Service Agreements

ICU  Admission 

• Call ICU admission at the time ICU level of care is identified while pending workup and stabilization. Specifically for the following diagnoses: 

• DKA 

• Intubated 

• ICH requiring Q1h neurochecks 

• CVA (no LVO) requiring TPA/TNK 

• ROSC 

• On Pressors

• ED RN charge nurse to notify ICU charge at the time of intensivist consult for bed preparation and ICU transfer. 

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Neurosurgery 

• Neurosurgery will not provide recommendations unless a formal consult is placed. 

• Intracranial Hemorrhage Pathway 

• Non-traumatic ICH: Consult neurosurgery immediately. CTA head and neck indicated if any concern for AVM/aneurysm. If CTA is not done, may be requested prior to admit to see if patient needs neuroIR for coiling. 

• Neurosurgery will inform the ED within 15 minutes of CTA completed if need to transfer. If the resident does not respond within 15 minutes, escalate the call to NSx attending. 

• NSx should advise of transfer prior to MICU consult. 

• Osteomyelitis 

• In the setting of osteomyelitis without sepsis: hold antibiotics if the patient is SIRS positive. Follow sepsis protocol. 

• Pediatric Neurosurgery 

• For patients 15 yo or younger, consult adult in-house. Neurosurgery will avoid reflexively recommending to transfer but can advise to call LLUMC Peds Neurosurgery for direction. 

• We have had cases where adult neurosurgery wrote to transfer, but LLUMC was able to coordinate close follow-up. We want to avoid conflicting recommendations. 

• LLUMC is on-call for Peds Neurosurgery, but currently just by phone. Discuss management with them regarding need for transfer or potential for outpatient follow-up (e.g. mass). 

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Neurology 

• Continuous EEG is available from 0700-0000 (this should mostly be done in the ICU) 

• Spot EEG is available almost 24/7. Respiratory therapist will set it up with approval of neurologist on call. 

Obstetrics 

• ​​OB (Per Chair Dr. Johnson) would like all pregnant patients with opiate addiction that warrant admission (mainly inmates) to be admitted to their service (potentially for suboxone therapy). 

• Please refer to this memo regarding psychiatric care of pregnant patients.

• For previable PROM (second trimester with rupture of membranes) please consult OB while the patient is in the department. 

Orthopedics 

• Discharge Consults 

  • The orthopedic team prefers to be called for all cases that will ultimately need surgical care (even if discharged), so they can pre-op the patient and arrange follow-up. ​

• Reductions 

  • Orthopedics prefers to be called for all cases that will ultimately need surgical care (even if discharged) so they can pre-op the patient and arrange follow-up. ​

• Would Cultures 

  • Call ortho prior to ordering or performing a wound culture on any post-operative ED visits. They want to avoid unnecessary cultures of post-op wounds. ​

  • If patient does not meet SIRS criteria, hold off on antibiotics for osteomyelitis 

• Sedation

  • ED will perform sedation for all reductions unless there are significant contra-indications/unsafe conditions (E.g. unstable vitals; airway management concerns) that prevent performing sedation in the ED. ​

• Orthopedic Contacts

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Pediatrics

• Goal from consult for admit order is 60 minutes. 

• Family Medicine residents have been instructed to receive the consult at the first point of contact and see the patient (even within the last hour of on-call time). If they cannot see the patient, they will sign the patient/consult out to the oncoming resident. The ED will not routinely call a second resident to perform the consult. 

• Bronchiolitis pathway 

• Status epilepticus order set is available in EPIC. 

• The pediatric attendings are available after hours for telephone consultation. The pediatrician can then make telephone recommendations OR the family medicine resident may be asked to see the patient to obtain information to the pediatrician on call. 

• Hyperbilirubinemia: see hour specific calculator linked. 

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Psychiatry 

• ED psychiatry workflow*** 

• MSE of Agitated or Intoxicated Patients 

  • Ensure your MSE note addresses the assessment of the chief or associated complaints. ​

  • Placement and care of severely agitated patients: 

    • anyone under a 5150 hold needs a sitter order and a legal hold order. ​

    • Patients arriving from custody that are very agitated and aggressive OR who were extricated from their cells CANNOT be placed in a security cell. They must be placed in a medical, resuscitation bed. 

      • Do NOT place severely agitated patients into the G beds or into security cells until they have been stabilized. ​

      • Children CANNOT be placed inb G beds (except fort the single rooms). 

