Harbor:ED follow-up options: Difference between revisions
 
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<big>'''''REFER TO
* Outpatient Follow up is based on patient’s insurance network
*[[:File:AED followup flowchart 8-23-21.pdf]]
* '''Out of Plan (OOP)''', means the patient has Non-DHS insurance network, Private insurance, Other Medi-Cal HMOs, or could be out of County/Country.  
*[[:File:PED followup flowchart 8-23-21.pdf]] '''''</big>
*Outpatient Follow up is based on patient’s insurance network
*'''Out of Plan (OOP)''', means the patient has Non-DHS insurance network, Private insurance, Other Medi-Cal HMOs, or could be out of County/Country.  
* '''DHS''' means LA County Department of Health Services network eligible
* '''DHS''' means LA County Department of Health Services network eligible
* '''MHLA''', MyHealthLA, are > 18yo, “uninsurable,” community clinic PCP that can e-consult to get subspecialty & inpatient care through DHS
*'''Patient Relations Representatives (PRR)''' in ED 7 days a week;
 
** Call Registration for PRR who can help empanel into DHS or change empanelment/network in real time.  For any questions, send the patient to Window 6 in the AWR.
===[[Same/Next Day Specialty Clinic Follow up]]===
* [[:File:AED followup flowchart 8-23-21.pdf]] - note:  using DC to specialty order, not clerk scheduling
*Sending or discharging directly to specialty clinic
* [[:File:PED followup flowchart 8-23-21.pdf]] - note:  using DC to specialty order, not clerk scheduling


===RESULTS/SYMPTOM FOLLOW-UP===
===RESULTS/SYMPTOM FOLLOW-UP===
*OOP, MHLA, DHS can all have phone follow up for results (labs or imaging), symptoms checks
*OOP, MHLA, DHS can all have phone follow up for results (labs or imaging), symptoms checks
*[[Adults results/symptom phone follow up]]
*[[Adults results/symptom phone follow up]] (Lab Follow-up - HAR)
*[[Peds results/symptom phone follow up]]
*[[Peds results/symptom phone follow up]] (Peds - HAR/USC)
*Follow-up of outpatient labs/imaging
**Any imaging/labs requested by a consultant in the ED that will NOT be resulted during the patient's stay in the ED should be ordered by the consultant making the request.
**Follow-up of outpatient tests can be either performed by the consultant OR by the CCC
 
===[[Same/Next Day Specialty Clinic Follow up]]===
* Sending or discharging directly to specialty clinic
* ED Extension Appointments
* Please utilize the [https://lacounty.sharepoint.com/:w:/s/medicineoutpatientspecialtycare/ESLCad7IJDxCjklxFLNfWwIBUJUwhIar7dLm90WEL1Q-dQ?CID=0533F57A-1097-40F3-B225-6179CAD98347&wdLOR=c0DBF4B05-F1CA-4BAD-9ABB-0D52156AED09 ED to Specialty Clinic Referral Guidelines]


===[[OOP follow up options]]===
===[[CCC]]===
*Bridges DHS eligible patients to primary care until empaneled
*Refer all DHS patients with substance use disorder (SUD) started on medication assisted treatment (MAT) to CCC for enrollment in Dr. Brown's addiction clinic


===DHS eligible patients===
===DHS eligible patients===
*[[DHS-Eligible patient needing Primary Care]]
*[[DHS-Eligible patient needing Primary Care]]


===[[Urgent Specialty Follow-up for DHS or MHLA Patients]]===
===[[OOP follow up options]]===
*Within 2 weeks or less


===[[Direct book without consultant discussion]]===
===[[Urgent Specialty Follow-up for DHS]]===
* Within 4 weeks or less
* Place the "ED Request for Specialty Appointment" order (7/23/2023)
** If no approval is needed per the ED to Specialty Clinic Referral Guidance document, write your name (ordering provider) in the approving provider field.
** When specialty approval is required per the document, place the approving specialty provider’s name in the field. 
* After a conversation with a consulting specialist, their specific recommendation supersedes any timeframe listed in the ED to Specialty Clinic Referral Guidance document.
 
===[[Pediatrics CCS Follow up]]===
 
===[[Harbor:Opiate Withdrawal/MAT/BUP|MAT/BUP/Opiate Withdrawal]]===


===[[NERF]]===
===[[NERF]]===
* This periodically changes, but there is currently limited space with the exception of Geriatrics, HIV, and OB care


===[[Patient wants to switch to Harbor]]===
===[[Patient wants to switch to Harbor]]===


===[[Instructions for clerk requesting/booking an appointment]]===
====DHS Patients Lost to Follow-up====
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange for routine follow-up for the patient:


===[[Pediatrics CCS Follow up]]===
** HAR-OP-Anesthesiology: Pain Management-Clerical
** HAR-OP-Cardiology: Anticoagulation-Clerical
** HAR-OP-Cardiology: General Cardiology-Clerical
** HAR-OP-Cardiology: HFDMP-Clerical
** HAR-OP-Cardiology: Pulmonary Hypertension-Clerical
** HAR-OP-Dermatology-Clerical
** HAR-OP-Endocrine: Diabetes-Clerical
** HAR-OP-Endocrine: General-Clerical
** HAR-OP-Endocrine: Pituitary-Clerical
** HAR-OP-Endocrine: Thyroid-Clerical
** HAR-OP-Endocrinology: Diabetes Specialty-Clerical
** HAR-OP-Endocrinology: General Endocrinology-Clerical
** HAR-OP-Gastroenterology-Clerical
** HAR-OP-Hematology/Oncology-Clerical
** HAR-OP-Infectious Disease-Clerical
** HAR-OP-Neurology-Clerical
** HAR-OP-OB/Gyn: Gyn Oncology-Clerical
** HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical
** HAR-OP-OB/Gyn: Reproductive Endo/Infertility-Clerical
** HAR-OP-OB/Gyn: UroGyn-Clerical
** HAR-OP-OB/Gyn: Women's Health-Clerical
** HAR-OP-Pulmonology-Clerical
** HAR-OP-Renal: General Nephrology-Clerical
** HAR-OP-Renal: Renal Hypertension-Clerical
** HAR-OP-Renal: Renal Transplant - Clerical
** HAR-OP-Rheumatology-Clerical
** HAR-OP-Surgery: Bariatric Surgery-Clerical
** HAR-OP-Surgery: Breast Surgery-Clerical
** HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
** HAR-OP-Surgery: Colorectal Surgery-Clerical
** HAR-OP-Surgery: Dentistry-Clerical
** HAR-OP-Surgery: Neurosurgery-Clerical
** HAR-OP-Surgery: Ophthalmology-Clerical
** HAR-OP-Surgery: Oral and Maxillofacial Surgery-Clerical
** HAR-OP-Surgery: Orthopedic Surgery-Clerical
** HAR-OP-Surgery: Otolaryngology-Clerical
** HAR-OP-Surgery: Plastic Surgery-Clerical
** HAR-OP-Surgery: Surgical Oncology-Clerical
** HAR-OP-Surgery: Trauma Surgery-Clerical
** HAR-OP-Surgery: Urology-Clerical
** HAR-OP-Surgery: Vascular Surgery-Clerical
 
 
** HAR-OP-Pediatrics: Allergy/Asthma-Clerical
** HAR-OP-Pediatrics : Cardiology - Clerical
** HAR-OP-Pediatrics : Child Development - Clerical
** HAR-OP-Pediatrics : Craniofacial - Clerical
** HAR-OP-Pediatrics : Diabetes - Clerical
** HAR-OP-Pediatrics : Endocrinology - Clerical
** HAR-OP-Pediatrics : Failure to Thrive - Clerical
** HAR-OP-Pediatrics : Gastroenterology - Clerical
** HAR-OP-Pediatrics : Hematology - Clerical
** HAR-OP-Pediatrics : High Risk Infant - Clerical
** HAR-OP-Pediatrics : Immunology - Clerical
** HAR-OP-Pediatrics : Infectious Disease - Clerical
** HAR-OP-Pediatrics : Medical Genetics - Clerical
** HAR-OP-Pediatrics : Nephrology - Clerical
** HAR-OP-Pediatrics : Neurology - Clerical
** HAR-OP-Pediatrics : Nursery - Clerical
** HAR-OP-Pediatrics : Oncology - Clerical
** HAR-OP-Pediatrics : Rheumatology - Clerical
** HAR-OP-Pediatrics : Surgery - Clerical


