System of Care Playbook

University Hospital, UnityPoint Health - Meriter, and UW Health at East Madison Hospital

Last Update 10/25/2024

Introduction

The UW Health and UPH-Meriter System of Care is centered on a simple idea: Ensure that our patients get the right care, at the right time, at the right place. While both UW Health and UPH-Meriter hospitals have the capability to treat a wide range of patients at various UW Health and UPH-Meriter locations, this System of Care Playbook was created to provide general guidance on the preferred placement of patients requiring inpatient care within the System of Care.

Any movement of a patient from one location to another will be made in compliance with UW Health and UPH-Meriter policies and applicable laws, including the Emergency Medical Treatment and Labor Act ("EMTALA"). Patients presenting to an Emergency Department with an unstable emergency medical condition will not be transferred out of the Emergency Department unless the patient's emergency medical condition has been resolved or the transfer otherwise complies with hospital policy and applicable law. Deviations from this Playbook should be made if it is in the patient's best interest considering real-time variables and circumstances.

Contents

  • I. EMH Medicine
  • II. Meriter Medicine
  • Meriter Preferred Patients
  • III. Advanced Pulmonary Service
  • IV. Bone Marrow Transplant
  • V. Burn Surgery
  • VI. Cardiology
  • VII. Cardiac Surgery
  • VIII. Colo-Rectal Surgery*
  • IX. Dental
  • X. Dermatology
  • XI. Emergency General Surgery
  • XIV. ENT/Facial Trauma
  • XIX. Family Medicine
  • Patients in UH ED
  • Patients in EMH ED
  • Patients in Meriter ED
  • XV. Gastroenterology Procedures
  • XVI. Gynecologic Oncology
  • XVII. Hematology
  • XVIII. Hepatology
  • XIX. Hospital Medicine/General Medicine
  • XX. ICU-Meriter
  • XXI. IMC-Meriter Preferred
  • XXII. Medical Transplant Kidney
  • XXIII. Medical Transplant Liver and/or Pancreas
  • XXIV. Medical Transplant Lung
  • XXVI. Neurology
  • XXVII. Neurosurgery
  • XXVIII. Obstetrics and Gynecology
  • XXIX. Oncology
  • XXX. Ophthalmology
  • XXXI. Orthopedics
  • XXXII. Palliative Care
  • XXXIII. Pediatrics/NICU
  • XXXIV. Peritoneal Dialysis
  • XXXV. Psychiatry
  • XXXVI. Rheumatology
  • XXXIX. Transplant Surgery Cardiac
  • XL. Transplant Surgery Kidney or Pancreas
  • XL. Transplant Surgery Liver
  • XLI. Trauma Surgery
  • XLII. Urology
  • XLIII. Vascular Surgery
  • XLIV. Wound Service
  • Diabetic Foot Ulcer Admissions (DFU)
  • XLV. Escalation Procedure

I. EMH Medicine

Strong preference against admission to EMH:

  • Pediatric Patients
  • Dept of Corrections Patients
  • Mendota Mental Health Forensic Patients
  • Heart Failure Service Patients
  • Advanced Pulmonary Patients
  • STEMI Patients
  • Patients needing Ophthalmology
  • Patients needing a stress test on Sat or Sun
  • Patients needing electrophysiology
  • Patients requiring ICU level of care
  • Patients with a trach or chronically ventilated patients
  • Complex withdrawal patients
  • Patients needing psychiatric admission
  • Patients with transplant other than kidney or hematopoietic transplants
  • Patients in active oncological treatment
  • Patients requiring eating disorders consult (prefer UH F6/4 for Hospitalist/Gmed and D4/6 for Family Medicine)
  • Patients requiring GI procedures
  • Patients with neurology consult needs
  • Patients needing inpatient rheumatology consultation
  • Patients needing inpatient dermatology consultation

II. Meriter Medicine

Strong preference against admission to Meriter:

  • Pediatric Patients (exceptions
  • Central Wisconsin Center (CWC) Patients
  • Mendota Mental Health Forensic Patients
  • Dept of Corrections Patients
  • Transplant patients other than renal or renal less than 12 months post op
  • Patients admitted for traumatic injuries
  • Patients with STEMI
  • Pt. requiring Neuro-Endovascular Care
  • Patients needing Burn consultation
  • Patients undergoing or likely to need liver transplant evaluation
  • Patients that are being admitted for cystic fibrosis and patient needing advanced hepatology consultation (see section XI Consultation)

Meriter Preferred Patients

  • Patients with a GI problem followed by gastroenterology at Meriter not meeting GI procedure exclusion criteria
  • Antonio Bosch
  • Siobahn Byrne
  • Bryan Magenheim
  • Jay Stangl
  • John Williams
  • Patients being admitted with oncology related problem followed by oncology at 1 S Park
  • Dr. Rob Hegeman
  • Dr. David Hei
  • Dr. Mike Huie
  • Dr. Saurabh Rajguru
  • Dr. Amy Stella
  • Meriter can provide IMC level of care. Meriter can provide most ICU level of care.

