UH Hospitalist Triage: Duties and Workflow¶

Coverage Hours¶

6am-7am Admit 1 hospitalist

7am-6pm Triage Day hospitalist

6pm-6am Triage Night hospitalist

Objectives and Duties¶

Accurate Triage of new admissions from ED and Access Center, planned admissions, and transfers from other services while avoiding unnecessary admissions or location maltriage events. Right patient, right bed, right time per UW Health.

Expeditious Throughput for patient movement via early identification, order writing, active bed placement, and timely assignment of other admitters.

Day Triage Workflow¶

7am: Assume Triage Responsibility

1. Ensure you are physically present at UH, available on secure chat and on pager.

2. Print Triage Worksheet. This is emailed weekly and on Box (Service Duties and Performance > University Hospital Service Lines > UH Triage Details)

3. Receive handoff from Admit 1

   a. review whether surge is needed/called

   b. review bed status of UH, EMH and Meriter for admissions

   c. review patients on the Hos UH System Triage List

   d. review HOS Admission Team patients (HAT)

   e. Review HOS EMH Queue Team patients and assign pts to Hos 1-7 for rounders to see, if not already done

   f. review any work being done by admitters/rounders at present

4. Determine GMED censuses and which is long, short, post and no call

5. Determine Family Medicine census. FM cap is 14 from 7am-7pm and 16 from 7pm-7am

6. Assess census and APP staffing of HosMed services

7. Identify the HosOnc censuses; compare to cap

8. Review CVM censuses: they may contact us to take some CVM pts if CMB+CMR≥26 and HosMed at UH \< 86; we may contact them to take some HosMed pts if CMB+CMR≤14

9. Review HOS TRIAGE PLANNED ADMISSIONS list for planned admissions for the current day

10. If EMH is "Green", then screen Hos 1-7 inpatient boarders in "Ready to Plan" Status in the ED for potential EMH appropriateness. If plausible for inpatient care at EMH, reach out to rounder via secure chat to ask them to consider whether the patient could have their care provided at EMH and to ask the patient about willingness to have their room at EMH. If this all works later, then UH triage should identify receiving EMH team, connect rounder with EMH provider, enter new Decision to Admit & Bed Request order in the ED Orders, update any sign and held admission orders to new team, and communicate update with ED RN.

11. Reconcile the patients on the "Hos Triage System Declined Transfer List" with the patients accepted to HosMed on the "HOS Triage Access Center Patients" list

7am (Mondays only):

Send secure chat message to all rounding attendings and APP about geographic placement. One possible message:

"Tonight, triage and XC will facilitate reassigning patients to HosMed services to improve geographic placement. If you have a patient who you think should not change service (e.g. followed by a medical student, followed by an APP that is providing continuity, etc), then please put "NO TRADE" in the Handoff To Do column of the signout list."

7-7:30am: Surge

If surge has been called into UH, then ensure that there are appropriate patients copied to HOS UH Surge list. This may require communication with specific rounding teams. If any adjustments are made after 7:30am, explicit communication with the surge hospitalist is needed.

7am-5pm: Triage Critical Care Patients to Medicine Services

7am-6pm: Take Access Center (AC) Calls

11am-6pm on non-holiday weekdays: take access center calls that are known to require UH HosMed acceptance, especially admissions from a UH clinic to a UH medicine team. Other AC calls (e.g. unclear to what hospitals the patient may be appropriate or to what service) should be managed by System Triage.

7am-12pm on weekdays and 7am-6pm on weekends and holidays: take all access center calls requiring Hospital Medicine involvement

The AC expects that pages to triage hospitalists will be answered within 5 minutes. Let the AC RN know if you receive another AC page, so that they can convey the expected delay.

There are many suggestions for optimizing the taking of AC calls in the "Access Center-mediated admissions" section of this document

7am-6pm: Triage ED Requests for Admission/Consult

Triage hospitalist is to respond to all pages from the UH ED. Triage hospitalist (or an assigned other hospitalist or GM team) will evaluate accepted patients. The EMH Queue process started 3/2025. Patients accepted to HosMed at EMH should be accepted to "Hospitalist EMH Queue Admission Team" as the receiving service whether or not EMH has beds available. This list will need to be monitored closely -- when a bed is assigned at EMH, the, the access center should communicate to you and admitter/rounder depending on if same day placement or next day placement for boarder. At that time, a Transfer/Update Patient order is needed to move pt from Hospitalist EMH Queue Admission list to the appropriate EMH team (e.g. A/B/C/D). This will require guidance from EMH Triage/Admitter for team selection. Patients accepted to EMH need to be seen most expeditiously. See the EMH Triage guidelines if you are unfamiliar with what can be accepted to EMH, and stay in regular communication with EMH Triage/Admitter.