===[[CCC]]===
=== Clinics not included in ED to Specialty Care Order (2023)===
*Bridges DHS eligible patients to primary care until empaneled (still need to NERF)
* [https://lacounty.sharepoint.com/:w:/s/medicineoutpatientspecialtycare/ESLCad7IJDxCjklxFLNfWwIB1hRf_HGr2t2n8u6MvqNHfw?e=4%3AFvJCKk&fromShare=true ED to Specialty Clinic Referral Guidelines]
*Refer all DHS patients with substance use disorder (SUD) started on medication assisted treatment (MAT) to CCC for enrollment in Dr. Brown's addiction clinic


===[[Harbor:Opiate Withdrawal/MAT/BUP|MAT/BUP/Opiate Withdrawal]]===
====BURN CENTER CLINIC====
* For DHS eligible patients that need Burn Center follow up at LAC+USC, please call over 24/7 to their Burn Unit Front Desk 323-409-7991 to get an appointment w/in 2-5d depending on your assessment of their acuity.
** Inform the clerk there that you’d like to book a patient into the Burn Eval and Treatment area, which is in 5D in the Inpatient Tower (NOT their A5D Clinic).
** Patients can also call if they have questions about their appointment logistics or want to change their appointment time.
** This is NOT a transfer, so you should NOT call MAC to make an appointment 
* For OOP patients, they can go to Torrance Memorial


===[[Harbor:ED follow-up options|Follow up]] In Other Clinics===
=====[[Stress Testing]]=====
<big>'''For DHS eligible patients only: Clerk will book into appointment slot, or if unable, will place a request into the scheduling queue for Patient Access Center/Call Center to take over. Patients can also call PAC to schedule appointments (Rather than calling the clinic directly)'''</big>
====Anticoagulation (Coumadin) Clinic====
*Book without consultant approval
* Book at 7d post initiation of anticoagulation
*M-F 8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, S- Sun 8am-8pm Pager 9995


====Breast Diagnostic Center (Radiology)====
*Follow the breast abscess or breast mass pathways below.
*BDC is a Radiology Imaging Center for mammograms and ultrasounds. NOT the same as Breast Surgery Clinic
**Breast Abscess - needing ultrasound guided needle aspiration as per https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis
**Breast Mass - need imaging and biopsy of mass/malignancy as per  https://www.wikem.org/wiki/Harbor:Admission_and_consultation_guidelines#Breast_mass.2Fmalignancy


====Breast Surgery Clinic====
*needs e-Consult via PCP
*If patient does not have PCP, consider CCC (if patient qualifies) to start eConsult process
**If urgent needs follow up <2 weeks for DHS patient, consider consult to breast surgery resident (through Trauma surgery) from the ED
*'''Only for Breast Abscess in DHS patients s/p bedside I&D, recurrent breast abscess/mastitis''', as per https://www.wikem.org/wiki/Template:Harbor_Admission_Guidelines#Breast_abscess.2Fmastitis
*'''Only for Breast Mass in DHS patient with imaging and tissue biopsy results already done''' https://www.wikem.org/wiki/Harbor:Operations_manual#Breast_mass.2Fmalignancy
** Otherwise, they need referral to the Breast Diagnostic Center (BDC) first
** Not for patients with metastatic disease, must see medical oncology first - consult in ED before discharge for an urgent appt


====CARDIOLOGY====
====Gyn UCC====
*Daytime: Talk to CORE during the day, Afterhours: Talk to C-team Night fellow (listed on MedHub)
* Book without consultant approval
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up. (Cards will message Mariedel Morales and Sheila Walters IC, the Cardiology clerks, to book).
* '''3-4d f/up for ALL DHS PID patients''' (cervical motion tenderness or adnexal tenderness, empirically treated)
* For ZioPatch (holter monitor) - message empaneled PCP or CCC for cardiology
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical


=====Stress Testing=====
====Interventional Radiology====
* OOP - refer back to in-network PCP for cardio workup
[[Harbor:Urgent_Outpatient_IR|Urgent Outpatient IR]]
* '''DHS empaneled''' - message PCP for further cardio workup or schedule for stress test
** 1 - '''Ensure patient is ambulatory''' (walk 2 blocks); if not able to complete a treadmill stress test, consult cardiology to determine best option
** 2 - Send COVID test  via "'''AMB Coronavirus Covid-19'''" order
*** Select "nasopharyngeal" then modify order
**** Change order for '''future visit to "no"'''
**** Change '''collection priority to "STAT"'''
*** If the stress test appointment is more than a week in advance, DHS patients can be tested at N26 (the COVID test has to be resulted within 3-7 business days of the procedure)
****  Modify to: "future order";  "RN collect"; "anterior nares"
**** Call x67786 (N-26) with any questions about the COVID testing procedure
** 3 - Place order for "CV Treadmill Stress Test"
*** Reason for procedure "Chest Pain"
*** '''Special Instructions "Schedule in 3-4 business days"'''
** 4 - In DEPART section, click '''"Schedule Follow-up Appointment"''' so clerk makes appointment prior to patient DC
*** If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss
**** 1 - COVID symptoms
***** If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
***** If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
**** 2 - Cardiac Symptoms
***** The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
****** If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
****** If deemed low-risk, stress testing will be deferred to the PCP for follow up


* '''DHS Eligible without assigned PCP'''
====Limb Salvage====
** 1 - '''Ensure patient is ambulatory'''(walk 2 blocks); if not able to complete a treadmill stress test, consult cardiology to determine best option
* Opting out of automatic 30-day automatic f/up consult
** 2 - Send COVID test  via "'''AMB Pre-surgical/Procedure Coronavirus COVID-19 Screening'''" order
*** Select "nasopharyngeal" then modify order
**** Change order for '''future visit to "no"'''
**** Change '''collection priority to "STAT"'''
** 3 - Place order for "CV Treadmill Stress Test"
*** Reason for procedure "Chest Pain"
*** '''Special Instructions "Schedule in 3-4 business days"'''
** 4 - In DEPART section
*** '''***CCC for NERF***''' (get a PCP assigned)
*** Click '''"Schedule Follow-up Appointment"''' so clerk makes appointment prior to patient DC
** If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss
*** 1 - COVID symptoms
**** If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
**** If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
*** 2 - Cardiac Symptoms
**** The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
***** If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
***** If deemed low-risk, stress testing will be deferred to CCC for follow up


Drs. Chappell, Shah, & Pillutla 8/19/2020
* '''Weekdays 7a - 5p'''
** If the patient seems stable for outpatient follow-up:
*** Page limb salvage p0847
*** After discussion with on-call resident/NP, initiate a TEAMS Chat with:  ED attending, ED resident, LS on-call res/NP, LS on-call Attending and send a picture of the involved foot
*** The limb salvage team may respond with appropriate outpatient f/up timeframe or may notify you they will come see the patient in the ED if they feel it is necessary


====DERM====
* '''Afterhours''' (5p - 7a weekdays, weekends, holidays)
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
** '''Consult trauma if the patient needs surgical evaluation''';  trauma will liaise with limb salvage attending
====ENT====
*** '''Do NOT consult surgery for appointment'''
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
** '''For appointment only''', can directly contact limb salvage '''OR''' defer to PCP for e-consult to podiatry (at MLK) if appropriate (several weeks to f/up)
====Expedited Work-up Clinic (EWC)====
*** Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*The Expedited Workup Clinic (EWC) is an option for patients who are stable but require close outpatient follow-up for further diagnostic evaluation (ex. uncharacterized mass, anemia, etc). These are patients that would have been admitted otherwise, but are clinically stable. The EWC is for patients who do not have a primary care provider and must have reliable contact information.
**** Clerk books directly into HAR Surg VASC -> Podiatry New
*Clerk books WITHOUT consultant approval
*HAR CCC Rm 4, every Monday afternoons.
*Must have reliable contact info, confirm phone number and address