III. Advanced Pulmonary Service

Strong preference against admission to EMH or Meriter Hospitalist services:

  • Patients who carry a diagnosis of Cystic Fibrosis
  • Patients with Pulmonary Hypertension on prostan'oids
  • Patients post lung transplant
  • Some patients with chest tubes can be managed at Meriter (see thoracic surgery)
  • Patients under the age of 18 are strongly preferred for AFCH

IV. Bone Marrow Transplant

  • Strong preference against for admission to EMH or Meriter
  • Patients under the age of 18 are strongly preferred for AFCH
  • All autologous stem cell transplant patients who have myeloma (To BMT if < 100 days and to hematology if > 100 days)
  • All autologous stem cell transplant patients for lymphoma < 1 year from transplant (To BMT if < 100 days and to hematology if > 100 days)
  • All allogeneic stem cell transplant patients
  • All recipients of CAR T-cell therapy < 1 year (To BMT if < 8 weeks and to Hematology if > 8 weeks)

V. Burn Surgery

  • All patients being admitted for burn care should preferentially be admitted to UH

VI. Cardiology

  • Cardiology: Referral calls from community hospitals and clinics should be preferentially routed to the Cardiology Triage – UW Health attending physician. The Cardiology Triage attending has the option to accept in transfer to UH, Meriter, or EMH based on the Cardiovascular Medicine Admission Criteria (Admission Guidelines for Cardiology Patients (wisc.edu)). In cases where the referring physician wishes a consultation but not transfer, we can provide consultative services.
  • Heart Failure: Referral calls for patients who have had or are currently being evaluated for heart transplant or LVAD and patients on IV inotropes for treatment of heart failure, should be preferentially routed to the Heart Failure attending physician with the understanding that in some circumstances the decision will be made to route to Cariology Triage after consultation. HF patients followed longitudinally in the HF clinic that are being actively managed by HF clinic, have had multiple readmits, and may benefit from ongoing goals of care discussions with the HF team would be appropriate for admission to the HF service on a case-by-case basis.

VII. Cardiac Surgery

  • Any patient requiring the services of cardiac surgery should with strong preference be admitted to UH.
  • Patients under the age of 18 are strongly preferred for AFCH

VIII. Colo-Rectal Surgery*

IX. Dental

  • UW Health and UnityPoint Health - Meriter has the capability to treat emergent soft tissue head and neck infections, traumatic oral and facial injuries, and emergency medical conditions that usually require immediate intervention
  • UW Health and UnityPoint Health - Meriter do not provide routine outpatient dental services or a dental phone consult service.

X. Dermatology

  • Patients being admitted with the following dermatological conditions should be preferentially admitted to University hospital
  • Drug Rash with Eosinophilia and Systemic Symptoms (DRESS)
  • Steven Johnson Syndrome (SJS)
  • Toxic Epidermal Necrolysis (TEN)
  • Staphylococcal scalded skin syndrome
  • Pemphigus
  • Pemphigoid
  • Pyoderma gangrenosum
  • Other conditions such as vasculitis that would require intensive multi-specialty workup (discuss with dermatology on call prior to location assignment)
  • Meriter may be preferred for other secondary skin conditions or admissions for wet wraps (erythrodermic eczema or psoriasis)
  • Telederm is available at EMH but can be logistically difficult. If EMH placement is considered, please discuss with dermatology on call prior to placement.
  • Patients under the age of 18 are strongly preferred for AFCH

XI. Emergency General Surgery

Preference for Routing Referrals to University Hospital EGS

  • Referral calls from community hospitals and clinics should be preferentially routed to EGS on call at University Hospital. The EGS surgeon has the option to accept in transfer to UH, preferentially route to Emergency Surgery at Meriter or, in cases where the referring physician wishes a consultation but not transfer, can provide consultative services.
  • Referrals received for clinically stable patients with paraoesophageal or hiatal hernias should be referred directly to Minimally Invasive Surgery
  • Post-bariatric patients with surgical complications should be referred initially to Minimally Invasive Surgery, with the understanding that in some circumstances the decision will be made to route to EGS after consultation.