    • Severely agitated patients should be medicated parenterally. Past behavior should be considered when deciding to medicate for acute agitation. 

  • For depressed, suicidal, intoxicated, or delusional patients, please address SI, HI, and grounds to hold or not hold them against their will on MSE notes. Capacity to refuse care (treatment, studies, admission, can be addressed later), but the MSE needs to include if they are a danger to themself, to others, gravely disabled, and/or a flight risk. 

    • For patients with a primary medical complaints, but also showing signs of agitation, intoxication, or mental illness, the above needs to be addressed in the MSE note. ​

  • If patient does not have a psychiatric illness but lacks capacity to leave, please them on a medical incapacity hold (i.e. dementia, encephalopathy, delirium, etc). 

    • There is an order available for this in EPIC. ​

  • Restraint order and documentation

  • Document when giving IM/IV medications (uncooperative, violent, etc). 

• Medical Clearance 

  • This is largely a clinical determination. There are no specific labs required, but caution needs to be taken to exclude underlying acute medical issues.

  • POCT Covid test if they are symptomatic. Covid test is not necessary if patient is not showing any symptoms.

  • New onset psychosis or mental status changes typically require more medical work-up. 

  • Caution to assess for any signs of trauma or other injuries in altered patients, even with a psychiatric history, should be taken. ​

  • Unstable vital signs (e.g. severely elevated blood pressure) and severely elevated blood sugars (>350) are challenging for ETS to manage without onsite medical staff at all hours; care should be taken to stabilize patients as much as reasonably possible prior to clearance to ETS. 

  • Patient should be "transferred" to ETS and not discharged. Transfer paperwork should be completed (in EPIC discharge section and by the MUC) with accepting physician given report and documented in the medical record. 

  • EPIC note should be completed at the time of transfer with documentation that the patient is "medically stable for ETS". 

• Outpatient Psychiatric Support 

  • For outpatient psych support (close follow-up) for patients of all ages that do NOT need admission for medical or ***   ​

General Surgery 

• Consult the surgery team if a patient has had a recent procedure, surgery, or was discharged from their service within 30 days and is returning to the ED for a related chief complaint. 

• General Surgery Pathways 

  • Appendicitis ​

  • Diverticular Disease 

  • Gallbladder 

  • GI Bleed (Critical) 

  • Hernia 

  • Pancreatitis 

  • SBO/Bowel Perforation 

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Trauma

• Trauma Activations 

  • MICN will activate field calls if trauma activation criteria is met ​

  • ED Attending should, when in doubt, activate pre-arrival (err on the side of activation) 

  • Trauma and ED senior need to make sure introductions are made when possible prior to major trauma arrival and tasks are assigned by trauma senior and understood by the team. 

  • If patient's conditions changes in the ED, activation should be made or upgraded as appropriate. Life threatening injuries should be activated as major traumas. 

  • If a patient does not meet activation but requires a work-up (CT scans) to investigate for traumatic injuries, when appropriate, the ED will expedite the care (e.g. bypass labs for CT if indicated, expedite CT, etc.) 

  • When appropriate, trauma activation can/should be used outside the protocol to facilitate expedites care as well (access additional nursing, lab, CT, and other resources). 

  • For medical arrests with associated signs/suspicion of trauma, trauma activation will occur (e.g. elderly fall with signs of significant bruising/trauma). 

  • For cardiac arrest in custody, if there is no clear medical indication (e.g. asthma, chest pain prior to arrest, ingestion), it should be activated as a trauma. If cause is unknown (found down), activate. 

  • Consult/minor trauma: place a consult and call trauma nurse (ext 18132) and ask for a minor trauma consult. See consult criteria. 

  • All trauma transfers out of our facility to be approved by a trauma service/attending. 

  • If patient meets criteria for stroke or RRT/sepsis, please activate in parallel to trauma activation/workup. 

• Airway 

  • ED senior will direct trauma airway management with ED attending supervising, present, and at the head of the bed. ​

  • ED senior will coordinate and make sure all necessary equipment is set-up and ready; can direct the RT on equipment needs. 

  • Airway requires continual re-assessment throughout the patient's stay (before, during, and after CT when appropriate). 

  • Difficult Airway Cart is located in the trauma bay. 

    • Airway divert: directing a trauma patient to a non-trauma center should only occur if the patient can NOT be ventilated or oxygenated. Low GCS alone is not an indication to route a non-trauma center. ​

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