8:30am: Attend JOA Huddle (optional)

Non-holiday weekdays only. This meeting updates bed status and expected upcoming changes to those statuses. The meeting starts on time and lasts no more than 5 minutes. The link is https://uwhealth.webex.com/uwhealth/j.php?MTID=m3fb096b46c6aa0d7b8bdccce66991a95.

11am: Check in with Admit 2

11am (non-holiday weekdays): check in with System Triage

Ideally, system triage will reach out to you via secure chat. UH Triage should communicate any Access Center cases still being evaluated and determine whether UH Triage or System Triage should be contacted for next steps. Having an active Access Center case without disposition is anticipated to be uncommon.

10:30am-1pm: Connect with GMED Meet with the long call (and short call if weekday) GMED team residents in their team rooms or via Secure Chat to assess discharges and case diversity.

3pm: Check in with Admit 3

5pm: Check in with Admit 4

6pm: Sign out to night triage

1. Ensure that UH System Triage List includes all active triage cases, remove completed cases

2. Give handoff to Triage Night hospitalist

   a. review bed status of UH, EMH and Meriter for admissions

   b. identify the long call GMed team, how many "spots" the night admission team has remaining, and when they last received an admission

   c. convey which Hos teams have APPs the following day

   d. identify the admitters and provide update on what work they have been given already

   e. review patients on the UH System Triage List

   f. review HAT patients being managed by triage (if any)

   g. review HOS EMH Queue Team list

3. Ensure that admissions/consults/transfers are submitted to REDCap (https://redcap.medicine.wisc.edu/surveys/?s=JH3C3ND4WT8EJK4J)

Subspecialty Nuances & Random Tips

1. If called about patient in ED with traumatic injury, there is "Trauma Guidelines" in Triage folder available to review if you have concerns about trauma evaluation.

2. Family Medicine -- sometimes the ED doesn't recognize the patient has Fam Med attending, consider reviewing the PCP when accepting admissions. Patients who were originally on Fam Med and then transferred to IMC or TLC, can be sent back to Fam Med when appropriate for Gen Care, regardless of cap. Same with bouncebacks to the same attending, they can go over cap.

3. Obstetric & Postpartum care (see document on Box). In brief, if no beds at Meriter, we can accept pts that are \<18 weeks gestation with a MFM consult. Any post-partum patient >6 weeks post can be cared for at UH with MFM consult.

4. Cardiology: they can be expected to see consults in the ED during daytime hours Mon-Sat. There is a specific admission criteria that is uploaded on Box in Triage folder that directs whether pts should be on Cardiology service or Medicine service.

5. Pain pump patients: We occasionally care for planned admit pain pump placement patients. See Box for details.

6. IR & Radiology procedures: We admit post-ablation & post-TIPS patients, including TIPS pts that are on GMed (they will come to us for one night and then transfer back to GMed if stable).

7. Chronic trach & vent weaning patients are accepted to Hos services.

8. Orthopedic patients that need IMC should transfer to Hos as primary with Ortho as consult.

9. Hos-Oncology: Two Hos-Oncology services rotate admissions starting at 7 AM. The \"Oncology Admissions\" pager reflects who is responsible. The first 2 admissions before 4pm should be done by Hos-Oncology. The 3^rd^ and subsequent admissions for the day should be discussed between Triage and Hos-Oncology, with preference for Hos-Oncology to do them if not otherwise too busy. The service caps at 20 patients (10 per team). See Box for further details on Green/Yellow/Red zones and proposed transfer criteria from Hos-Oncology to Hospital Medicine to offload Hos-Oncology to accept new preferred patients. The hospitalist on oncology may triage the patient to EMH, after which an admitter or triage will need to be assigned and admit the patient. Patients followed by East Park providers (formerly 1 S Park) should be preferentially accepted to Meriter rather than UH--see Box for list of these providers.

Night Triage Workflow¶

6pm: Assume Triage Responsibility

1. Ensure you physically present, and are available on secure chat and on pager

2. (optional) Print Triage Worksheet. This is emailed weekly and on Box (Service Duties and Performance > UWHC Service Line Info and Agreements > Triage Hospitalist).