Preference for Routing Referrals to Meriter Hospital EGS

  • Referral calls from East Madison Hospital should be preferentially routed to EGS on call at Meriter.
  • Any referring physician who requests to refer a general surgery issue to Meriter should be routed to the EGS surgeon at Meriter.

XII. XI. Endocrine Surgery*

XIII. Endocrinology*

  • Patients who require admission for a water deprivation test must be admitted to IMC status due to the need for frequent lab draws at UH.

XIV. ENT/Facial Trauma

Patients with preference for admission to UH

  • Patients with head and neck injuries secondary to trauma requiring facial trauma evaluation and/or treatment.
  • Patients with head and neck injuries requiring complex airway management
  • Patients with primary or secondary head or neck conditions not typically amendable to outpatient or emergency department treatment and discharge. Examples include but are not limited to:
  • Ludwigs angina
  • Buccal space infection
  • Parapharyngeal space infections

Patients with preference for admission to Meriter

  • Patients with a secondary head or neck conditions requiring evaluation or treatment by otolaryngology that would typically be managed in an outpatient or emergency department setting who are being admitted for an unrelated primary reason. Examples include but are not limited to"
  • Sinusitis
  • Epistaxis
  • Peritonsillar abscess

Patients with primary or secondary head and neck conditions requiring otolaryngology evaluation and treatment should not be preferentially admitted to East Madison Hospital.

XIX. Family Medicine

  • Patients under the age of 18 are strongly preferred for AFCH UW Family

Medicine Clinic Direct Admission Requests

  • Direct admission requests for patients with UW Family Medicine PCP at these clinics Admitting Providers - Employee Service Center (uwhealth.org) should be discussed with the Family Medicine Service attending.
  • If service is capped or unable to accept the patient, then the outpatient provider should discuss admission with hospitalist triage.

Regional Calls

  • All other patients requesting direct admission from outside clinics and hospitals should be discussed with the hospitalist triage provider.

Patients in UH ED

  • Hospital admission location should be determined based primarily on medical appropriateness and service needs. Patients with a PCP in UW Family Medicine clinics listed above should be admitted to the hospital that best meets their medical needs. The ED provider should contact the appropriate triage physician for admission.
  • Admission to EMH: UH Triage Hospitalist
  • Admission to Meriter: Meriter triage hospitalist or system triage hospitalist
  • Admission to UH: UH Family Medicine resident
  • Admit to Family Medicine Service at UH if:
    • UW Family Medicine Service is not capped*
    • Family medicine service cap is 14 from 7a-7p
    • Family medicine service cap is 16 from 7p-7a
    • If patient is eligible for EMH/Meriter, but the facilities are unable to accommodate this need or patient refuses, may consider admitting to UH FM.
    • If patient needs a UH-exclusive specialty consult, patient can also be primarily admitted to the UH FM team if seen at one of the 16 clinics.

Patients in EMH ED

  • Hospital admission location should be determined based primarily on medical appropriateness and service needs. Patients with a PCP in UW Family Medicine should be admitted to the hospital that best meets their medical needs. The ED provider should contact the appropriate triage physician for admission.
  • Admission to EMH: EMH Triage Hospitalist
  • Admission to Meriter: Meriter triage hospitalist or system triage hospitalist
  • Admission to UH: UH Triage Hospitalist
    • Pt will be seen by the EMH hospitalist and admitted to UH Hospital Medicine. If on arrival to UH, family medicine is not capped, UH triage can discuss patient with Family Medicine and transfer to their service.

Patients in Meriter ED

  • Family Medicine patients seen in the Meriter ED who require general medical admission should preferentially be admitted to Meriter or EMH unless not meeting Meriter or EMH criteria.
  • Admission to EMH: EMH Triage Hospitalist
  • Admission to UH: UH Triage (include FM attending on call if FM not capped, however is wait time to transfer to UH is prolonged, should not hold a bed on FM service, if FM not capped on arrival, FM should admit)

