central division adult admission pathway active admission ...€¦ · bleeding, major surgery or...

Central Division Adult Admission Pathway

PATIENT REQUIRES THESE CONSULTS?

TraumaPCI

OB/GYNHepatobiliary

Thoracic SurgeryLevine Cancer Institute

Radiation Therapy Toxicology

NeurosurgeryHemePsych

Stable per criteria:

HR < 120 or > 50SBP < 220 or > 90

RR < 28O2 Sat > 90% unresponsive to

nasal cannula

N

Active

Inactive

V3 10/1/2018

1

CMC 3KSHORT STAY

MERCY

Y

N

Y

CMC MAIN

Admission Decision

N

• Non-ambulatory• SNF/ALF resident• Needs new post acute facility placement• AMS• More than a single acute condition

Y

Does not meet Mercy

pathways?

One of the listed CMC 3K SHORT STAY

DIAGNOSES

Stable per criteria:

HR < 130 or > 50SBP < 220 or > 90

RR < 32O2 Sat > 90% unresponsive to

nasal cannula

3K at capacity?

N

Y Y

YY

Psych patient?

Y

N

CMC to Mercy Admission Pathway

A-FIB WITH RVR

ICU PATHWAYS

DKA

COPD

Active

Inactive

V3 10/1/2018

2

Neuro Pathway (TIA)

MEDICAL PATHWAYS

Chest Pain Pathway

Ortho Pathway (Foot & Ankle)

SEPSIS

DECISION-MAKING TOOLS

• ICU requires acute transport

• FAMILY MEDICINE: Biddle Point & Elizabeth Family Medicine

• CHG bounce-back rule: Same CHG provider within the same week (Tuesday- Tuesday)

MERCY

MICU to MERCY ICU PATHWAY

CMC ED to CMC 3K Short Stay Admission Pathway Active

Inactive

V3 10/1/2018

3

Chest Pain Pathway

CMC 3KSHORT STAY

Acetaminophen overdose

Allergic reaction

Asthma Exacerbation

CHF

Hypertensive urgency

COPD exacerbation

DVT

Dehydration/ Vomiting/ Diarrhea

Interventional radiology/Procedures

Syncope

Transfusion of blood

products

Pneumonia

Pyelonephritis

Renal colic

TIA

HeadacheCellulitis

CMC to MERCY:Chest Pain Pathway

Heart Score 0-3 Heart Score 4-6 Heart Score ≥7

Discharge from ED + Troponin

N

Status: ActiveActivation Date: 10/10/16

V3 10/1/2018

4

Y

MERCY

CMC MAIN

• Troponin>5 to Sanger• Troponin<5 to CHG

Follow Heart Score

Neurological Symptoms resolved?

CMC to MERCY:Neuro Pathway (TIA)

Y

Y

N


CT of Head Negative?

Y

N

V3 10/1/2018

5

MERCY

CMC MAIN

Patient presents with:1. Foot/Angle Fragility Fx2. Periprosthetic Fx3. Fall from Standing

CMC to MERCY:Ortho Pathway

Consult Ortho at Main first to see patient to initiate

Mercy transferCMC MAIN

N


Y

V3 10/1/2018

6

Patient presents with:Diabetic Foot Infection

MERCY

Pathway Approval: Dr. Gary Little, Dr. Michael Johnson, Dr. Gena Walker, Dr. Geoffrey Murphy, Dr. Jessica Salzman

Stable per DKA Criteria:

BG ≥250mg/dL

pH ≥7

HCO3 ≥10

Anion Gap ≥15

Status: Active

Activation Date: 3/14/17

Request to transfer to Mercy

via PCL with appropriate

bed:

Regular, Med tele, or

Cardiac tele

Request ROUTINE Transport

DKA ICU Pathway

Accuchecks:

≤Q2h

Y

Patient on an

Insulin drip?