*Ideal candidates are those patients that would be admitted in the absence of EWC, and '''do not have a primary care provider.''' Patients must have '''reliable contact information to attend this clinic.'''
*'''If no slots available, send a message to CCC to book the patient.'''
*Clinical criteria:
#'''New onset ascites:''' New diagnosis and first presentation of ascites. Requires paracentesis performed in ED to rule out infection, SAAG >1.1, transaminases < 3x normal, rapid HIV, CBC, lipase, CMP. No referral for therapeutic paracentesis alone, No evidence of pancreatitis or biliary obstruction.
#'''Anemia (Hgb< 8g/dL on initial presentation):''' Requires CBC, peripheral smear, CMP, rapid HIV, ECG, CXR, type and screen No evidence of pancytopenia, HIV, leukemia, active GI/GU bleeding, or evidence of hemolysis. Patients with suspected gynecologic etiology should be referred to the GYN service. Post transfusion CBC required.
#'''Weight loss, unexplained >10% within 1 month or >15% in 6 months:'''  Requires CBC, CMP, ECG, CXR, rapid HIV. Patients with prior imaging must have actual images or be instructed to retrieve images  prior to clinic appointment.
#'''Undiagnosed mass ''(excluding primary breast, brain, renal, head and neck masses)'':''' Requires results or radiographic imaging to confirm presence of mass. Patients with prior imaging must have actual images or be instructed to retrieve imaging prior to clinic appointment. Send CBC, CMP, PT/INR, HIV on all patients.
#'''New onset pleural effusion:''' Requires thoracentesis, CMP, CBC, serum amylase, LDH, and pleural fluid analysis (predominant lymphocytic effusion or high suspicion for Tuberculosis must be admitted). Chest CT only if immediately clinically indicated (ie. suspicion for pulmonary embolism).


*Patient is stable (T< 38.3c, HR<100, RR <24, BP >110/50, BP <180/110, pulse ox >92% on room air, oriented x 4)
A. Wu, MD -  ED Director of Ops  &  A. Miller, DPM - Director of Limb Salvage, Co-Chair of DHS Podiatry Workgroup 3/30/22
*Able to be seen in 2-10 business days without significant risk
*No ACTIVE co-morbidities (ie infection, CAD, CHF, stroke, metastatic cancer, renal failure, dyspnea).


====GYN====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
====Gyn UCC====
* Book without consultant approval
* '''3-4d f/up for ALL DHS PID patients''' (cervical motion tenderness or adnexal tenderness, empirically treated)


====Interventional Radiology====
#REDIRECT [[https://wikem.org/wiki/Harbor:Main#Outpatient_IR]]


====Nephrology Clinic====
====Nephrology Clinic====
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**3 slots a week specifically earmarked for ED use for Thursday morning Nephrology clinic (GN, diabetes, other CKD)
**3 slots a week specifically earmarked for ED use for Thursday morning Nephrology clinic (GN, diabetes, other CKD)
**2 “Discharge” slots for the Friday afternoon Hypertension (complex/resistant HTN, HTN with CKD, stones, PCKD, SLE)
**2 “Discharge” slots for the Friday afternoon Hypertension (complex/resistant HTN, HTN with CKD, stones, PCKD, SLE)
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Renal: General Nephrology-Clerical
** HAR-OP-Renal: Renal Hypertension-Clerical
** HAR-OP-Renal: Renal Transplant - Clerical


====Neurosurgery====
====Neurosurgery====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


====Limb Salvage====
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
** HAR-OP-Surgery: Neurosurgery-Clerical
*Clerk books directly into HAR Surg VASC -> Podiatry New


====OB====
====OB====
*For new pregnancy: discharge patient with OB clinic intake phone number (424-306-7200) so they can schedule appointment
*For new desired pregnancy w/out anticipated complications: discharge patient with OB clinic intake phone number (424-306-7200) so they can schedule appointment. OB intake is a medical assistant appt, NOT a provider
*For patients with needing serial beta HCGs, patient should follow with Gyn UCC w/in 2-4 days
*For patients considering pregnancy termination or interested in discussing options: discharge patient with general Gyn clinic phone number (424-306-4061), they can request appointment with ROC (reproductive options clinic)
*For patients considering pregnancy termination or interested in discussing options: discharge patient with general Gyn clinic phone number (424-306-4061), they can request appointment with ROC (reproductive options clinic)


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*Book without consultant approval for next day follow up for orbital wall fractures w/o orbital injury concerns, ok per Dr. Prasad, Division Chief
*Book without consultant approval for next day follow up for orbital wall fractures w/o orbital injury concerns, ok per Dr. Prasad, Division Chief
*All other cases: Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*All other cases: Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Surgery: Ophthalmology-Clerical
*Ophtho Alphabet soup:
AAU: acute anterior uveitis
AFT: artificial tears
AGV: Ahmed glaucoma valve
ARMD or AMD: age-related macular degeneration
DR: diabetic retinopathy
BRAO: branch retinal artery occlusion
BRVO: branch retinal vein occlusion
BULB: bilateral upper lid blepharoplasty
BVS: borderline visually significant
C/D: cup-to-disc ratio
CEIOL: cataract extraction with insertion of intraocular lens
CME: cystoid macular edema
CRAO: central retinal artery occlusion
CRVO: central retinal vein occlusion
CSME: clinically significant macular edema
CS: cortical spoking (cataract)
CSR: central serous retinopathy
DES: dry eye syndrome
DME: diabetic macular edema
DWC: dense white cataract
ED: epithelial defect
EL: endolaser
ERM: epiretinal membrane
FML: focal macular laser
GS: glaucoma suspect
HST: horseshoe tear
HVF: Humphrey visual field
K: cornea
LH/WC/AFTs: lid hygiene, warm compresses, artificial tears
LPI: laser peripheral iridotomy
MMCR: Muller's muscle conjunctival resection
MP: membrane peel
NCVH: non-clearing vitreous hemorrhage
NPDR: non-proliferative diabetic retinopathy
NS: nuclear sclerosis (cataract)
NTG: normal tension glaucoma
NVG: neovascular glaucoma
NVS: not visually significant
OD: right eye
OHTN: ocular hypertension
OS: left eye
OU: both eyes
POAG: primary open angle glaucoma
PCO: posterior capsular opacity (aka, secondary cataract)
PDR: proliferative diabetic retinopathy
PKP: penetrating keratoplasty (aka corneal transplant)
PPV: pars plana vitrectomy
PRP: pan retinal photocoagulation
PSC: posterior subcapsular cataract
PTG: pterygium
PVD: posterior vitreous detachment
RRD: rhegmatogenous retinal detachment
RT: retinal tear
SB: scleral buckle
SRD: serous retinal detachment
Trab: trabeculectomy
TRD: tractional retinal detachment
VA: visual acuity
VH: vitreous hemorrhage
VS: visually significant
XT: exotropia
YAG cap: YAG capsulotomy
====ORTHO====
====ORTHO====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
* Starts 5/1/23
* Make sure you're signed off on splinting [https://docs.google.com/spreadsheets/d/1DxK1GWgP3s_bGk4pZ9IFgYLXGuXLTnzJDtUfof_xgic/edit#gid=0 Splinting Guide with Videos]
* [https://lacounty.sharepoint.com/:w:/t/EDOperations-HUCLA/ES3s8sXJdKBLpukbDXsHZfoBwhQCS17ogqrR8mC2TVNvcQ?e=xp82nc Ortho Consult Criteria]
 
* Book: depends on injury, see below, with or without consultant approval - write name of approving doctor, time frame, and reason for follow up
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Surgery: Orthopedic Surgery-Clerical


* Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
* <big>'''Diagnoses Where Orthopedics SHOULD Be Consulted While Patient is in the ED'''</big>
**'''ADULT:'''
** Consult after XR or other appropriate workup is complete. A single scout film may be the appropriate initial imaging for polytrauma patients with obvious open fracture.
*** Clavicle: <5mm mid-shaft;  sling, ortho in 2 weeks
** Incarcerated or non-DHS patients with a diagnosis not found on the “refer to primary care list” may benefit from an orthopedic consult ('''call orthopedics to review if unsure''') to optimize their pre-discharge care and specify timeframe for f/up
*** Shoulder dislocation:  after reduction, place in shoulder immobilizer, ortho 1 week
** '''Always ask/consult if unsure!'''
*** Humerus: 
*** General:
**** Proximal: non-displaced;  sling, ortho in 1 week
**** Acute hardware infection
**** Shaft: non-displaced; sugar tong/sling, ortho 1 week
**** Amputation (including subtotal amputation with dysvascular distal part)
*** Radius:
**** Chronic osteomyelitis (not related to [[Harbor:Admission_and_consultation_guidelines#Diabetic_Foot_Infections|diabetic foot infection [admission guideline]]])
**** Non-displaced distal or shaft; volar splint, ortho 2 weeks
**** Compartment syndrome in extremity with fracture
**** Non-displaced head with good ROM:  sling, ortho in 2 weeks
**** Crush injury to the extremity (other than distal tuft)
*** Ulna:  non-displaced; volar splint, ortho 2 weeks
**** Irreducible fracture or dislocation
*** Occult Scaphoid:  thumb spica splint, ortho in 3 weeks
**** Laceration or fracture with tendinous or neurovascular injury or symptoms
*** Metacarpal:  non-displaced shaft and neck
**** Open fracture of an extremity or impending open fracture (eg, a fracture resulting in skin tenting)
**** MCP 4&5:  Ulnar gutter splint, ortho 3 weeks
**** Open joint, acute foreign body in joint (consult ortho prior to challenge when high suspicion)
**** MCP 2&3:  Radial gutter splint, ortho 3 weeks
**** Septic joint (ED to perform arthrocentesis outside region of erythema/cellulitis and consult if results are concerning for infection or if unable to aspirate)
*** PIP/DIP dislocations:  simple, no fracture;  buddy tape with padding between digits/splint, ortho 1 week
**** Any pediatric fractures requiring procedural sedation or surgery
*** Hand: Distal Phalanx - buddy tape/alumiform splint, ortho in 3 weeks
*** Clavicle
*** Metatarsal 2/3/4 with <2mm displacement and no rotational deformity:  post op shoe, ortho in 2 weeks 
**** Clavicle fracture with >5mm displacement
*** Foot: non-displaced phalanx fracture - buddy tape, ortho in 2 weeks
**** AC joint dislocations, types 4-6
*** Chronic or non-healing fracture:  CCC for e-consult (call ortho if needs closer follow-up)
*** Arm/forearm
**'''PEDIATRIC'''
**** Proximal humerus fracture with displacement
*** Radius, ulna, fibula, clavicle, tibia fractures
**** Humeral shaft fracture with displacement
**** < 5mm displaced and < 15 degrees angulation
**** Any displaced elbow fracture (radial head/neck, distal humerus, olecranon, coronoid)
**** Pain controlled by oral meds
**** Radius, Ulna, or both bone forearm fracture
**** Normal neurovascular status
**** Distal radius fracture with displacement (can attempt reduction first, but ortho should verify reduction is adequate)
**** 5 years and older
*** Wrist/Hand
*** Proximal humerus fractures with minimal displacement – place in sling
**** Scaphoid fracture with displacement
*** Elbow trauma with elevated posterior fat pad, no visible fracture
**** Acute lunate or perilunate dislocation
*** Foreign bodies not in bone or joint space
**** Flexor tenosynovitis
*** Salter Harris 1 fractures that are not displaced
**** Flexor tendon (palmar hand) injuries
*** Distal phalanx fractures not involving joint space
**** Metacarpal fractures with angulation or malrotation or involving multiple MCs
*** Tuft fractures
**** Any clenched fist injury, (aka: fight bite)
**** Pressure injection injuries
**** Hand/finger abscesses (excluding paronychia and felon)
**** Reduced DIP/PIP/MCP/CMC dislocations
**** Displaced Phalangeal fractures (other than distal tuft)
**** Nailbed injury with underlying distal phalanx fracture aka Seymour fracture (excluding tuft)
*** Pelvis/thigh/knee
**** Any pelvic fracture
**** All hip and knee dislocations
**** Any femur fracture
**** Patella fractures
**** Acute patellar or quadriceps tendon rupture
**** Multi-ligamentous knee injury (i.e. dislocated knee s/p spontaneous relocation)
*** Leg/ankle
**** Any tibial plateau fracture (please discuss case with ortho prior to ordering any CT)
**** Any tibial shaft fracture
**** Pilon (distal tibia articular impaction) fractures
**** Ankle fractures with displacement (call orthopedics to review XR if unsure)
*** Foot
**** Calcaneus fractures
**** Talus fractures
**** Subtalar dislocations
**** Lisfranc injuries (including 1st and 2nd metatarsal base fractures)
**** Navicular / Cuboid / Cuneiform fractures


*** <big>'''Diagnoses which can be stabilized by ED and REFERRED TO ORTHO Fracture Clinic in 2 weeks unless otherwise specified'''</big>
**** Establishing follow up after outside hospital orthopedic procedure
**** Any fracture with radiographic healing (eg, callus formation)
**** Chronic foreign body in joint
**** Fractured non-unions or malunions
**** Symptomatic orthopedic hardware
*** Shoulder/arm
**** Isolated scapular body fracture
**** Non-displaced/minimally displaced (<5mm midshaft clavicle fracture)
**** AC joint dislocation, types 1-3 (DESCRIBE TYPES 1,2,3)
**** Rotator cuff tear confirmed on MRI (Ortho Sports Clinic, NOT fracture clinic)
**** Nondisplaced proximal humerus fracture (DEGREE OF ANGULATION - sling vs sarmiento?)
*** Elbow/forearm
**** Elbow and shoulder dislocations with no associated fracture that have appropriate imaging confirming reduction** (perfect lateral for the elbow, axillary, Velpeau, or CT for the shoulder). call orthopedics to review XR if unsure
**** Nondisplaced Radial head/neck fracture (splint then Ortho Fracture Clinic - WHY IS THIS LISTED - WHOLE SECTION TO FX CLINIC)
**** Nondisplaced distal radius fracture (splint then '''Ortho Hand Clinic''', NOT Fracture Clinic)
*** Wrist/Hand
**** Occult scaphoid fracture ('''Ortho Hand clinic''', NOT Ortho Fracture Clinic)
**** Non-displaced phalangeal and metacarpal fracture (intrinsic plus splint then refer to clinic; boxer's fractures ok to put into soft dressing then refer to hand clinic - BUDDY TAPE?)
**** Extensor tendon (dorsal hand) injuries (splint then refer to '''Ortho Hand Clinic in <7 days''', NOT Ortho Fracture Clinic)
**** Distal phalanx fracture without nailbed injury (excluding tuft - '''Ortho Hand clinic''', NOT Ortho Fracture Clinic)
**** Distal phalanx fracture with subungual hematoma ('''Ortho Hand Clinic''', NOT Ortho Fracture Clinic)
**** Nailbed injury WITH tuft fracture or without underlying distal phalanx fracture, after ED repair ('''Ortho Hand Clinic''', NOT Ortho Fracture Clinic)  ABX IF OPEN?
*** Lower extremity
**** Patellar dislocation s/p relocation (if DHS Empaneled --> Ortho Sports Clinic)
**** Single knee ligament injuries (eg, isolated ACL rupture, meniscal injuries confirmed on outpt MRI - ED MRI not indicated;  if DHS Empaneled --> Ortho Sports Clinic)
**** Ankle fractures without displacement subluxation or dislocation (call orthopedics to review XR if unsure)
**** Achilles tendon rupture
**** Fracture of 1st-5th metatarsal shafts


*'''Call Orthopedics for the following fractures'''
*** <big>'''Diagnoses which can be stabilized by ED and referred to Primary Care (NO ORTHO CONSULT NEEDED)'''</big>
** Displaced radius, humerus, ulna, tibia, fibula fractures
**** Arthritis (osteoarthritis of knee or hip OR inflammatory arthritis [consider rheumatology referral])
*** >5mm displaced or >15 degrees of angulation all ages
**** Cellulitis
** All elbow and femur fractures (unless only posterior fat pad)
**** Chronic pain
** Open fractures or concern for
**** Toes:
** Fractures entering a joint space or concern for
***** Closed minimally displaced distal phalanx fracture can be treated with buddy tape & hard sole shoe
** Suspected septic joint
***** Closed fractures of the lesser (2nd-5th) toe phalanges
** Fractures with suspected neurologic or vascular injury or pain not controlled by oral pain meds
**** Deep foreign body in extremity without neurovascular symptoms, fracture, or joint involvement
** Excessive swelling or ecchymosis suggesting risk for compartment syndrome
**** Gunshot wound to extremity without fracture, tendinous, or neurovascular injury (DHS-empaneled patients may be referred to '''Ortho Joint Reconstruction Clinic''')
** Scaphoid fractures  
**** Shoulder impingement
** All fractures in children  less than 5 years
**** Sprains, strains, or contusions (no fracture or joint space widening on radiographs)
** Any fracture > or = to 10 days that may need reduction
**** Tendonitis
** Anytime unsure of what to do or if fracture not included on any of this protocol