XV. Gastroenterology Procedures

  • Patients under the age of 18 are strongly preferred for AFCH
  • No patients requiring GI intervention should preferentially be admitted to EMH
  • Patients can be preferentially admitted to Meriter unless one of the non-preferred criteria are met:
  • Need for Endoscopic Ultrasound
  • Liver patient with active variceal bleed
  • Liver transplant patient with active GI bleed
  • Pt. who may need TIPS
  • Pt. with known or suspected variceal bleeding
  • Recurrent GI bleed patients who made need a double balloon procedure for obscure bleeding
  • Pt. with Typhlitis
  • Pt. on research protocols/medications related to IBD treatment
  • The patients with the following should be discussed with the on-call GI attending provider before admission to a hospitalist service to determine best care.
  • Patients who will require an ERCP should be discussed with GI on call attending prior to determining preferred admission site.
    • Patients being transferred from outside hospitals, UW ER or EMH ER
    • Weekdays 8-5 AM contact assigned ERCP attending
    • Weekday nights contact on all attending
    • Weekend Fri 5 PM – Monday 8 AM contact ERCP on call
    • admitted thru Meriter ER
    • Contact Meriter attending
    • Weekday nights contact on all attending
  • Patients being admitted for IBD related concerns should be discussed with the GI attending on call prior to placement.
    • IBD patients requiring admission for IBD related issues should preferentially be admitted to the location that their IBD gastroenterologist practices at. This will preferentially be UH except for patients followed by Meriter based GI in which case Meriter is the preferred admission site for:
    • Antonio Bosch
    • Siobahn Byrne
    • Bryan Magenheim
    • Jay Stangl
    • John Williams
    • IBD patients requiring surgery may be preferred for Meriter if Dr. King is available to perform the needed intervention. GI attending provider will discuss case with Dr. King. If not available IBD patients requiring surgery should preferentially be admitted to UH.
  • Patients with IBD with abscess on imaging may be managed at Meriter if IR resources are available, otherwise will require admission at UH. Discuss case with GI attending on call provider
  • In times when capacity constraints or other factors may affect placement of patients based on this guideline contact the GI attending provider, as they will help problem solve to meet the needs of our patients where we can provide the best most timely care.

XVI. Gynecologic Oncology

  • Patients under the age of 18 are strongly preferred for AFCH
  • All patients being admitted for care related to their known or suspected gynecological malignancy should preferentially be admitted at UH

XVII. Hematology

  • Patients under the age of 18 are strongly preferred for AFCH
  • Non-preferred criteria for admission to EMH and Meriter
  • Any patient receiving treatment for a heme malignancy with the previous year
  • Any patient with suspected recurrence of their malignancy
  • Any patient suspected of microangiopathic hemolytic anemia (TTP, HUS)
  • Any patient with a bleeding disorder (for example hemophilia, type 2 or 3 von Willebrand disease, other clotting factor deficiency). Especially those with active bleeding or being monitored for bleeding, or that may require an invasive procedure. Meriter does not generally have clotting factor in house. Patients with mild von Willebrand, especially those that are responsive to desmopressin may be appropriate for transfer.
  • Any patient with active autoimmune hemolytic anemia or thrombocytopenic purpura

XVIII. Hepatology

Patients under the age of 18 are strongly preferred for AFCH

University Hospital strongly preferred (Liver Transplant Service or General Medicine with Liver Consult):

  • All Liver Transplant Recipients
  • EXCEPTION – Stable liver transplant recipients with good graft function admitted for non-transplant related indication
  • Patient with known cirrhosis AND
  • Waitlisted for Liver Transplant and MELD > 25
  • Under evaluation for Liver Transplantation and MELD > 25
  • Referral for Liver Transplant Evaluation
  • GI bleeding
    • Known history of varices OR likely varices AND hemodynamically significant upper gastrointestinal hemorrhage (SBP < 80, tachycardic, likely heading to ICU status or may need TIPS)
  • Hepatic tumors
  • Any patient with a known or suspected primary hepatic tumor (HCC or cholangiocarcinoma
  • Acute Liver Failure
  • ALT/AST > 500, INR > 1.5, and hepatic encephalopathy

Patients below will likely be strongly preferred for admission to UH, however if admission to Meriter or EMH is being considered for other reasons hepatology on call should be contacted to discuss the case prior to location assignment to ensure best care can be provided.