3. Receive handoff from Triage Day hospitalist

   a. review bed status of UH, EMH and Meriter for admissions

   b. identify the long call GMed team, how many "spots" the night admission team has, and when they last received an admission

   c. identify which Hos teams have APPs the following day

   d. Identify the HosOnc censuses; compare to cap

   e. identify the admitters and provide update on what work they have been given already

   f. review patients on the UH System Triage List

   g. review any HAT patients being managed by triage (if any) and HAT (UH to EMH) list

4. Determine Family Medicine census (cap is 14 6p-7pm, then 16 7p-7a)

ED admissions

1. All medicine admissions are to be triaged to either a Hospitalist or GMED service (when possible, it is recommended that night triage go directly to the GMED team rooms to discuss admissions).

2. All subspecialty services from 7:00pm to 6:00am. Please refer to 'Universal Night ED Triage' document which is located in the 'Service Duties and Performance' section of the division website under 'Nocturnist Duties' for full details on triaging these patients at night.

3. The EMH Queue process started 3/2025. Patients accepted to HosMed at EMH should be accepted to "Hospitalist EMH Queue Admission Team" as the receiving service whether or not EMH has beds available. This list will need to be monitored closely -- when a bed is assigned at EMH, the, the access center should communicate to you and admitter/rounder depending on if same day placement or next day placement for boarder. At that time, a Transfer/Update Patient order is needed to move pt from Hospitalist EMH Queie Admission Team list to the appropriate EMH team (e.g. A/B/C/D). This will require guidance from EMH Triage/Admitter for team selection.

Access calls overnight

1. There are many suggestions for optimizing the taking of AC calls in the "Access Center-mediated admissions" section of this document

2. The night triage hospitalist [does not]{.underline} take subspecialty Access calls. These calls go the subspecialty service attending. This includes oncology, who should be involved, though acceptance would be by triage hospitalist

REDCap Admissions/consults logging

Triage hospitalist logs any admission or consult done at UH into REDCap at https://redcap.medicine.wisc.edu/surveys/?s=JH3C3ND4WT8EJK4J

7pm: Check in with Subspecialty Cross-Cover

5am: Assign patients from HAT to patient services / Surge review

Consistent with the Geographic placement document, patients are to be reassigned from Hospitalist Admission Team to numbered services. This is best done with a "Transfer/Update Patient" order. Patients with Signed & Held orders (usually patients still in the ED), need this and also need to have any signed and held Admit to Inpatient or Place in Observation Order changed with the numbered service

EMH boarding patients: Review the HOS EMH Queue Team list. Any patients admitted overnight that are boarding in the ED and awaiting an EMH bed need to be assigned to a rounder service at UH. Ideally this is done by right-clicking and using the "Assign Teams" function to add the assigned numbered UH HOS team. Do not enter a transfer order at this stage (i.e. need to await a bed assignment from AC before doing that). Please make it obvious in Handoff tab they are awaiting a bed at EMH.

Before 6am: Surge

Review censuses of the UH teams. If 6am surge criteria are met (see "Hospitalist Sick-Surge" in the Service Duties and Performance folder on Box), assign an appropriate patient from each rounding service. This includes copying the patient to the "HOS UH Surge list" in HealthLink with a comment in the handoff section of the patient list (e.g. "on Hos2 and being seen November 27 by surge on UH Surge list"). Coordinate surge call in needs with EMH night triage.

6am: Sign out

1. Ensure that UH System Triage List includes all active triage cases and that completed cases are removed

2. Give handoff to Admitter 1 hospitalist

   a. review bed status of UH, EMH and Meriter for admissions

   b. review patients on the UH System Triage List

   c. review any HAT patients & HOS EMH Queie Team patients

   d. Relay surge status: convey who is to be called in to UH if surge is activated

3. Sign out to subspecialty services

   i. No sign out if a new admission is stable and admitted

   ii. Sign out to SS XC if a new/recent subspecialty admission needs something followed up in the early am. SS XC can then contact the subspecialist (either staff, fellow, or APP) via text at 7:00am.

   iii. Any new subspecialty admission from the ED who was complex or marginally unstable should be discussed in real time with subspecialty staff overnight. If this was not done for some reason, a verbal sign out to the subspecialty staff between 5:45-6am is of utmost importance for patient care.