Y

Request to transfer to

Mercy ICU bed via PCL

Request ACUTE

Transport

Update PCL on

patient status or bed

changes

Accucheck

frequency:

TBD by admitting

provider

Repeat BG/POC labs

60 mins after

acceptance

N

Y

N

Resume standard

protocol for admission

to CMC

Stable VS per ICU criteria:

HR < 130 or > 50

SBP < 220 or > 90

RR < 32

O2 Sat > 90%

V3 10/1/2018

7

GCS > 13

MERCY

• EKG shows A-Fib with RVR• Hemodynamically Stable• Check: O2 sat

K+Mg+POC-Chem 8Troponin if anginal Sx

Prior to departure:(If appropriate for

patient)• Repeat POC labs

CMC to MERCY:A-Fib with RVR

Pathway (ICU or Floor)

Update PCL on


request changes

Rate control:(bolus/drip)

• Diltiazem • Metoprolol

Stable VS per criteria:

HR < 130 or > 50

SBP < 220 or > 90

RR < 32

O2 Sat > 90% (responsive to nasal cannula)

Y

N

V3 10/1/2018

8

Status: ActiveTarget Start Date: 6/17/2017

MERCY

CMC MAIN

Hospital admission criteria:

• Severe/acute increase in symptoms• Failure to respond to outpatient or ED therapy• Dyspnea on exertion• New edema/cyanosis• Comorbidity concerns• Poor home support

Prior to departure:(If appropriate for patient)

• Repeat necessary Labs• Complete RT treatments• ABX initiation• Steroids

• Mercy CHG to notify RT navigator at Mercy to activate inpatient COPD Power Plan


CMC to MERCY:COPD Pathway

(ICU)

Update PCL on


changes

Exclusion Criteria:

• HR>130• End tidal CO2>60 mm Hg• New onset AMS• Severe comorbidities:

• Ie: active chest pain, decompensated CHF, severe pneumonia

Y

N

V4 6/3/20199

MERCY

CMC MAIN

Prior to departure:(If appropriate for patient)• Repeat necessary Labs• ABX initiation• IVF

CMC to MERCY:Sepsis Pathway/ Infected

Admissions (ICU)

Update PCL on


changes

• Code Sepsis• Hypotension after

20 ml/kg IVF bolus• SBP < 90 mmHg

• MAP < 65 mmHg • Lactate > 4• New infection in the

hospital

Y

CBCLactate < 4CXRBld cx

2x 20gauge IV

CVC with CXR confirming placement

IV ABX within 1 hr. of admission

N

Y

Y

N


V3 10/1/2018

Stable VS per criteria:

HR < 120 or > 50

SBP < 220 or > 90

RR < 32

O2 Sat > 90% (responsive to nasal cannula)

MERCY

CMC MAIN

CMC 3K SHORT STAY:ACETAMINOPHEN

OVERDOSE

• Accidental Ingestion or therapeutic

misadventure

• Liver functions tests normal

• Consult Toxicology prior to admission

• Abnormal LFTs

• Hemodynamic instability

• Unable to tolerate PO

Y

N

11

Y

V3 10/1/2018

CMC 3KSHORT STAY

3K at capacity


CMC MAIN

CMC 3K SHORT STAY:Allergic reaction

• Response to therapy in the ED

• Erythroderma, urticaria, or

angioedema not involving airway

• Minimum 2-hours of stability or

improvement in ED after treatment

• Suspicion of acute coronary syndrome

• Stridor, respiratory distress,

hoarseness

• IV pressors required

Y

N

12

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Asthma Exacerbation

• Intermediate response to therapy - improving but still wheezing

• PEFR (peak flow) 40-70% predicted (or personal best) after Beta 2 agonists

• Minimum ED treatment time > 2 hours

• Chest X-ray with no acute findings (pneumonia, pneumothorax, CHF)

• h/o previous intubation for severe exacerbation

• Poor response to initial ED treatment: RR> 28, requiring > 4 l n/c oxygen

• PCO2> 50 and decreased pH on either venous or arterial blood gas

Y

N

13

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Cellulitis

• Serial exams needed to exclude rapidly progressive cellulitis

• Cellulitis which requires > 1 dose antibiotics

• Cellulitis with a drained abscess which requires a brief period of

observation and wound care

• Immunocompromised patient's

neutropenia, HIV, transplant patients,

ESRD/hemodialysis patients, patients

on immunosuppressants or

chemotherapy, post-splenectomy

patients.