  • Meriter preferred for Acute Liver Injury (new injury) not suspected secondary to viral hepatitis – Defined as ALT and/or AST > 500 without a previous history of liver problem and no evidence of biliary obstruction and no hepatic encephalopathy
  • Primary reason for admission is liver related
  • Jaundice
  • Acetaminophen ingestion (known or suspected)
  • Patients not meeting the criteria above can be preferentially admitted to Meriter or EMH
  • Patients should not preferentially be admitted to EMH if they have a known liver issue that will require Hepatology subspecialty consultation

XIX. Hospital Medicine/General Medicine

  • Patients under the age of 18 are strongly preferred for AFCH
  • Patients with need for acute admission due to a medical problem or a combination of active medical and surgical problems, AND
  • Patients are not better served on a medical or surgical specialty service (see preferred /non-preferred criteria in this playbook)
  • Patients recently admitted to a specific Hospital/General Medicine service should be readmitted if the same care team, attending physician, and location (i.e. should "bounce back") as long as a strong argument can be made that the patient's care will benefit from continuity. If the desired admitting location is currently in red status, the patient should preferentially be admitted to another UW Health location unless they are meeting non-preferred criteria.

XX. ICU-Meriter

Strong non-preferred list for the ICU:

  • Patients needing:
  • Post cardiac arrest with underlying cardiac etiology
  • Transplant or have had a transplant within the last 90 days
  • Cardiac Surgery
  • ECMO/Ventricular assist device (essentially, any invasive cardiac support that is more than an intra-aortic balloon pump- IABP)
  • TIPS procedure
  • Care due to severe burns
  • Endovascular CNS intervention due to a subarachnoid hemorrhage or endovascular thrombectomy
  • Care for traumatic injuries or ongoing care related to mechanisms of injury except in the case of:
    • necessary stabilization of critically ill patients prior to transfer
    • isolated traumatic brain injuries with neurosurgical consultation
  • Conditions requiring cell separation, i.e. sickle cell and leukapheresis.
  • Patients with Wegener's Granulomatosis or Granulomatosis with polyangiitis requiring plasmapheresis

Preferred criteria

  • Patients under the age of 18 who are pregnant and require ICU level of care are preferred for the Meriter ICU in most cases
  • In addition to caring for hemodynamically unstable patients, Meriter also takes patients who need:
  • IABP
  • Therapeutic Plasma Exchange (aka PLEX aka: plasma exchange, aka: apheresis) Under nephrology direction, is provided for conditions including neurology, hematology, rheumatology, pulmonary, triglyceride removal, toxin removal and renal function. Cell separation is not available for Sickle cell disease
  • Continuous renal replacement therapy
  • ICP monitoring/ventriculostomy drains
  • Targeted Temperature Management
  • Proning therapy/Rotoprone

XXI. IMC-Meriter Preferred

  • Not Intubated,
  • staffed RN 3-1, drips
  • minimal titration (this is dependent on the types of drips),
  • BiPAP okay
  • Hospitalist Managed

XXII. Medical Transplant Kidney

  • Patients under the age of 18 are strongly preferred for AFCH
  • Patients <12mo out from surgery should preferentially be admitted to UH
  • Patients should preferentially be admitted to UH if:
  • They are experiencing fevers
  • Have acute renal insufficiency or are not at their baseline renal function
  • Have unexplained abdominal pain
  • Have been diagnosed with an opportunistic infection
  • Have been diagnosed with a post-transplant malignancy
  • Patients who do not have any of the above exclusions may be considered for EMH or Meriter Hospitalist service if:
  • Patient is unlikely to require renal transplant service consultation.
  • The admitting diagnosis is unlikely to require modification of the patient's immunosuppression.
  • The admitting diagnosis is unlikely to decrease the patient's renal function.
  • If considering admission to Meriter or EMH the case must first be discussed with medical transplant staff physician to determine best care for the patient, followed by the appropriate hospitalist for admission

XXIII. Medical Transplant Liver and/or Pancreas

  • Patients under the age of 18 strongly preferred for AFCH
  • All liver and pancreas transplant patients are to be discussed directly with the liver or pancreas transplant attending. These patients should preferentially be admitted to UH unless otherwise specified by the transplant attending.
  • Patients < 3 months out from surgery will be admitted to UH
  • Patients with concern for rejection or infection strongly preferred for UH. These patients must be discussed with Transplant staff.