====PEDIATRIC ORTHO====
* Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
** Radius, ulna, fibula, clavicle, tibia fractures
*** < 5mm displaced and < 15 degrees angulation
*** Pain controlled by oral meds
*** Normal neurovascular status
*** 5 years and older
** Proximal humerus fractures with minimal displacement – place in sling
** Elbow trauma with elevated posterior fat pad, no visible fracture
** Foreign bodies not in bone or joint space
** Salter Harris 1 fractures that are not displaced
** Distal phalanx fractures not involving joint space
** Tuft fractures


* Peds Specifics
* Peds Specifics
Line 243: Line 395:
====PEDIATRICS====
====PEDIATRICS====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Pediatrics: Allergy/Asthma-Clerical
** HAR-OP-Pediatrics : Cardiology - Clerical
** HAR-OP-Pediatrics : Child Development - Clerical
** HAR-OP-Pediatrics : Craniofacial - Clerical
** HAR-OP-Pediatrics : Diabetes - Clerical
** HAR-OP-Pediatrics : Endocrinology - Clerical
** HAR-OP-Pediatrics : Failure to Thrive - Clerical
** HAR-OP-Pediatrics : Gastroenterology - Clerical
** HAR-OP-Pediatrics : Hematology - Clerical
** HAR-OP-Pediatrics : High Risk Infant - Clerical
** HAR-OP-Pediatrics : Immunology - Clerical
** HAR-OP-Pediatrics : Infectious Disease - Clerical
** HAR-OP-Pediatrics : Medical Genetics - Clerical
** HAR-OP-Pediatrics : Nephrology - Clerical
** HAR-OP-Pediatrics : Neurology - Clerical
** HAR-OP-Pediatrics : Nursery - Clerical
** HAR-OP-Pediatrics : Oncology - Clerical
** HAR-OP-Pediatrics : Rheumatology - Clerical
** HAR-OP-Pediatrics : Surgery - Clerical
====Pediatric Adolescent Clinic====
====Pediatric Adolescent Clinic====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
====Pediatric Cardiology====
====Pediatric Cardiology====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Pediatrics : Cardiology - Clerical
====PLASTIC SURGERY====
====PLASTIC SURGERY====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Surgery: Plastic Surgery-Clerical
====PULMONARY====
====PULMONARY====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
Line 261: Line 443:
====RHEUM====
====RHEUM====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Rheumatology-Clerical
====STI Testing====
* HAR Positive Care Clinic
* '''DHS empaneled patients only''' 18 y/o and above with high-risk behavior (multiple partners, recurrent STI, etc)
** M-F 8a-4:40p
** x64350 to schedule appt
** can Orchid message Claudia Murray, RN and Vanessa Salguero (clerk) after hours;  include reason for referral (eg: “referral for HIV/STI testing in a patient with multiple partners”)
*** PrEP - Orchid message Tiffany Hogan (navigator)
*Offers:
** HIV/STI testing
** HIV Pre Exposure Prophylaxis (PrEP)
====SURGERY====
====SURGERY====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
*'''Please consult the appropriate surgical service on any patient presenting to the ED within the 30-day post-operative period, even if for something seemingly unrelated to the surgery.'''
** During the daytime (7a-7p), you should always directly call CRS (x0044), Bariatric/MIS (x0802), Pediatric (x6105), Breast/Surg Onc (x9397), and Vascular (x0503 – note the new pager number). 
** After hours (7p – 7a), these teams are covered by trauma. 
** If you inadvertently call trauma for these services during the daytime, they have been instructed to have you directly page the appropriate service. 
 
 
*'''Book: with consultant approval''' - write name of approving doctor, time frame, and reason for follow up
* If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Surgery: Bariatric Surgery-Clerical
** HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
** HAR-OP-Surgery: Colorectal Surgery-Clerical
** HAR-OP-Surgery: Plastic Surgery-Clerical
** HAR-OP-Surgery: Surgical Oncology-Clerical
** HAR-OP-Surgery: Trauma Surgery-Clerical
** HAR-OP-Surgery: Vascular Surgery-Clerical
 
====UROLOGY====
====UROLOGY====
*Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
* Nephrolithiasis
**'''OK for clerk to book per Dr. Blumberg within 7-10d ''without'' calling urology consultant if meet below criteria'''
*** '''New Dx Nephrolithiasis'''
**** BMP, UA, consider CT for size/location/hydro (US if pregnant), have patients strain urine
*** '''Established Nephrolithiasis'''
**** BMP, UA, bedside US for hydro
* '''CALL urology consult for patients with UTI (infected stone), h/o DM, solitary kidney, pregnancy'''
** PCP follow-up if not already established, then can NERF when appropriate.
** PCP for non-obstructive <5mm stones
* '''Ureteral stent or percutaneous nephrostomy tube pain''' without concern for infection, otherwise uncomplicated course, follow-up in urology clinic in 7 days
** Send Urine culture
 
*'''Acute urinary retention'''
** '''OK to book in Urology Clinic in 10-14 days WITHOUT consult approval per Dr. Blumberg''' if near baseline Cr, no significant electrolyte derangements, no evidence of post-obstructive diuresis, pain is controlled, and tolerating PO's
** Place foley, send UA, BMP;  do NOT sent PSA (falsely elevated with acute retention)
*** If <200ml output, remove catheter
*** If >400ml out, maintain catheter
*** Monitor for post obstructive diuresis. If >200ml/hr for 2 hours (not counting the initial output), consider further observation and IVF resusc
*** Discharge with tamsulosin 0.4 mg daily
 
* '''All other Urologic conditions:''' book with consultant approval - write name of approving doctor, time frame, and reason for follow up
 
* '''Epididymitis/orchitis''' just needs PCP f/up
 
* If the patient has '''previously been followed at Harbor, but was lost to follow-up''', you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
** HAR-OP-Surgery: Urology-Clerical


====72 HRS STRESS TEST====
Per Dr. Blumberg (Urology) & Dr. Wu  2/8/22
Place order in ORCHID for "CV Treadmill Stress Test"
*If test is abnormal, cardiology follow up automatically generated by HEART station.  
*If test is normal, no notification occurs, other than typical follow up. If you want someone to follow up on the result, consider messaging empaneled PCP or refer to CCC.
*Outpatient P-MIBI Nuclear stress has to be arranged by CORE


=== FOLLOW-UP FOR OUT-OF-COUNTY/OUT-OF-COUNTRY (OOC) PATIENTS===
=== FOLLOW-UP FOR OUT-OF-COUNTY/OUT-OF-COUNTRY (OOC) PATIENTS===

Latest revision as of 00:58, 5 February 2026

  • Outpatient Follow up is based on patient’s insurance network
  • Out of Plan (OOP), means the patient has Non-DHS insurance network, Private insurance, Other Medi-Cal HMOs, or could be out of County/Country.
  • DHS means LA County Department of Health Services network eligible
  • Patient Relations Representatives (PRR) in ED 7 days a week;
    • Call Registration for PRR who can help empanel into DHS or change empanelment/network in real time. For any questions, send the patient to Window 6 in the AWR.
  • File:AED followup flowchart 8-23-21.pdf - note: using DC to specialty order, not clerk scheduling
  • File:PED followup flowchart 8-23-21.pdf - note: using DC to specialty order, not clerk scheduling

RESULTS/SYMPTOM FOLLOW-UP

  • OOP, MHLA, DHS can all have phone follow up for results (labs or imaging), symptoms checks
  • Adults results/symptom phone follow up (Lab Follow-up - HAR)
  • Peds results/symptom phone follow up (Peds - HAR/USC)
  • Follow-up of outpatient labs/imaging
    • Any imaging/labs requested by a consultant in the ED that will NOT be resulted during the patient's stay in the ED should be ordered by the consultant making the request.
    • Follow-up of outpatient tests can be either performed by the consultant OR by the CCC

Same/Next Day Specialty Clinic Follow up

CCC

  • Bridges DHS eligible patients to primary care until empaneled
  • Refer all DHS patients with substance use disorder (SUD) started on medication assisted treatment (MAT) to CCC for enrollment in Dr. Brown's addiction clinic

DHS eligible patients

OOP follow up options

Urgent Specialty Follow-up for DHS

  • Within 4 weeks or less
  • Place the "ED Request for Specialty Appointment" order (7/23/2023)
    • If no approval is needed per the ED to Specialty Clinic Referral Guidance document, write your name (ordering provider) in the approving provider field.
    • When specialty approval is required per the document, place the approving specialty provider’s name in the field.
  • After a conversation with a consulting specialist, their specific recommendation supersedes any timeframe listed in the ED to Specialty Clinic Referral Guidance document.