4. Ensure that REDCap submissions are complete (https://redcap.medicine.wisc.edu/surveys/?s=JH3C3ND4WT8EJK4J)

5. New admissions should not be given to the GMED call team between 6-7am unless there are 2 or more admissions in the ED or their total census is \<12 toward the end of the night).

Admit 1's Triage Workflow:¶

6am: Assume Triage Responsibility

1. Receive handoff from Triage Night hospitalist

   a. review bed status of UH, EMH and Meriter for admissions

   b. review patients on the UH System Triage List (if there are pending consult requests, these should be signed out to day consults)

   c. review any HAT patients and HOS EMH Queue Team patients

   d. discuss whether surge is activated; if so, who is to be called in

2. Review Hos Triage Planned Admissions list

There may be planned admissions with early procedure times (e.g. 0730) that can be seen preprocedure and the admission started (or finished) early in the shift if there is no competing admissions work to do at the time

6am-7am: Take Access Center and ED calls / surge call-in

Generally, the same as for day triage -- HosMed does not accept subspecialty patients after 6am, except for oncology and Advanced Pulmonary Service. It is anticipated that patients accepted by Admit 1 in their triage role will be admitted by that admitter, but this should be discussed at signout to day triage.

Sometimes, a rounder may reach out to help with admissions between 6a-7a.

If surge is activated, Admit 1 is to call in the surge provider between 6a and 6:30a.

EMH Queue process: The EMH Queue process started 3/2025. Patients accepted to HosMed at EMH should be accepted to "Hospitalist EMH Queue Admission Team" as the receiving service whether or not EMH has beds available. This list will need to be monitored closely -- when a bed is assigned at EMH, the, the access center should communicate to you and admitter/rounder depending on if same day placement or next day placement for boarder. At that time, a Transfer/Update Patient order is needed to move pt from Hospitalist EMH Queue Admission Team list to the appropriate EMH team (e.g. A/B/C/D). This will require guidance from EMH Triage/Admitter for team selection.

7am: Sign out to Triage Day hospitalist

1. Ensure that UH System Triage List includes all active triage cases and that completed cases are removed

2. Give handoff to Triage Day hospitalist

a. review bed status of UH, EMH and Meriter for admissions

b. review patients on the UH System Triage List

c. review Hospitalist Admission Team patients (HAT) and HOS EMH Queue Team patients.

d. review any work being done by admitters/rounders at present

3. Ensure that REDCap submissions are complete (https://redcap.medicine.wisc.edu/surveys/?s=JH3C3ND4WT8EJK4J)

Basics of triaging admissions for UH triage¶

UH ED Admissions:

1. The ED physician pages the Triage hospitalist for all general care and IMC medicine admissions to UH and EMH. Admissions to Meriter do not go through UH triage. The triage hospitalist assigns provisional admitting service (e.g. HAT, HOS EMH Queue Team, or GMed) and level of care if this can be effectively done without seeing the patient. Triage might do the admission. If not, triage contacts an appropriate admitter or GMED team to do the admission.

2. Triage Hospitalist or admitter may need to assess the patient in ED if there is uncertainty as to disposition (IMC vs. general care; UH vs EMH; discharge directly from ED and no need for admission). In this case, no service assignment is given to the ED until after this assessment.

3. If the patient is accepted to EMH the ED will place "Decision to Admit & Bed Request\" order with "UW Hospitalist EMH Queue Admission" as the provider care team

   a. Bed immediately available: Admitter sees patient expeditiously, confirms EMH is appropriate destination, and can place order to admit to specific EMH service, per your communication with EMH Triage/Admitter.

   b. Bed not immediately available: Admitter sees patient, confirms EMH is appropriate destination, places admission order to "UW Hospitalist EMH Queue Admission" team. Patient will board in the UH ED until an EMH bed becomes available.

   a)  When bed assigned, a Transfer/Update Patient order to EMH
       Hos A/B/C/D will need to be placed and direct handoff
       between UH hospitalist managing to EMH hospitalist receiving
       should be performed. If it is same day it will likely be
       handled by UH admitter or UH Triage, if next day a UH
       rounder will be following the patient.
   

   c. If a patient that was accepted to EMH stops being appropriate to send to EMH for any reason, please contact patient placement (verbally at 720-3311 or through secure chat if that is already in process) as soon as possible to get the patient reassigned and stop the physical transfer

4. If the ED patient is not admitted to medicine:

   a. Admission to go to non-medicine service: This can be handled two separate ways. If it is obvious that a patient belongs on a subspecialty service (eg: otherwise healthy patient with obstructing kidney stone), ED contacts the primary service. If there is any 'gray area' on which service a patient belongs and the ED calls us to admit but we disagree, we are to contact the appropriate subspecialty service's staff to discuss the patient's admitting service.

   b. No admission needed but patient contact requested by ED: provide consultation to coordinate outpatient needs and give a medical recommendation; write a consult note to fully document the patient contact.

   c. No admission needed and ED does not request that patient be seen: either no documentation needed or a short miscellaneous note to document conversation with ED and recommendations given.