• High risk infections diabetic foot

infections; infections proximate to a

prosthesis, percutaneous catheter or

indwelling device; infections of the

orbit or upper lip/nose, neck;

infections of >9% TBSA; extensive

tissue sloughing; suspicion of

osteomyelitis or deep wound infection

Y

N

14

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Chest Pain Pathway

Heart Score 0-3Heart Score 4-6

• initial POSITIVE trop with minimal elevation

Heart Score ≤6• Initial NEGATIVE trop

• Heart Score ≥7• Normal cardiac cath or coronary CTA (no stenosis) in

last 6 months

Discharge from ED

Y

15

Acute EKG changes• Acute comorbidities

(i.e.: PNA, new/rapid A-fib or AMS, etc.)

V3 10/1/2018

Follow Heart Score

CMC 3KSHORT STAY

CMC MAIN

N

MERCY3K at

capacity


CMC 3K SHORT STAY:CHF

• Previous history of CHF

• Likelihood of correction to baselinewithin 24hrs with home support

• Hospitalization/ED/urgent care visitfor HF within 30 days can admit toObs unit.

• New onset CHF

• Acute cardiac ischemia (EKG changes, positive cardiac markers, ongoing ischemic chest pain, unstable angina) or new arrhythmias

• Acute co-morbidities: sepsis, PNA, new murmur, AMS

• Abnormal labs (unless baseline) -Severe anemia (Hb<8), renal failure (BUN>40 or Cr>3), Na<129

• Evidence of poor perfusion (confusion, cool extremity, weakness, N/V)

Y

N

16

Y

V3 10/1/2018

MERCY

CMC 3KSHORT STAY

3K at capacity


CMC 3K SHORT STAY:COPD exacerbation

• Good response to initial therapy (decreased RR and improved oxygenation

since presentation to ED)

• No acute process on chest X-ray (required)

• No indication of impending respiratory fatigue (defined as altered mental

status, pH< 7.3, PCO2 >60 on venous blood gas)

• Acute co-morbidities - Pneumonia,

CHF, cardiac ischemia

• Acute confusion / lethargy, elevated

pCO2 > 60 on venous blood gas (if

drawn) and pH < 7.3

• Poor response to initial therapy O2 sat

< 85 on 2 L O2 or sats < 85 on baseline

home oxygen after 5 mg aerosolized

Albuterol

• Persistent use of accessory muscles,

RR>28 after initial treatment

• Estimated likelihood of discharge from

observation unit is less than 70% (

frequent hospitalizations > 3 in last 6

months , less than 30 days readmit)

Y

N

17

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:DVT

• No evidence of PE, confirmed DVT

• candidate for home Low Molecular Weight

Heparin/coumadin or NOACs (newer oral anticoagulants)

• Known hypercoagulable or

bleeding disorder

• High risk of bleeding

complications e.g. active GI

bleeding, major surgery or

trauma within 2wks, recent

intracranial bleed, recent

head injury / tumor / AVM)

• Clinical conditions

pregnancy, prosthetic heart

valve, CRF on HD, morbid

obesity (>150kg)

Y

N

18

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Dehydration/

Vomiting/ Diarrhea

• Self-limiting or treatable cause

• Hyperemesis Gravidarum (LESS THAN 20 WEEKS)

• Known hypercoagulable or

bleeding disorder

• High risk of bleeding

complications e.g. active GI

bleeding, major surgery or

trauma within 2wks, recent

intracranial bleed, recent

head injury / tumor / AVM)