Pediatrics CCS Follow up

MAT/BUP/Opiate Withdrawal

NERF

  • This periodically changes, but there is currently limited space with the exception of Geriatrics, HIV, and OB care

Patient wants to switch to Harbor

DHS Patients Lost to Follow-up

  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange for routine follow-up for the patient:
    • HAR-OP-Anesthesiology: Pain Management-Clerical
    • HAR-OP-Cardiology: Anticoagulation-Clerical
    • HAR-OP-Cardiology: General Cardiology-Clerical
    • HAR-OP-Cardiology: HFDMP-Clerical
    • HAR-OP-Cardiology: Pulmonary Hypertension-Clerical
    • HAR-OP-Dermatology-Clerical
    • HAR-OP-Endocrine: Diabetes-Clerical
    • HAR-OP-Endocrine: General-Clerical
    • HAR-OP-Endocrine: Pituitary-Clerical
    • HAR-OP-Endocrine: Thyroid-Clerical
    • HAR-OP-Endocrinology: Diabetes Specialty-Clerical
    • HAR-OP-Endocrinology: General Endocrinology-Clerical
    • HAR-OP-Gastroenterology-Clerical
    • HAR-OP-Hematology/Oncology-Clerical
    • HAR-OP-Infectious Disease-Clerical
    • HAR-OP-Neurology-Clerical
    • HAR-OP-OB/Gyn: Gyn Oncology-Clerical
    • HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical
    • HAR-OP-OB/Gyn: Reproductive Endo/Infertility-Clerical
    • HAR-OP-OB/Gyn: UroGyn-Clerical
    • HAR-OP-OB/Gyn: Women's Health-Clerical
    • HAR-OP-Pulmonology-Clerical
    • HAR-OP-Renal: General Nephrology-Clerical
    • HAR-OP-Renal: Renal Hypertension-Clerical
    • HAR-OP-Renal: Renal Transplant - Clerical
    • HAR-OP-Rheumatology-Clerical
    • HAR-OP-Surgery: Bariatric Surgery-Clerical
    • HAR-OP-Surgery: Breast Surgery-Clerical
    • HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
    • HAR-OP-Surgery: Colorectal Surgery-Clerical
    • HAR-OP-Surgery: Dentistry-Clerical
    • HAR-OP-Surgery: Neurosurgery-Clerical
    • HAR-OP-Surgery: Ophthalmology-Clerical
    • HAR-OP-Surgery: Oral and Maxillofacial Surgery-Clerical
    • HAR-OP-Surgery: Orthopedic Surgery-Clerical
    • HAR-OP-Surgery: Otolaryngology-Clerical
    • HAR-OP-Surgery: Plastic Surgery-Clerical
    • HAR-OP-Surgery: Surgical Oncology-Clerical
    • HAR-OP-Surgery: Trauma Surgery-Clerical
    • HAR-OP-Surgery: Urology-Clerical
    • HAR-OP-Surgery: Vascular Surgery-Clerical


    • HAR-OP-Pediatrics: Allergy/Asthma-Clerical
    • HAR-OP-Pediatrics : Cardiology - Clerical
    • HAR-OP-Pediatrics : Child Development - Clerical
    • HAR-OP-Pediatrics : Craniofacial - Clerical
    • HAR-OP-Pediatrics : Diabetes - Clerical
    • HAR-OP-Pediatrics : Endocrinology - Clerical
    • HAR-OP-Pediatrics : Failure to Thrive - Clerical
    • HAR-OP-Pediatrics : Gastroenterology - Clerical
    • HAR-OP-Pediatrics : Hematology - Clerical
    • HAR-OP-Pediatrics : High Risk Infant - Clerical
    • HAR-OP-Pediatrics : Immunology - Clerical
    • HAR-OP-Pediatrics : Infectious Disease - Clerical
    • HAR-OP-Pediatrics : Medical Genetics - Clerical
    • HAR-OP-Pediatrics : Nephrology - Clerical
    • HAR-OP-Pediatrics : Neurology - Clerical
    • HAR-OP-Pediatrics : Nursery - Clerical
    • HAR-OP-Pediatrics : Oncology - Clerical
    • HAR-OP-Pediatrics : Rheumatology - Clerical
    • HAR-OP-Pediatrics : Surgery - Clerical

Clinics not included in ED to Specialty Care Order (2023)

BURN CENTER CLINIC

  • For DHS eligible patients that need Burn Center follow up at LAC+USC, please call over 24/7 to their Burn Unit Front Desk 323-409-7991 to get an appointment w/in 2-5d depending on your assessment of their acuity.
    • Inform the clerk there that you’d like to book a patient into the Burn Eval and Treatment area, which is in 5D in the Inpatient Tower (NOT their A5D Clinic).
    • Patients can also call if they have questions about their appointment logistics or want to change their appointment time.
    • This is NOT a transfer, so you should NOT call MAC to make an appointment
  • For OOP patients, they can go to Torrance Memorial
Stress Testing

Gyn UCC

  • Book without consultant approval
  • 3-4d f/up for ALL DHS PID patients (cervical motion tenderness or adnexal tenderness, empirically treated)
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical

Interventional Radiology

Urgent Outpatient IR

Limb Salvage

  • Opting out of automatic 30-day automatic f/up consult
  • Weekdays 7a - 5p
    • If the patient seems stable for outpatient follow-up:
      • Page limb salvage p0847
      • After discussion with on-call resident/NP, initiate a TEAMS Chat with: ED attending, ED resident, LS on-call res/NP, LS on-call Attending and send a picture of the involved foot
      • The limb salvage team may respond with appropriate outpatient f/up timeframe or may notify you they will come see the patient in the ED if they feel it is necessary
  • Afterhours (5p - 7a weekdays, weekends, holidays)
    • Consult trauma if the patient needs surgical evaluation; trauma will liaise with limb salvage attending
      • Do NOT consult surgery for appointment
    • For appointment only, can directly contact limb salvage OR defer to PCP for e-consult to podiatry (at MLK) if appropriate (several weeks to f/up)
      • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
        • Clerk books directly into HAR Surg VASC -> Podiatry New


A. Wu, MD - ED Director of Ops & A. Miller, DPM - Director of Limb Salvage, Co-Chair of DHS Podiatry Workgroup 3/30/22


Nephrology Clinic

  • For non-dialysis patients only: Don’t need Nephrology fellow approval per Sharon Adler, MD, Chief, Division of Nephrology and Hypertension, 7/28/17)
    • 3 slots a week specifically earmarked for ED use for Thursday morning Nephrology clinic (GN, diabetes, other CKD)
    • 2 “Discharge” slots for the Friday afternoon Hypertension (complex/resistant HTN, HTN with CKD, stones, PCKD, SLE)
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Renal: General Nephrology-Clerical
    • HAR-OP-Renal: Renal Hypertension-Clerical
    • HAR-OP-Renal: Renal Transplant - Clerical

Neurosurgery

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Neurosurgery-Clerical

OB

  • For new desired pregnancy w/out anticipated complications: discharge patient with OB clinic intake phone number (424-306-7200) so they can schedule appointment. OB intake is a medical assistant appt, NOT a provider
  • For patients with needing serial beta HCGs, patient should follow with Gyn UCC w/in 2-4 days
  • For patients considering pregnancy termination or interested in discussing options: discharge patient with general Gyn clinic phone number (424-306-4061), they can request appointment with ROC (reproductive options clinic)

ONCOLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up.
  • Newly diagnosed, metastatic cancer - discuss with oncology fellow p7862