EMH ED Admission to UH: You may be called for admissions.¶

EMH hospitalist should be involved. The default assumption is that EMH hospitalist should see the patient at EMH and write the H&P and orders.

Transfers from medical (TLC), cardiac (CCU) or Surgical ICU (SICU)¶

Presumably, you are being called because the patient is improved in the ICU and appropriate for IMC or general care. If the patient is appropriate to step down to a medical service, then UH triage takes the call. It is not uncommon to need to see the patient before determining the level of care. Patients that are appropriate to step down to a medicine service could potentially be appropriate to step down to HosMed, GMED or FamMed. The last only applies if the patient was admitted to FamMed or Critical care initially, has not been managed by HosMed or GMED, and is appropriate for general care.

Some calls will be for patients that are not appropriate for a medical service and would be most appropriate for otolaryngology, urology, general surgery, cardiology, etc. These cases may require multiple phone calls to determine the appropriate service much in the same way that many ED calls do.

Triage Hospitalist will answer all requests for transfer from ICU teams and determine appropriateness of transfer. Sometimes, in-person evaluation is needed to know if appropriate.

a) Medical Critical Care ("TLC") team is to write interim summary if patient has been on their service for 3 days or more.

b) If a Medical Critical Care patient is located on B6/3 (i.e. in the TLC), requires IMC status, and there are no IMC beds available for the patient to transfer into, the patient should remain on TLC service until an IMC bed is available elsewhere. There are rare exceptions to this rule (e.g. patient is IMC status due to frequent labs but is otherwise HD stable) that should be taken into consideration. See "TLC to IMC Transfer Policy" for details.

1) Triage Hospitalist is to transfer ICU patients to Hospitalist services as time allows. If time does not allow, then timely assignment and hand off to an admitter or other hospitalist provider is needed. Transfers to GMED services are to have transfer orders written by house staff only.

2) If an ICU transfer request is called after 5pm, please refer to the details about those late calls below. However, if a transfer to general care (IMC patients should not be transferred to new service after 5pm) is straightforward and the available admitters are not busy, then the transfer should be done after 5:00pm.

There are time-related considerations about taking late transfers from the ICUs:

TLC patient transfer after 5pm: .

"TLC patient transfer after 5pm: If this occurs, the TLC resident or fellow will notify the triage hospitalist that the patient is ready for transfer to the IMC (providing an IMC bed is available-please refer to 'TLC to IMC transfer policy' for details) or general care. The triage hospitalist will assess whether the patient is appropriate for early am transfer at 7am or if TLC service should see the patient the following am to ensure clinical stability prior to transfer. This applies to both IMC and general care patients (ie-appropriate for general care but with active medical issues such as ongoing encephalopathy or frequent labs which require early am assessment may not be appropriate to transfer at 7am). The patient will remain on TLC service until the following am with the option of having eICU follow the patient overnight. The triage hospitalist, depending on acceptance, will either add the patient to a Hos list with appropriate sign out or, if not

deemed acceptable for early am transfer, add the patient to the Hos

A) Patient appropriate for transfer the following am to Hos service: The triage hospitalist will ensure, via morning sign out to the following day triage hospitalist or Hos staff of the Hos service assigned that the patient is to be seen and their care transferred to a hospitalist service the following am. The TLC team has the option of utilizing eICU to follow this patient

overnight.

B) Patient deemed not appropriate for early am transfer: The TLC resident will round on the patient in the am. If the patient remains stable for transfer, TLC resident will notify the day

triage hospitalist"

If a patient needs IMC status, the current agreement is below:

"1) TLC resident is to page the Triage Hospitalist with all IMC transfers between the hours of 7am and 5pm as per prior agreement.

