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Admitting

Page history last edited by Mary Lacy 5 months, 2 weeks ago


ADMITTING

  • Please submit a bed request form ASAP as soon as you know a patient's desired level of care.  Don't wait to write orders to submit your bed request as this will delay the flow of patients out of the ER.
  • The ED is expected to have established:
    • that the patient needs to be admitted 
    • that IM is the appropriate service (ie the pt is not FP & not surgical, ect)
    • the appropriate level of care (MICU, step down, floor)
    • that the labs and imaging necessary to determine the above have been completed
    • that initial stabilizing interventions are done (abx started, BIPAP initiated, etc.)

 

 

 

 

 

Notify the oncoming attending by phone for the next call team in the cycle if they have any overflow.

Notify the Gold attending by phone if both teams are capped and you are giving them overflow.

 

 

 

General Rules 

  • For overflow, the day call resident should do the H&P, admit orders & pass the patients off to the appropriate attending and resident in the overflow cycle. 
  • Patients who have not been seen get passed off to Silver Medicine on weekdays, and the Day call resident on Weekends  

 

 

BOUNCE-BACKS

  • Bounce-backs follow all residents (R1, R2, R3), externs, and Sub-Is for 14 days after discharge.  If any one of these people was on service on the day of discharge and is still on service, regardless of who writes notes or "knew" the patient, the patient bounces.  Bounces do not follow Phase II medical students or attendings on teaching teams. 
  • For heavy metals, the patient "bounces-back" to the discharging APP or attending (provider, not team) if the patient is re-admitted within 14 days after discharge and that APP/attending is currently on any metal service.
  • New admissions that happen to also be bounce-backs are admitted by the on call team like any other admission, and this is irrespective of the source of the patient (ER, clinic, direct admit, etc).  If the team that is receiving the bounce is up for admissions on that day in the call cycle, this should be done as one of their admissions if the receiving team chooses. If the patient has already received other admissions (i.e. gray admissions), then those stay on their team and are not redistributed due to a bounce-back. However, if a team learns about a bounce and gray patients at the same time, then the "unknown" patient should be redistributed to allow them to take the bounce-back without super cap. The team that will receive the bounce-back is not responsible for this patient's care until the patient has been fully worked up, stabilized, H&P completed, staffed, and after the end of the on admitting residents on-call period (i.e. triage at 5pm, long-call team at 7pm, etc).  A verbal communication between the admitting service and the bounce-back team should be performed to convey any pertinent items related to the patient's clinical situation. 
  • If a bouncing patient SUPER CAPS a team (i.e. >16pts), the attending should be direct call and manager for any patients >16 on the team (does not have to be the bounce patient). Team touch counts should not include the patient the attending is managing.
  • Examples (times in the below examples have been arbitrarily chosen and have no bearing on practice):
    • A patient who should bounce is received through Triage/Gray at 4pm from the ER and is staffed with the Long Call attending at 5pm.  The day call team provides cross coverage and care for the bounce overnight and until the bounce recipient team accepts the patient at 7am the following day.
    • A patient who should bounce is received through Triage/Gray at 3pm from the ER and is admitted/staffed by the Triage resident and the Long Call attending.  The Triage resident provides cross coverage and care for patient until their handoff at 5pm and the bounce recipient team accepts the patient at 5pm and completes signout.
    • A patient who should bounce is seen in rheumatology clinic at 10am.  The rheumatology fellow calls the day call team at 10:30am to request admission.  The patient is 1) admitted by Triage resident to pre-Call or Long Call team or (2) admitted by Post-Call or Post-Post Call team themselves during the 1100-1500 admission period.
    • A patient who should bounce is seen in the ER. The ER resident calls night float for admission at 6am.  Night float is unable to evaluate the patient before rounds and passes the patient off to the Triage team.  The Triage team should admit the patient that morning to the bounce recipient team. The recipient team should resume patient care at 11. This patient counts as a touch but not a team admission.
    • A patient who should bounce is seen in the ER and is admitted by night float at 1am.  Night float admits the patient to the bounce recipient team's service, and the patient is staffed with the bounce recipient's attending at 8:30am that morning (i.e. 7.5 hours later).

 

TRANSFERS

  • Transfers out of the MICU before 3pm bounce according to the above criteria.  If the receiving team is capped or post night call, the bounce depends on the receiving team’s attending.  The patient will go to the original team the next day regardless of team cap. 
  • Transfers from Cardiology, Hematology, and Family Practice are taken by the MICU/Overflow Team. 
  • Transfers from other services should be discussed attending to attending and not accepted by the resident.  Transfers should not occur in the middle of the night.
  • The exception to "other services" is MICU; if the MICU needs a bed, please accept a patient transfer if that patient is medically appropriate for step down or floor level of care
  • Detailed information on transfers, transfer flow, and MOT responsibilities can be found here.   

UNM Wards Handbook

 

Comments (2)

Kendall Rogers said

at 2:39 pm on Jan 26, 2010

Jay/Dana: 2 Areas to Clarify that were brought up today (delete this comment when it has been explained above):
Scenario 1: night call resident does a consult on a patient and at the end it is decided the patient needs to be transfered to a medicine service - which team should take the patient, night call resident or the day call? I think this should go to night call, they have done the work and it will count towards their cap for that night. If we do make it day call, then they are split between ER and upstairs. I think all requests for transfer should be seen by night call resident as a consult to decide how the patient will be best treated, this should not matter to the team as the work will be the same if the patient is followed as a consult each day or as a patient on the team.
Scenario 2: PALS transfer arrives before noon - Gold Medicine or day call team. I do not know what to do here, should we consider it similar to a MICU transfer? The gold team is in ER doing triage so maybe difficult to split between the two areas, but we should discuss and decide this as well.

dkdavis@salud.unm.edu said

at 2:28 pm on Jan 27, 2010

Consults in the ER vs floor.
Consults in the ER should be done by Night Float and admitted to the night call team if admission is warranted.
Consults on the floor are supposed to be seen by OCD. If it seems that transfer of service is needed I would prefer that OCD manage them for the night and then they are transferred to one of the day teams (Day call would seem most appropriate).
PALS transfers before noon should go to the day call team.

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