OPHTHO

  • Book without consultant approval for next day follow up for orbital wall fractures w/o orbital injury concerns, ok per Dr. Prasad, Division Chief
  • All other cases: Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Ophthalmology-Clerical
  • Ophtho Alphabet soup:
AAU: acute anterior uveitis
AFT: artificial tears
AGV: Ahmed glaucoma valve
ARMD or AMD: age-related macular degeneration
DR: diabetic retinopathy
BRAO: branch retinal artery occlusion
BRVO: branch retinal vein occlusion
BULB: bilateral upper lid blepharoplasty
BVS: borderline visually significant
C/D: cup-to-disc ratio
CEIOL: cataract extraction with insertion of intraocular lens
CME: cystoid macular edema
CRAO: central retinal artery occlusion
CRVO: central retinal vein occlusion
CSME: clinically significant macular edema
CS: cortical spoking (cataract)
CSR: central serous retinopathy
DES: dry eye syndrome
DME: diabetic macular edema
DWC: dense white cataract
ED: epithelial defect
EL: endolaser
ERM: epiretinal membrane
FML: focal macular laser
GS: glaucoma suspect
HST: horseshoe tear
HVF: Humphrey visual field
K: cornea
LH/WC/AFTs: lid hygiene, warm compresses, artificial tears
LPI: laser peripheral iridotomy
MMCR: Muller's muscle conjunctival resection
MP: membrane peel
NCVH: non-clearing vitreous hemorrhage
NPDR: non-proliferative diabetic retinopathy
NS: nuclear sclerosis (cataract)
NTG: normal tension glaucoma
NVG: neovascular glaucoma
NVS: not visually significant
OD: right eye
OHTN: ocular hypertension
OS: left eye
OU: both eyes
POAG: primary open angle glaucoma
PCO: posterior capsular opacity (aka, secondary cataract)
PDR: proliferative diabetic retinopathy
PKP: penetrating keratoplasty (aka corneal transplant)
PPV: pars plana vitrectomy
PRP: pan retinal photocoagulation
PSC: posterior subcapsular cataract
PTG: pterygium
PVD: posterior vitreous detachment
RRD: rhegmatogenous retinal detachment
RT: retinal tear
SB: scleral buckle
SRD: serous retinal detachment
Trab: trabeculectomy
TRD: tractional retinal detachment
VA: visual acuity
VH: vitreous hemorrhage
VS: visually significant
XT: exotropia
YAG cap: YAG capsulotomy

ORTHO

  • Book: depends on injury, see below, with or without consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Orthopedic Surgery-Clerical
  • Diagnoses Where Orthopedics SHOULD Be Consulted While Patient is in the ED
    • Consult after XR or other appropriate workup is complete. A single scout film may be the appropriate initial imaging for polytrauma patients with obvious open fracture.
    • Incarcerated or non-DHS patients with a diagnosis not found on the “refer to primary care list” may benefit from an orthopedic consult (call orthopedics to review if unsure) to optimize their pre-discharge care and specify timeframe for f/up
    • Always ask/consult if unsure!
      • General:
        • Acute hardware infection
        • Amputation (including subtotal amputation with dysvascular distal part)
        • Chronic osteomyelitis (not related to diabetic foot infection [admission guideline])
        • Compartment syndrome in extremity with fracture
        • Crush injury to the extremity (other than distal tuft)
        • Irreducible fracture or dislocation
        • Laceration or fracture with tendinous or neurovascular injury or symptoms
        • Open fracture of an extremity or impending open fracture (eg, a fracture resulting in skin tenting)
        • Open joint, acute foreign body in joint (consult ortho prior to challenge when high suspicion)
        • Septic joint (ED to perform arthrocentesis outside region of erythema/cellulitis and consult if results are concerning for infection or if unable to aspirate)
        • Any pediatric fractures requiring procedural sedation or surgery
      • Clavicle
        • Clavicle fracture with >5mm displacement
        • AC joint dislocations, types 4-6
      • Arm/forearm
        • Proximal humerus fracture with displacement
        • Humeral shaft fracture with displacement
        • Any displaced elbow fracture (radial head/neck, distal humerus, olecranon, coronoid)
        • Radius, Ulna, or both bone forearm fracture
        • Distal radius fracture with displacement (can attempt reduction first, but ortho should verify reduction is adequate)
      • Wrist/Hand
        • Scaphoid fracture with displacement
        • Acute lunate or perilunate dislocation
        • Flexor tenosynovitis
        • Flexor tendon (palmar hand) injuries
        • Metacarpal fractures with angulation or malrotation or involving multiple MCs
        • Any clenched fist injury, (aka: fight bite)
        • Pressure injection injuries
        • Hand/finger abscesses (excluding paronychia and felon)
        • Reduced DIP/PIP/MCP/CMC dislocations
        • Displaced Phalangeal fractures (other than distal tuft)
        • Nailbed injury with underlying distal phalanx fracture aka Seymour fracture (excluding tuft)
      • Pelvis/thigh/knee
        • Any pelvic fracture
        • All hip and knee dislocations
        • Any femur fracture
        • Patella fractures
        • Acute patellar or quadriceps tendon rupture
        • Multi-ligamentous knee injury (i.e. dislocated knee s/p spontaneous relocation)
      • Leg/ankle
        • Any tibial plateau fracture (please discuss case with ortho prior to ordering any CT)
        • Any tibial shaft fracture
        • Pilon (distal tibia articular impaction) fractures
        • Ankle fractures with displacement (call orthopedics to review XR if unsure)
      • Foot
        • Calcaneus fractures
        • Talus fractures
        • Subtalar dislocations
        • Lisfranc injuries (including 1st and 2nd metatarsal base fractures)
        • Navicular / Cuboid / Cuneiform fractures
      • Diagnoses which can be stabilized by ED and REFERRED TO ORTHO Fracture Clinic in 2 weeks unless otherwise specified
        • Establishing follow up after outside hospital orthopedic procedure
        • Any fracture with radiographic healing (eg, callus formation)
        • Chronic foreign body in joint
        • Fractured non-unions or malunions
        • Symptomatic orthopedic hardware
      • Shoulder/arm
        • Isolated scapular body fracture
        • Non-displaced/minimally displaced (<5mm midshaft clavicle fracture)
        • AC joint dislocation, types 1-3 (DESCRIBE TYPES 1,2,3)
        • Rotator cuff tear confirmed on MRI (Ortho Sports Clinic, NOT fracture clinic)
        • Nondisplaced proximal humerus fracture (DEGREE OF ANGULATION - sling vs sarmiento?)
      • Elbow/forearm
        • Elbow and shoulder dislocations with no associated fracture that have appropriate imaging confirming reduction** (perfect lateral for the elbow, axillary, Velpeau, or CT for the shoulder). call orthopedics to review XR if unsure
        • Nondisplaced Radial head/neck fracture (splint then Ortho Fracture Clinic - WHY IS THIS LISTED - WHOLE SECTION TO FX CLINIC)
        • Nondisplaced distal radius fracture (splint then Ortho Hand Clinic, NOT Fracture Clinic)
      • Wrist/Hand
        • Occult scaphoid fracture (Ortho Hand clinic, NOT Ortho Fracture Clinic)
        • Non-displaced phalangeal and metacarpal fracture (intrinsic plus splint then refer to clinic; boxer's fractures ok to put into soft dressing then refer to hand clinic - BUDDY TAPE?)
        • Extensor tendon (dorsal hand) injuries (splint then refer to Ortho Hand Clinic in <7 days, NOT Ortho Fracture Clinic)
        • Distal phalanx fracture without nailbed injury (excluding tuft - Ortho Hand clinic, NOT Ortho Fracture Clinic)
        • Distal phalanx fracture with subungual hematoma (Ortho Hand Clinic, NOT Ortho Fracture Clinic)
        • Nailbed injury WITH tuft fracture or without underlying distal phalanx fracture, after ED repair (Ortho Hand Clinic, NOT Ortho Fracture Clinic) ABX IF OPEN?
      • Lower extremity
        • Patellar dislocation s/p relocation (if DHS Empaneled --> Ortho Sports Clinic)
        • Single knee ligament injuries (eg, isolated ACL rupture, meniscal injuries confirmed on outpt MRI - ED MRI not indicated; if DHS Empaneled --> Ortho Sports Clinic)
        • Ankle fractures without displacement subluxation or dislocation (call orthopedics to review XR if unsure)
        • Achilles tendon rupture
        • Fracture of 1st-5th metatarsal shafts
      • Diagnoses which can be stabilized by ED and referred to Primary Care (NO ORTHO CONSULT NEEDED)
        • Arthritis (osteoarthritis of knee or hip OR inflammatory arthritis [consider rheumatology referral])
        • Cellulitis
        • Chronic pain
        • Toes:
          • Closed minimally displaced distal phalanx fracture can be treated with buddy tape & hard sole shoe
          • Closed fractures of the lesser (2nd-5th) toe phalanges
        • Deep foreign body in extremity without neurovascular symptoms, fracture, or joint involvement
        • Gunshot wound to extremity without fracture, tendinous, or neurovascular injury (DHS-empaneled patients may be referred to Ortho Joint Reconstruction Clinic)
        • Shoulder impingement
        • Sprains, strains, or contusions (no fracture or joint space widening on radiographs)
        • Tendonitis

