University Health Network
Policy & Procedure Manual Clinical – Consultation & Admissions from Emergency Department Policy University Health Network (UHN) has developed a referral process to ensure that patients with identified diagnoses or presenting problems in the Emergency Department (ED) are referred to the most appropriate service from which a consult may be obtained. (See Service Referral Guide.) This policy is meant to recognize the areas of expertise of each of the Services, but is not meant as a substitute for clinical judgment. It is therefore recognized that individual circumstances may alter consultation choice. This policy encompasses only those diagnoses in which expertise may overlap and subsequent disposition may be otherwise unclear unless stated a priori. Should a dispute arise between two or more Services regarding which Service is to admit a patient for ongoing investigation and/or care, the Staff consultants will be notified. When an inter-departmental policy for resolution does not apply, or when a dispute cannot be resolved, the Clinician on-call will determine the most responsible Service for admission (refer to Dispute Resolution Mechanism for Consults). In order to achieve and expedite optimal care to both undifferentiated and known patients who present with acute medical issues in the ED, and to minimize misunderstandings between referring and receiving physicians, referrals to the ED will be accompanied by proper verbal and written communication (see Referrals to the Emergency Department).
Service Referral Guide Diagnosis/Presenting Problem Ambulation (inability)
Modifying Factors
Service
All fractures impairing ambulation, operative or non-operative
Orthopedics
Osteoporotic vertebral compression fractures without direct neurologic sequelae
Internal Medicine
Vertebral compression fracture with cord compression
Neurosurgery
All other non fracture causes
Internal Medicine
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number Section Issued By Approved By
3.10.018 Professional Practice Service Chiefs; Medical Affairs Medical Advisory Committee; UHN Operations Committee; Senior Management Team
Original Date Revision Date(s) Review Date Page
08/91 07/99; 07/05; 09/08 1 of 22
Diagnosis/Presenting Problem
Modifying Factors
Service
Involving ascending aorta and arch (―Type A‖)
Cardiovascular Surgery
Distal to left subclavian artery (―Type B‖)
Vascular Surgery
Bowel Obstruction Operative and Nonoperative
Gyne-Oncology surgery within 3 months
Gyne-Onc
>3 months post-surgery under PMH care
Med Onc/Rad Onc
All others
General Surgery
Cellulitis/Gangrene
Lower limb requiring amputation
Orthopedics
Facial
Plastics
Oropharyngeal/laryngeal
ENT
Upper limb affected, or surgical intervention (excluding above) required
Plastics
Perineum involved
General Surgery
Proven or probable necrotizing fasciitis
Plastics
All others
Internal Medicine
Congenital Cardiology
Cardiology
ACS with ST elevation
Cardiology
ACS with raised troponin (0.3)
Cardiology
ACS with dynamic or persistent new ECG changes
Cardiology
ACS with hemodynamic instability
Cardiology
ACS with PCI within last year
Cardiology
ACS with negative troponin
Internal Medicine
Aortic Dissection
Chest Pain
Note: 1. 2. 3. 4.
Borderline raised troponin (0.2-0.3) in the absence of ECG changes, ongoing chest pain, hemodynamic instability does not mandate Cardiology referral. Borderline raised troponin (0.2-0.3) may be seen in pulmonary embolus and should be referred to MSICU or Internal Medicine as per Pulmonary Embolus guidelines below. Borderline raised troponin (0.2-0.3) may be seen in congestive heart failure (CHF) and should be referred to Cardiology or Internal Medicine as per Congestive Heart Failure guidelines. Raised troponin in terminally ill, DNR patients with other conditions in whom invasive cardiac intervention is not part of the anticipated continuing care of the patient, does not mandate Cardiology referral.