XXIV. Medical Transplant Lung

  • Patients under the age of 18 are strongly preferred for AFCH
  • All patients with planned or completed lung transplant requiring admission should preferentially be admitted to UH

XXV. Minimally Invasive Surgery*

XXVI. Neurology

  • Patients under the age of 18 are strongly preferred for AFCH
  • Any patient requiring admission for known or suspected ischemic stroke should be triaged by paging UH "Stroke Staff" prior to admission to UH or Meriter
  • Patients with non-stroke complaints requiring admission for neurological issues can be preferentially admitted to Meriter except for:
  • Patients in refractory status epilepticus should preferentially be admitted to University hospital
  • Patients with complex neuromuscular disease should preferentially be admitted to University hospital
  • Patients with neurological issues needing admission should not preferentially be admitted to EMH
  • Seizure patients on a ketogenic diet have a strong preference for UH admission

XXVII. Neurosurgery

  • Patients under the age of 18 are strongly preferred for AFCH
  • Most neurosurgery patients will preferentially be admitted to UH, however patients already in the Meriter ED with the following are usually preferred for admission to UH but may be appropriate for Meriter:
  • aneurysmal subarachnoid hemorrhage
  • strokes with need for possible endovascular treatment
  • Neurosurgical issues with co-morbid conditions that exceed Meriter ICU capability
  • Neurosurgery attending should be involved in all regional referrals to determine best location (Meriter or UH)
  • Neurosurgery patients are not preferred for admission to EMH

XXVIII. Obstetrics and Gynecology

  • Patients requiring admission for OB/GYN issues should preferentially be admitted to Meriter
  • For any patient under the age of 18 and not pregnant that requires admission or a procedure for a Gynecological condition there is a strong preference for AFCH
  • For gyn onc admission see separate playbook section

XXIX. Oncology

EMH: Hospital Medicine team is primary. Appropriate patients are those with:

  • Solid-organ malignancy on active treatment admitted for simple medical conditions or non-cancer-related conditions who will not require inpatient chemotherapy.
  • No procedural interventions or inpatient radiation is anticipated. Ex:
  • AKI
  • Gastrointestinal side effects from chemo.
  • Hemodynamically stable neutropenic fever without the need for Procedure.
  • Failure to thrive.
  • Weakness.
  • Mechanical fall with trauma.

UH: Preferentially admitted to the Hospitalist-Oncology service. Patients with:

  • Established solid-organ malignancy admitted with complex medical illness requiring subspecialty or procedural support.
  • Severe reactions to chemotherapy or immunotherapy.
  • Need for inpatient radiotherapy.
  • Also appropriate are patients being hospitalized with new diagnosis of likely solid-organ malignancy based on labs & imaging.

Meriter: Hospital Medicine team is primary.

  • Patients are preferential for Meriter if they are followed by the general oncologists (listed below) who consult at UPH-Meriter, and the patients do not have a subspecialty need warranting admission at UH. Inpatient chemotherapy is possible at Meriter.
  • Dr. Robert Hegeman
  • Dr. Saurabh Rajguru
  • Dr. Amy Stella
  • Dr. Johanna Poterala
  • Dr. Luke Zurbriggen
  • Dr. Elyse Harris
  • Dr. Trevor Dennie
  • Ali Colwell APNP
  • Danielle Lima APNP
  • Nicki Seager APNP

XXX. Ophthalmology

  • Patients under the age of 18 are strongly preferred for AFCH
  • Patients needing ophthalmology procedures or consultation are non-preferred for admission to EMH
  • Patients needing ophthalmology procedures or consultation are non-preferred for admission to Meriter
  • Most patients requiring admission for primary ophthalmology evaluation will be preferentially admitted to UH

XXXI. Orthopedics

  • Patients under the age of 18 are strongly preferred for AFCH
  • Preferred for Admission to EMH Ortho
  • Infected joint replacement
  • Isolated wrist, hand, foot, and ankle fractures (per on-call physician)
  • Non-fracture spine (per on-call physician)
  • Preferred for admission to Meriter Ortho
  • Geriatric Hip Fractures (age 65 or older) with an isolated hip fracture (per on-call physician)
  • Hip fractures (per call physician)
  • Isolated foot and ankle fractures (per on-call physician)
  • Isolated wrist/hand (per on-call physician)
  • Non-operative stable pelvic fractures
  • Preferred for Admission to UH Ortho
  • Trauma (level 1 & 2)
  • Long bone fractures (femur, tibia, humerus)
  • Peri-prosthetic fractures
  • Open fractures
  • Spine fractures
  • Pediatric fractures
  • Pelvic fractures
  • Elbow fractures
  • Shoulder fractures
  • Hip fractures – Non-Geriatric (per on-call physician)
  • All admissions should be discussed with on call orthopedic resident/ faculty to determine best care for the patient

XXXII. Palliative Care

  • Patients under the age of 18 are strongly preferred for AFCH
  • Palliative Care can be provided preferentially by UH and Meriter. Patient preference should be used to determine placement

XXXIII. Pediatrics/NICU

Most pediatric admission should be preferentially admitted to AFCH except:

