APPENDIX K – MEDICINE/ENT/FACE/ED INTER-SERVICE AGREEMENT

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. Acute chest pain or EKG/enzyme evidence of ischemia (including troponin above upper limit of normal) 2. 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) 3. Decompensated Heart Failure 4. Uncontrolled arrhythmia or new arrhythmia with persistent/recurrent HR >110 5. DKA 6. Severe valve disease 7. EF <30% on most recent ECHO 8. 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. 9. Acute kidney injury 10. Persistent/Recurrent systolic BP >180 or diastolic >100 11. Persistent/Recurrent systolic BP < 90 despite appropriate fluid challenge (ICU consult recommended) 12. Any signs of active internal bleeding (Except epistaxis alone would be admitted to ENT. Epistaxis due to hematologic disorder would be admitted to Heme.) 13. Acute alcohol intoxication with significant behavioral disturbance or acute alcohol withdrawal 14. Decompensated liver disease including any of: hepatic encephalopathy, INR >1.7, new onset jaundice 15. Focal central neurologic changes including stroke and TIA (admit to neurology) 16. Patients currently on hospice or requiring comfort care who will be managed nonoperatively 17. 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). 3. 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.

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.

4. For non-emergent medical issues that develop overnight (5pm – 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). 5. For non-emergent after hours (5pm – 7 am) consults on patients not followed by the SCM hospitalist, the otolaryngology resident should contact the on-call medicine consult resident (p27111) who then staffs the consult with the on-call SCM hospitalist. 6. For emergent medical issues, the ICU fellow should be contacted directly.

Otolaryngology Consult Role 1. If otolaryngology is consulted on a patient admitted to a medical service, they will see the patient within that day (if called STAT for an airway, they will be seen immediately). 2. Otolaryngology consults will write daily notes and will write recommendations pertaining to evaluation of the chief concern, anesthesia evaluation, OR scheduling, NPO status, equipment orders, PT/OT, perioperative antibiotics, wound care, and activity level.

Transfer Requests

From Otolaryngology to a Medical Service 1. Patients on the otolaryngology service should be considered for transfer to a medical service if: i. Any of the above criteria used to determine appropriate admission service develop. ii. Other active medical issues that supersede active otolaryngology issues that cannot be reasonably/safely managed by the SCM Hospitalist/Nocturnist develop. 2. For non-urgent transfer requests, the decision to request transfer should be discussed with the consulted SCM hospitalist prior to the request. 3. 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 Otolaryngology 1. Patients whose medical issues are stable should be considered for transfer to the otolaryngology service in the postoperative period. 2. Patients originally admitted to the otolaryngology service, who were transferred to a medical service for an active medical issue, should be considered for transfer back to the otolaryngology service after stabilization of the medical issue. 3. Patients transferring from the medicine service to the otolaryngology service are expected to be verbally signed out to the SCM hospitalist at the time of transfer. 4. For patients transferred from the ICU overnight, the nocturnist (N1; p12012) should be contacted to physically see the patient and determine stability for transfer to otolaryngology.

Emergency Department Role 1. The Emergency department (ED) will page the appropriate admission service based on the above criteria. 2. The ED will not determine the appropriate admission service until an adequate workup is obtained to assess for the above criteria. 3. The service initially paged by the ED is responsible for admitting the patient if the above process has been followed

C. Kwang Sung, MD Program Director, Otolaryngology Sam Shen, MD Medical Director, Adult Emergency Medicine Neera Ahuja, MD Medical Director, General Inpatient Medicine