• Clinical conditions

pregnancy, prosthetic heart

valve, CRF on HD, morbid

obesity (>150kg)

Y

N

19

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Headache

• Persistent pain in tension or

migraine headache

• Hx of migraine with same

aura, onset, location and

pattern

• Drug related headache

• No focal neurological signs

• Normal CT scan (if done)

• If LP is needed, then it must

be done and normal (unless

failed attempt and IR

consult for LP arranged in

ED BEFORE transfer to

short stay unit)

• Focal neurologic signs

• Meningismus

• Elevated intraocular

pressure as cause (i.e.

glaucoma)

• Abnormal CT scan (if done)

• Abnormal LP (if performed)

• Hypertensive emergency

(diastolic BP > 105 or SBP >

200 with symptoms)

• Suspected temporal

arteritis

• Blocked VP shunt

• Frequent ED visits,

suspected habitual patient,

narcotic seeking behavior

Y

N

20

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Hypertensive urgency

• No evidence of acute end-

organ injury

• SBP < 180 and DBP < 100

after initial treatment

• Normal mentation, normal

head CT (only if done)

• No acute ECG

abnormalities, normal chest

Xray, no acute nephropathy

(Cr > 2.5 or 2x greater than

baseline Cr )

• Evidence of end-organ

injury: acute renal failure,

hypertensive

encephalopathy,

intracranial hemorrhage,

papilledema, focal

neurologic abnormalities,

CVA, CHF, acute coronary

syndromes, aortic

dissection

• BP remains > SBP 180 or

DBP > 100 after initial ED

treatment

• EKG changes new

• Pregnancy

• Continuous infusion

required for control of BP

Y

N

21

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Interventional

radiology/Procedure

• Agreement from

INTERVENTIONAL

RADIOLOGIST that

procedure will be

performed in a timely

fashion (within 24 hours)

• Patient receives outpatient

procedure by IR and has

unexpected course in

recovery and needs

additional observation

services

• Need for Observation post procedure; services not

available for PACU overflow

Y

N

22

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Pneumonia

• History, exam, and CXR consistent with acute pneumonia

• CURB 65 SCORE = 0 or 1 (if calculated)

• O2 saturation >92 % on room air or with max of 4l O2

• Outpatient support and capable of managing pneumonia at home if discharged

• Initial dose of antibiotics given in the ED

• Significantly abnormal ABG if done

(pCO2>45, pH<7.35)

• Potential respiratory failure CURB score > 1

• Multi-lobar pneumonia

• poor candidate for outpatient therapy

• Immunocompromised patients: HIV, PCP

pneumonia, chemotherapy, chronic

corticosteroid use, active cancer, sickle cell

disease, asplenic patients.

• High risk patients: Nursing home patient,

cancer, cirrhosis, ESRD, altered mental

status, nosocomial etiology, aspiration risk

(ie. bulbar stroke)

• High suspicion of DVT/PE, SARS, H1N1, or

TB (HIV/AIDS, institutionalized, recent

prison, native of endemic region, history of

pulmonary TB, apical disease on CXR)

Y

N

23

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Pyelonephritis

• Clinical evidence of

pyelonephritis (flank pain,

urgency, frequency, dysuria)

• UA evidence of pyelonephritis

(significant pyuria, nitrates,

and/or leukocyte esterase)

• Not suitable for discharge from

the ED

• Urine cultures obtained

• Ability to take sips of liquids

• Male patients

• Pregnant females

• Significant comorbidities –

diabetes, renal failure, sickle

cell disease

• Immunosuppressed patients -

HIV, transplant patients,

chronic high dose steroids,

asplenic

• Urinary tract anatomic

abnormality (solitary kidney,

reflux, or indwelling device)

• Urethral or ureteral obstruction

(ie. kidney stones, urinary

retention)

• Poor candidate for outpatient

treatment of pyelonephritis (ie

poor home support)

Y

N

24

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Renal colic

• Diagnosis of renal colic

established by CT, IVP or

ultrasound

• Uncomplicated stone ( no

associated hydronephrosis or

acute renal failure)