PEDIATRIC ORTHO

  • Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
    • Radius, ulna, fibula, clavicle, tibia fractures
      • < 5mm displaced and < 15 degrees angulation
      • Pain controlled by oral meds
      • Normal neurovascular status
      • 5 years and older
    • Proximal humerus fractures with minimal displacement – place in sling
    • Elbow trauma with elevated posterior fat pad, no visible fracture
    • Foreign bodies not in bone or joint space
    • Salter Harris 1 fractures that are not displaced
    • Distal phalanx fractures not involving joint space
    • Tuft fractures
  • Peds Specifics
    • OK to Splint; DHS Eligible
      • Call ortho and ask for approval to book in clinic the next Tuesday for Pediatric fracture clinic.
      • Ortho does not have to see the patient or write a consultation
    • OK to splint; OOP (these will not qualify for CCS)
      • D/c patient with copies of films
      • Specific instructions to family to call and get ortho referral
      • Hand-out available with options for families (PMD, Shriner’s, Orthopedic institute)
    • Patients Seen at OH splinted and referred to Harbor; Call ortho if:
      • DHS eligible or empaneled
      • Believe urgent/emergent intervention needed
      • Needs a reduction
      • Patient having difficulty getting into empaneled orthopedist (can give hand-out of other options).
        • Ortho attempts to get CCS and if not able helps get care
          • Ortho and CCS (California Children’s Services)
            • Ortho has hired Anna Contreras ( Daisy) to help get CCS for many of the OOP ortho patients
            • If patient is OOP and ortho requests to see them after they splint or cast send a communication to Anna Contreras through Cerner and she gets back to families within 1 business day.
            • Instructions on each computer in PED doc box
            • If the patient doesn’t qualify for CCS, they will help the family get into their orthopedist

PEDIATRICS

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Pediatrics: Allergy/Asthma-Clerical
    • HAR-OP-Pediatrics : Cardiology - Clerical
    • HAR-OP-Pediatrics : Child Development - Clerical
    • HAR-OP-Pediatrics : Craniofacial - Clerical
    • HAR-OP-Pediatrics : Diabetes - Clerical
    • HAR-OP-Pediatrics : Endocrinology - Clerical
    • HAR-OP-Pediatrics : Failure to Thrive - Clerical
    • HAR-OP-Pediatrics : Gastroenterology - Clerical
    • HAR-OP-Pediatrics : Hematology - Clerical
    • HAR-OP-Pediatrics : High Risk Infant - Clerical
    • HAR-OP-Pediatrics : Immunology - Clerical
    • HAR-OP-Pediatrics : Infectious Disease - Clerical
    • HAR-OP-Pediatrics : Medical Genetics - Clerical
    • HAR-OP-Pediatrics : Nephrology - Clerical
    • HAR-OP-Pediatrics : Neurology - Clerical
    • HAR-OP-Pediatrics : Nursery - Clerical
    • HAR-OP-Pediatrics : Oncology - Clerical
    • HAR-OP-Pediatrics : Rheumatology - Clerical
    • HAR-OP-Pediatrics : Surgery - Clerical

Pediatric Adolescent Clinic

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Cardiology

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Pediatrics : Cardiology - Clerical

PLASTIC SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Plastic Surgery-Clerical

PULMONARY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


PROCEDURE CLINIC

  • For patient needing recurrent paracentesis
  • From Dr. Anshu Abhat:
  • only available for patients who are empaneled to Harbor-UCLA Internal Medicine or Geriatrics clinic.
  • If an ED provider thinks a patient could benefit from procedure clinic, they should include this in the ER note/documentation (ideal) or message the empaneled provider. Referrals to procedure clinic should only come from PCP's (not from ER providers).

RHEUM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Rheumatology-Clerical


STI Testing

  • HAR Positive Care Clinic
  • DHS empaneled patients only 18 y/o and above with high-risk behavior (multiple partners, recurrent STI, etc)
    • M-F 8a-4:40p
    • x64350 to schedule appt
    • can Orchid message Claudia Murray, RN and Vanessa Salguero (clerk) after hours; include reason for referral (eg: “referral for HIV/STI testing in a patient with multiple partners”)
      • PrEP - Orchid message Tiffany Hogan (navigator)
  • Offers:
    • HIV/STI testing
    • HIV Pre Exposure Prophylaxis (PrEP)

SURGERY

  • Please consult the appropriate surgical service on any patient presenting to the ED within the 30-day post-operative period, even if for something seemingly unrelated to the surgery.
    • During the daytime (7a-7p), you should always directly call CRS (x0044), Bariatric/MIS (x0802), Pediatric (x6105), Breast/Surg Onc (x9397), and Vascular (x0503 – note the new pager number).
    • After hours (7p – 7a), these teams are covered by trauma.
    • If you inadvertently call trauma for these services during the daytime, they have been instructed to have you directly page the appropriate service.


  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Bariatric Surgery-Clerical
    • HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
    • HAR-OP-Surgery: Colorectal Surgery-Clerical
    • HAR-OP-Surgery: Plastic Surgery-Clerical
    • HAR-OP-Surgery: Surgical Oncology-Clerical
    • HAR-OP-Surgery: Trauma Surgery-Clerical
    • HAR-OP-Surgery: Vascular Surgery-Clerical

UROLOGY

  • Nephrolithiasis
    • OK for clerk to book per Dr. Blumberg within 7-10d without calling urology consultant if meet below criteria
      • New Dx Nephrolithiasis
        • BMP, UA, consider CT for size/location/hydro (US if pregnant), have patients strain urine
      • Established Nephrolithiasis
        • BMP, UA, bedside US for hydro
  • CALL urology consult for patients with UTI (infected stone), h/o DM, solitary kidney, pregnancy
    • PCP follow-up if not already established, then can NERF when appropriate.
    • PCP for non-obstructive <5mm stones
  • Ureteral stent or percutaneous nephrostomy tube pain without concern for infection, otherwise uncomplicated course, follow-up in urology clinic in 7 days
    • Send Urine culture
  • Acute urinary retention
    • OK to book in Urology Clinic in 10-14 days WITHOUT consult approval per Dr. Blumberg if near baseline Cr, no significant electrolyte derangements, no evidence of post-obstructive diuresis, pain is controlled, and tolerating PO's
    • Place foley, send UA, BMP; do NOT sent PSA (falsely elevated with acute retention)
      • If <200ml output, remove catheter
      • If >400ml out, maintain catheter
      • Monitor for post obstructive diuresis. If >200ml/hr for 2 hours (not counting the initial output), consider further observation and IVF resusc
      • Discharge with tamsulosin 0.4 mg daily
  • All other Urologic conditions: book with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • Epididymitis/orchitis just needs PCP f/up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Urology-Clerical

Per Dr. Blumberg (Urology) & Dr. Wu 2/8/22

FOLLOW-UP FOR OUT-OF-COUNTY/OUT-OF-COUNTRY (OOC) PATIENTS

Per DHS Policy 516.1, Out of County/Country Patients who need an urgent follow-up for an emergency medical condition may be provided such follow-up at Harbor

  1. Emergent Conditions:
    1. Places health in serious jeopardy
    2. Threatens serious impairment to bodily functions
    3. Threatens serious dysfunction to any organ or body part
  2. If they are from a county close by - consider referring them to their home county. Call 2-1-1 social services hotline.
  3. Do not arrange follow-up for NON-EMERGENT/URGENT issues
  • If patient is no longer Out of Country/County, they can go to Registration Rm 108, 1st floor main hospital), ext 8101 to change their address.

Dir AED, Dir OPS, DHS Policy 516.1 9/25/17

See Also

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