Choledocholithiasis
With sepsis (cholangitis) and/or obstructive jaundice
General Surgery
Congestive Heart Failure
Accompanied by ongoing chest pain
Cardiology
Accompanied by ventricular rhythm disturbance
Cardiology
Intubated
CCU (TGH) ICU (TWH)
Patient of Heart Failure Clinic UHN or MSH
Cardiology
Congenital Cardiology
Cardiology
All others
Internal Medicine
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number Section Issued By Approved By
3.10.018 Professional Practice Service Chiefs; Medical Affairs Medical Advisory Committee; UHN Operations Committee; Senior Management Team
Original Date Revision Date(s) Review Date Page
08/91 07/99; 07/05; 09/08 2 of 22
Diagnosis/Presenting Problem
Modifying Factors
Service
COPD/Asthma
Requiring ventilation or BiPAP
ICU
Patient of Resp Staff
Respirology
All others including pneumonia
Internal Medicine
Dental Trauma/Avulsion
———
Mount Sinai Hospital Oral & Maxillofacial Surgery (TGH & TWH – see Dental Trauma)
All Diverticulitis
———
General Surgery
Facial Fractures
(Includes mandibular fractures orbital fractures)
Plastics (TWH) or Otolaryngology (TGH) or Mount Sinai Hospital Oral & Maxillofacial Surgery (TGH & TWH – see Plastics)
Nasal fractures
Otolaryngology (TGH)
Maxilla/zygoma/mandibular fractures
Mount Sinai Hospital Oral & Maxillofacial Surgery (TGH & TWH – see Dental Trauma)
If GI patient (ongoing care, seen within the previous 12 months for related problem or diagnosis)
GI
All lower GI bleed & hemodyn. STABLE
General Surgery
Upper GI bleed and hemodyn. STABLE
Internal Medicine
All GI bleeds – Upper or lower and hemodynamically UNSTABLE
Admit to ICU with GI and/or General Surgery consultation at the discretion of the admitting physician
If GI patient (ongoing care, seen within the previous 12 months)
GI
If on liver transplant list
Transplant
All others
Internal Medicine
If patient in TGH home parenteral nutrition program
GI
GI Bleed
Hepatitis/Liver Failure
Home Parenteral Nutrition
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number Section Issued By Approved By
3.10.018 Professional Practice Service Chiefs; Medical Affairs Medical Advisory Committee; UHN Operations Committee; Senior Management Team
Original Date Revision Date(s) Review Date Page
08/91 07/99; 07/05; 09/08 3 of 22
Diagnosis/Presenting Problem
Modifying Factors
Service
Hypertensive Crisis
Requiring IV antihypertensive therapy
ICU
All others
Internal Medicine
IBD
GI
Ischemic Limb
———
Vascular Surgery
Ischemic Colitis
———
General Surgery
Medical/Radiation Oncology Problem with complication of cancer or cancer treatment
Current PMH patients
Appropriate PMH services
Surgical Oncology Patient with complication of cancer or cancer treatment
Appropriate surgical service
Medical/Radiation Oncology with complication of cancer or cancer treatment
Not PMH patient, not needing immediate med/rad onc assessment or treatment
Internal Medicine
Pancreatitis
ETOH causes
Internal Medicine
All other causes
General Surgery
Organic cause requiring ongoing medical treatment
Internal Medicine
Exacerbation of chronic psychiatric condition and no complicating organic causes identified
Psychiatry
No organic cause identified, no previous history
Psychiatry
Pneumonia
Not discharged within last 14 days from a non-GIM service
Internal Medicine
Pulmonary Embolus
If hemodynamically unstable or intubated
ICU
Stable but requires admissions
Internal Medicine
Obstructing ureteric stone or GU procedure within last 14 days
Urology
All others requiring admission
Internal Medicine
Known to Dialysis Service
Refer to Admissions for Dialysis Patients
New onset, urgent dialysis required
Nephrology
New onset, obstructive requiring percutaneous or surgical intervention
Urology
New onset, urgent dialysis not required
Internal Medicine
Chronic pain (e.g., Chronic low back pain)
Outpatient family doctor for referral to appropriate consultant
Psychosis
Pyelonephritis
Renal Failure, Acute
SPINAL PAIN
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number Section Issued By Approved By
3.10.018 Professional Practice Service Chiefs; Medical Affairs Medical Advisory Committee; UHN Operations Committee; Senior Management Team
Original Date Revision Date(s) Review Date Page
08/91 07/99; 07/05; 09/08 4 of 22
Diagnosis/Presenting Problem
Stroke/Cerebral Hemorrhage
Syncope
Transplant Patient Trauma
Modifying Factors
Service
Cord compression (unless known PMH patient with metastatic disease), epidural hematoma/abscess
Neurosurgery
Cerebellar, subdural/epidural and subarachnoid hemorrhage
Neurosurgery
Intracranial hemorrhage/brain stem hemorrhage
Neurology
Ischemic and < 3 hrs
Refer to Stroke Protocol
Transient Ischemic Attack (TIA) and all others
Refer to TIA/Minor Stroke Protocol
Documented Ventricular Arrhythmia or patient of Congenital Cardiology or Heart Failure Clinic
Cardiology
All others
Internal Medicine
During day
Organ-specific Transplant
After hours
Transplant on-call
Thoracic injury (penetrating, blunt) requiring surgical consult
Thoracic Surgery (TGH) General Surgery (TWH)
Abdominal injury (penetrating, blunt) requiring surgical consult
General Surgery (TGH & TWH)
Extremity fracture requiring surgical consult
Orthopedics
Pelvic fracture (unstable)
Orthopedics
Facial Fracture requiring surgical consults
Plastics
Vascular injury
Vascular Surgery
Intracranial Hemorrhage, subdural/ epidural/subarachnoid Hemorrhage
Neurosurgery
Vertebral Fracture: Unstable Cervical Neurological compromise
Neurosurgery or Spine Service
Hemodynamic instability (ongoing despite initial resuscitative measures, or immediately depending on ED Physician judgment).
