining to evaluation of the fracture, anesthesia evaluation, OR scheduling, NPO status, anticoagulation, equipment orders, PT/OT, perioperative antibiotics, wound care, and activity level (orthopedics will notify the medical service of any order that they are writing).Transfer RequestsFrom Orthopedics to a Medical ServicePatients on the orthopedics service should be considered for transfer to a medical service if:Any of the above criteria used to determine appropriate admission service develop.Other active medical issues that supersede active orthopedic issues that cannot be reasonably/safely managed by the SCM Hospitalist/Nocturnist develop.For non-urgent transfer requests, the decision to request transfer should be discussed with the consulted SCM hospitalist prior to the request.The on call chief medicine resident reviews/approves transfer requests to the general medicine service. Transfer requests to sub-specialty medical services (e.g., general cardiology and CCU/CSU) are reviewed/approved by the respective service attending. From a Medical Service to OrthopedicsPatients whose medical issues are stable should be considered for transfer to the orthopedics service in the post-operative period.Patients originally admitted to the orthopedics service, who were transferred to a medical service for an active medical issue, should be considered for transfer back to the orthopedics service after stabilization of the medical issue.Patients transferring from the medicine service to the orthopedic service are expected to be verbally signed out to the SCM hospitalist at the time of transfer.For patients at risk of acute fluid shifts, delirium, aspiration or other serious medical adverse events, transfer should occur during daytime hours 12-24 hours postoperatively after medical stabilization on the floor. Otherwise, medically stable patients may be transferred immediately postoperatively if mutually agreed upon between servicesFor patients transferred from the ICU overnight, the nocturnist (N1; p12012) should be contacted to physically see the patient and determine stability for transfer to orthopedics.Emergency Department RoleThe Emergency department (ED) will page the appropriate admission service based on the above criteria. The ED will not determine the appropriate admission service until an adequate workup is obtained to assess for the above criteria.The service initially paged by the ED is responsible for admitting the patient if the above process has been followed.573637134400N. AhujaMichael J. Gardner, MDNeera Ahuja, MDMedical Director, General Inpatient MedicineChief, Orthopaedic TraumaSam Shen, MDMedical Director, Adult Emergency Medicine ................
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