  • Neonates with Hyperbilirubinemia requiring admission will most commonly be admitted to the general pediatric hospitalist team at AFCH. If the following are present discussion with the AFCH NICU attending should occur for triage prior to placement decision in general care vs NICU:
  • Referring provider anticipates exchange transfusion may be needed
  • Neonate demonstrates vital sign instability
  • Neonate demonstrates excessive irritability
  • Neonates requiring NICU level of care should be discussed with the AFCHNICU attending for triage prior to placement decision.
  • All neonates being discussed for admission who have been discharged from the Meriter or AFCH NICU within the preceding 7 days should be discussed with the AFCH NICU attending before placement.
  • Pediatric patients who are pregnant and in their 3rd trimester may be preferred for admission to Meriter. OB and Pediatrics staff should discuss these cases prior to placement.

XXXIV. Peritoneal Dialysis

EMH Criteria

  • Patients needing Peritoneal Dialysis should be preferentially admitted to Meriter UH

XXXV. Psychiatry

  • Psychiatry non-preferred criteria for admissions to EMH
  • Patients requiring in person psychiatric consultation during admission. (Tele consults are available)
  • Meriter and UH have similar psychiatric capabilities and preferred admissions decisions should be based on each site's real-time capability to care for the patient
  • Patients under the age of 18 are strongly preferred for AFCH

XXXVI. Rheumatology

Patients preferred for admission to University Hospital

Patients that carry a diagnosis of:

  • SLE
  • Polymyositis/dermatomyositis
  • Scleroderma
  • Relapsing polychondritis
  • Raynaud's (requiring hospitalization for critical ischemia)
  • Behcet's disease
  • Vasculitis (except giant cell arteritis)
  • Sarcoidosis (neuro/cardiac)
  • Any rheumatic disorder with interstitial lung disease
  • Antiphospholipid syndrome
  • Autoinflammatory diseases (includes FMF, Still's disease, TRAPS, Muckle-Wells, NOMID/CINCA, DADA2)
  • Macrophage activation syndrome (MAS)

Patients under the age of 18 are strongly preferred for admission to AFCH

Preferred for admission to EMH or Meriter

Patients that carry a diagnosis of:

  • RA
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Giant cell arteritis (preferred for Meriter not preferred for EMH)

Patients with the following condition may be preferred for EMH or Meriter after consultation with radiology to determine the availability of MSK ultrasound at the preferred site.

  • Gout
  • Pseudogout
  • Septic arthritis
  • Acute mono arthritis

XXXVII. Surgical Oncology*

XXXVIII. Thoracic Surgery

  • Patients with chest tubes not requiring surgical intervention can be preferentially admitted to Meriter hospital medicine service with consultation from pulmonary medicine
  • No patient with or who is likely to require a chest tube should be preferentially admitted to EMH
  • Patients being admitted with chest tubes status post recent thoracic surgery or admitted as a complication of thoracic surgery should be preferentially admitted to UH
  • Patients in need of possible thoracic surgery should be admitted with strong preference to UH
  • Patients under the age of 18 are strongly preferred for AFCH

XXXIX. Transplant Surgery Cardiac

  • All patients with a heart transplant should be preferentially admitted to UH
  • Patients under the age of 18 are strongly preferred for AFCH

XL. Transplant Surgery Kidney or Pancreas

  • Patients who are <3 months post op from transplant
  • All should be admitted with strong preference to UH
  • Patients under the age of 18 are strongly preferred for AFCH

XL. Transplant Surgery Liver

  • Patients who are <3 months post op from transplant.
  • All should be admitted with strong preference to UH

XLI. Trauma Surgery

  • Patients seen and evaluated at UH for a traumatic injury being admitted for treatment of the traumatic injury should be admitted with strong preference to UH.
  • Patients seen an evaluated at UH who are found to have a traumatic injury but will be admitted predominately for a medical issue should be admitted preferentially to UH and non-preferentially to Meriter or EMH.
  • Patients evaluated at EMH who need admission for care of their traumatic injury should be admitted with strong preference to UH.
  • Patients evaluated at EMH who are found to have a traumatic injury but require admission for a predominately medical issue can be preferentially admitted to EMH if no other EMH non-preferred criteria are met.
  • Patients evaluated at Meriter or come to Meriter through the access center who are found to have a traumatic injury but are being admitted predominately for medical reasons can be preferentially admitted to Meriter or EMH if no other EMH or Meriter non- preferred criteria are met.