ICU
Occasionally, a trauma patient who would best be served by a designated trauma site (i.e., Sunnybrook or St. Michael’s Hospital) may be inappropriately triaged by EMS to a UHN Emergency site. Although every effort will be made by the ED staff to stabilize and transfer such patients to the appropriate trauma centre, this may not always be possible for several reasons: The patient is hemodynamically unstable. The trauma centre is unwilling/unable to accept patient. The trauma patient has presented via his/her own means and will require urgent/emergent care (e.g., stabbing or GSW victim in close proximity to ED site). In such cases, the Emergency Department physician will initiate resuscitative measures, and the relevant Services will be consulted (as per above). This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number Section Issued By Approved By
3.10.018 Professional Practice Service Chiefs; Medical Affairs Medical Advisory Committee; UHN Operations Committee; Senior Management Team
Original Date Revision Date(s) Review Date Page
08/91 07/99; 07/05; 09/08 5 of 22
Diagnosis/Presenting Problem
Modifying Factors
Service
Discharge within last 14 days
Excluding acute critical illness requiring immediate alternative subspecialty management (e.g., MI, stroke, appendicitis)
Previous services
Osteomyelitis
Post-operative
Service involved
Osteomyelitis
Sepsis
Internal Medicine or MSICU
Osteomyelitis
All others
Orthopedics
Responsibilities of Consultants The Staff physician will have consultation with one or more appropriate members of the medical staff: when requested by the patient or family when required by statute when requested by departmental chief or delegate in each case in which the policy of a specific clinical department states that a consultation will be obtained The Staff physician has a responsibility to request a consultation in situations where a patient fails to progress as expected. Consultation will be provided by other services when requested by the appropriate resident or delegate of the Staff physician responsible for the patient. Consultants scheduled for on-call duty must be available for timely consultation to all sites and the Emergency Department. The Staff Physician or delegate will initiate consultation by contacting the appropriate service directly. The Staff Physician or delegate should record in the patient’s chart that a request for consultation has been made. See Consultation Form (form 2154). The consultant on-call will, on all but rare circumstances, travel to the Hospital site requesting consultation. The consultation may be provided by the appropriate Fellow/Resident on-call, or on-site Fellow/Resident on-call. Although consideration will be given for deferring immediate consult requests for stable patients during early morning hours (4 am to 8 am) or when the consultant is engaged in other clinical duties, such consideration will be waived during times of Emergency Department overcrowding. During these times, consultation will be provided promptly regardless of time of day or a service’s bed capacity.
This material has been prepared solely for use at University Health Network (UHN). UHN accepts no responsibility for use of this material by any person or organization not associated with UHN. No part of this document may be reproduced in any form for publication without permission of UHN. A printed copy of this document may not reflect the current, electronic version on the UHN Intranet.
Policy Number Section Issued By Approved By
3.10.018 Professional Practice Service Chiefs; Medical Affairs Medical Advisory Committee; UHN Operations Committee; Senior Management Team
Original Date Revision Date(s) Review Date Page
08/91 07/99; 07/05; 09/08 6 of 22
Patients referred to site-specific services may be transferred between sites for the purpose of consultation. In those circumstances where transfer is necessary, the referring physician should speak directly with the staff consultant or the appropriate oncall resident (depending on service preference). Although the on-call resident may discuss and clarify the reasons for the consult request with the referring physician, all requests for consults will be honoured without exception.
Expected Response Times Expected response times for consultation in the Emergency Department (ED) will be: To answer page for: a. b.
STAT page (designated by ―99‖ prior to extension):
