Appendix K – Medicine/ENT/FACE/ED Inter-Service Agreement Medicine/ENT/FACE/ED Inter-Service Agreement (Effective September 2019) Admissions Patients with an ENT/FACE issue will be admitted to ENT/FACE, UNLESS the patient has one of the following medical conditions, in which case they will be admitted to a medical service: 1,2,3,4,5 1. 2. 3. 4. 5. 6. 7. 8.
9. 10. 11. 12. 13. 14. 15. 16. 17.
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 requirement (If these signs or symptoms are due to an upper airway obstruction then admit to ENT) Decompensated Heart Failure Uncontrolled arrhythmia or new arrhythmia with persistent/recurrent HR >110 DKA Severe valve disease EF <30% on most recent ECHO Sepsis or any complicated active infections (e.g. diverticulitis or pneumonia but not bronchitis or uncomplicated UTI) Infections of the Ear/Mastoid/Nose/Throat/Epiglottis with sepsis would be admitted to ENT with medicine or ID consult if needed. 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 bleeding (Except epistaxis alone would be admitted to ENT. Epistaxis due to hematologic disorder would be admitted to Heme.) Acute 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 nonoperatively Patients in need of vulnerable adult or elder abuse evaluation
Consults Surgical Co-Management Hospitalist/Nocturnist/Medicine Resident Consult Role 1.
If the SCM hospitalist is consulted on a patient admitted to the otolaryngology service, they will see the patient within 3 hours (if called STAT within 1 hour).
2.
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 otolaryngology resident on call, 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 then 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.
3.
1
Admitting medical service is dependent on active medical issues (e.g., decompensated heart failure to CCU/CSU instead of general medicine) and will be determined as per the ED Admissions Grid. 2
Patients with an active issue that is more appropriate for a non-ENT/FACE/medicine service will be admitted as per the ED Admission Grid (e.g., a patient with facial cellulitis, elevated creatinine, and acute appendicitis would go to general surgery). 3
Uncertainty regarding the appropriate primary admitting team should be resolved through a discussion between the otolaryngology/medicine admitting residents. If after discussion uncertainty persists, it should be resolved through an attending to attending discussion initiated by the service initially called by the ED for admission. (ED Decides on admit service; if a different service is felt to be more appropriate then a transfer to that service can be done per the workflow in this agreement after the admit order) 4
Patients with invasive fungal sinusitis will be admitted to the medicine service with otolaryngology consulting.
5
Patients requiring direct admission after an elective otolaryngology surgery or directly from otolaryngology clinic are subject to this agreement.
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