XLII. Urology

  • No patient requiring urology consult or intervention should be preferentially admitted to EMH
  • Urology admissions from the ED should be discussed with urology. Urology attending (Meriter and EMH ED) or Urology adult res ER/Consult (UH ED) to determine preferred admission location.
  • In general, the following patients are preferred for Meriter.
  • They are being admitted from an ED for management of nephrolithiasis.
  • Patients that are recently post-op from a procedure performed at Meriter.
  • Patient is followed by Meriter urology attending (list below)
    • Sarah McAchran
    • Brian Le
    • Tudor Borza
    • Chris Manakas
    • Craig Kozler
    • David Paolone
  • Most Regional Referrals should preferentially be admitted to UH, discuss with on-call urology attending.

XLIII. Vascular Surgery

  • Non-preferred for admission to EMH and Meriter
  • Vascular patients should not preferentially be admitted to EMH
  • Patients with emergent vascular intervention or operation needs should be with strong preference admitted to UH
  • Patients with other non-emergent conditions still requiring admission to vascular surgery may be considered for preferential admission to Meriter
  • All patients considered for admission to vascular should be discussed with on call vascular surgery attending to determine best care for the patient

XLIV. Wound Service

Rationale: "Complex wounds" are wounds that require a specialized wound nurse &/or provider to perform and oversee wound care, wound cares that use extra medications necessitating special monitoring, or if there is a need for a multidisciplinary approach to the treatment (i.e. ortho/plastics/vascular, etc.).

Patients who need to stay at UW:

  • Burns
  • Frostbite
  • Necrotizing fasciitis
  • TENS
  • Purpura fulminans
  • Complex surgical wounds – requiring VACs, dressings that the bedside nurse is unable to complete
  • Wounds with fistulas/ostomies involved in wound area
  • Complex painful wounds requiring extensive wound care and pain control
  • Complex pressure ulcers that require multidisciplinary approach (ortho/plastics interventions in the long run)
  • LE edema that requires compression wraps (UW or Meriter Not EMH)

Patients who could go to Meriter:

  • Complex pressure ulcers that are currently managed by Meriter Plastic Surgeon Dr. Jeff Larson or Meriter Wound Physician Dr. Ifat Kamin
  • LE edema that requires compression wraps (UW or Meriter – Not EMH)
  • If unsure about triaging, please call the Burn Unit 263-1490 and ask to speak to the Care Team Leader. They will be able to help you with the decision. The use of Image Mover (or future image capture applications) to upload images into the EMR will facilitate the discussion if possible. If there are still questions, please admit the patient to UW and the Burn and Wound service will triage as soon as they are able to evaluate the patient and determine needs.
  • No patients with complex wound needs should be triaged to EMH – this includes cellulitic swollen legs that require compression.

Diabetic Foot Ulcer Admissions (DFU)

  • For patients with a primary medical issue requiring admission that is NOT the DFU/foot wound, preference is either UH or Meriter, according to the Playbook for the medical issue.
  • For patients requiring admission with a primary issue of DFU/foot wound who have established UWH/Meriter care with either vascular surgery or orthopedic surgery for the wound, preference is per the established team, vascular or ortho.
  • For patients requiring admission with a primary issue of DFU/foot wound who have established local care with podiatry, preference is for admission to Hospital Medicine at Meriter.
  • For patients requiring admission with a primary issue of DFU/foot wound who do not have established local care for the wound, preference is for admission to Hospital Medicine at Meriter.
  • EMH is not preferred for DFU/foot wound patients unless they have established care with orthopedic surgery.

XLV. Escalation Procedure

  • Providers and Access Center should follow the playbook unless the playbook creates a patient safety issue or does not account for a unique clinical situation or unstable emergency medical condition.
  • If there is disagreement on service, location, or level of care the UWHealth (including Meriter) attendings involved should discuss and decide on best course of action for the patient.
  • If in the rare event the attending provider discussion does not lead to resolution, then the issue should be escalated in the following manner:
  • Division Heads or equivalent for the involved services should be contacted to remedy the barrier.
  • Department Chairs for the involved services should be contacted to remedy the barrier.
  • Chief Inpatient Medical Officer/s for the involved hospital/s should be contacted to remedy the barrier.
  • UWHealth Chief Clinical Officer should be contacted to remedy the barrier.
  1. Any "cap" referenced in this Playbook reflects a preference and there may be situations where the "cap" is exceeded. For example, patients presenting to the UH ED with unstable emergency medical conditions requiring admission will be admitted to the UH despite a cap if the UH has the capability and the capacity to treat the patient.

Version: 10/25/24