• Persistent pain or vomiting

despite medication

• Urology resident notified

• Clinical evidence of a UTI

(fever > 101 F, wbc > 20,000, significant pyuria > 6 wbc on UA)

• Solitary kidney

• Relatively large proximal stone (>6 mm) with high grade

obstruction

• Acute renal failure

Y

N

25

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Syncope

• Minimum ED interventions: ECG, monitor, IV, labs

• No acute dyspnea or history of CHF

• No acute EKG changes, new bundle branch block, or significant

arrhythmias

• No new neurologic deficits

• Ambulatory

• High risk factors: syncope in supine position,

during exertion, with chest discomfort

• ECG: BB blocks {LBBB; RBBB+LAFB; RBBB+LPFB -

esp. with 1st degree heart block}; Prolonged QTc

(>500mS), new *ECG ST/T wave changes, Third

degee or Type 2 second degree Heart Block)

• Significant cardiac arrhythmias (v. tach, a fib,

bradycardia etc.)

• Serious cause suspected – ACS, PE, GI Bleed,

sepsis, AAA, IC bleed etc.

• History of CHF, major valvular disease, family

history of sudden death (<50)

• Significant injury (eg fracture, subdural).

Lacerations acceptable.

• Unsafe home environment

Y

N

26

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:Transfusion of blood

products

• Symptomatic anemia or

thrombocytopenia in a patient with

known etiology

• Deficiency correctable by transfusion

• Active bleeding present unless transfusing platelets for

thrombocytopenia and patient stable

• End stage renal failure, dialysis patients

• Hgb <5

• Unknown and unexpected causes of severe anemia (Hb < 5) or

severe thrombocytopenia (plts < 50,000)

Y

N

27

Y

V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


CMC 3K SHORT STAY:TIA

• Transient ischemic attack – resolved deficit, not crescendo

• Negative head CT

• Head CT imaging positive for bleed, mass, or acute infarction.

• Known extra-cranial embolic source – history of atrial fibrillation, cardiomyopathy,

artificial heart valve, endocarditis, known mural thrombus, patent foramen ovale, or

recent MI.

• Known carotid stenosis (>50%)

• Any persistent acute neurological deficit or crescendo TIAs

• Non-focal symptoms – ie confusion, weakness, seizure, transient global amnesia

• Hypertensive encephalopathy

• Severe headache or evidence of cranial arteritis

• Prior large stroke - making serial neurological examinations problematic

Y

N

28V3 10/1/2018

CMC 3KSHORT STAY

MERCY3K at

capacity


Transfer Admission Criteria

• Severe/acute increase in symptoms• Critically Stable • No further surgeries • Dyspnea on exertion• New edema/cyanosis• Comorbidity concerns• Poor home support• COPD• Sepsis


(MICU Transfer to Mercy)

• Continuous nebulizers• ≤6 L High Flow/NC• CXR• FiO2 <60% • PEEP <10• Dialysis • No further surgeries • Critically Stable • Therapy initiated

Update PCL on


changes

• Bi-pap• HR>130• End tidal CO2>60 mm Hg• New onset AMS• GCS < 15• Intubated

Y

N

29V3 10/1/2018

MERCY

CMC MAINY

Prior to departure:(If appropriate for patient)• Repeat necessary Labs• Complete RT treatments• ABX initiation• Steroids

CMC ICU to Mercy Admission Pathway


(MICU Transfer to Mercy)

30V3 10/1/2018

CMC ICU to Mercy Admission Pathway

Questions?

31

Please contact Patient flow navigators:

Ascom# 704-446-9797

Heena Nagarji, MSN, BS, RN, CNL

[email protected]

Valerie Short MSN, RN, CMSRN, CNL

Katisha Seward BSN, RN, CEN, SANE

V3 10/1/2018

mailto:[email protected]

central division adult admission pathway active admission ...€¦ · bleeding, major surgery or...

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