2) The Triage Hospitalist is to accept the transfer if there are IMC beds available. If there are no

IMC beds available, the TLC resident is to do the following:

a) Write a 'Transfer to Intermediate Care' order. The patient is to remain on the TLC service.

b) Change vital signs to q4h to keep in line with IMC vital sign frequency.

c) Discontinue ICU level of care orders such as pressors and sedation. Discontinue vent orders as appropriate-i.e. this would not apply to patients with tracheostomy who require ongoing ventilator support.

d) Write a nursing communication order stating "Please page triage hospitalist (pager 6687) when patient is transferred out of TLC to an IMC unit."

3) The triage hospitalist is to assign the IMC patient who will remain in the TLC a service. They will then notify the appropriate hospitalist (e.g. Hos1, Hos2, etc) and note on the signout that the patient will need to be seen and have transfer orders written when the patient transfers out of

TLC to an IMC unit. If the patient transfers out of TLC between 5pm and 7am, the patient is to

remain on the TLC service (see #4 below).

4) As per TLC-Hospitalist transfer policy, if the patient transfers out of TLC after 5pm, the patient will remain on the TLC service overnight and care will be assumed by the hospitalist service the

next am (shortly after 7am)"

Planned admissions¶

These are usually called by IR APP, GI RN, or pain anesthesia fellow the business day prior to the planned admission. There are other admissions planned by ophthalmology that may be called prior to or day of desired admission by the ophthalmology resident.

When called about these cases, triage should:

- review the chart (and especially the med list) and make hold recommendations as appropriate (e.g. prior to an IT pump placement, a patient would need to have anticoagulants held) to whoever is calling. Obtain information about

- when/where the patient arrives prior to procedure

- when the procedure is scheduled to begin

- add the patient to the "HOS TRIAGE PLANNED ADMISSIONS" list

- Use the "Handoff Summary (Cross Encounter)" column to put the date of the planned admission, the relevant PMH, history, arrival time, procedure time, and any other noteworthy recommendations or facts

- if the patient will be admitted on a day that the UH triage receive the call is not working, then triage needs to send an email to the person doing UH triage that day to let them know that a patient is planned to be admitted and provide the MRN

- if the patient will present early (e.g. 6:30am to 10-bed or FDS for a 7:30 procedure), then triage needs to send an email to the person doing Admit 1 that day to let them know that a patient is planned to be admitted, and provide the MRN. It is reasonable to send a text message the night before alerting the person that an email was sent about an early planned admission.

Access Center-mediated admissions:¶

Transfer requests (except UH ED to EMH) and direct admissions need to be routed through the access center. If you are called directly from a provider to accept such a patient, direct them to call the Access Center (263-3260, option 2). Otherwise, no bed will be arranged.

When called by the AC, open the patient's chart in the Intake Encounter. Two ways to do this follow:

- Under 'Chart Review', open the 'Enc' tab on the left. The AC RN will have created

an 'Intake' encounter. Open the Intake encounter (this may require you to alter your filters).

- enter the patient's chart from the "HOS Triage Access Center Patients" list.

Then, create a new note. For "note type", enter 'Progress' or 1. This will open a 'JOA Triage Hospitalist Access Center Note' (if not working, smart phrase is .JOAACTRIAGENOTE for the template). Once the JOA note is written, place the patient on the "Hos UH System Triage" list. If the patient is placed by the access center on the Declined Trasfer List (DTL), then instead place the patient on the "Hos System Declined Transfer List". Under the 'Notes' section of either

triage list, enter the date the call was taken and "Please see JOA triage note"-the JOA note

replaces all prior written synopses. If a patient is Meriter-appropriate, please make a note of

this in the 'Notes' section for future triage reference if a bed becomes available at Meriter.

How to approach an AC call depends on why they are calling:

Transfer of care:

- If an OSH is unable to provide the patient a service/level of care but we are able to

provide the necessary service/care for the patient. If the patient is best served on a medicine service, these patients should always be accepted.

- If the provider at the OSH is uncomfortable taking care of the patient's medical issues.

- "Patient/Family is requesting transfer" is acceptable if there is lack of certainty in

diagnosis and/or treatment or if the OSH provider seems unsure of plan of care. If an

OSH is comfortable managing the patient there, you are not obligated to accept the

patient due to patient/family request.

- If the reason for transfer is that a subspecialist is needed that is not available at the referring facility, then it may be useful to involve someone from that subspecialist on the call.

Procedure is desired:

You must ensure the procedure can be done in a timely manner prior to patient acceptance. The subspecialist who will be doing the procedure should be made part of the call to discuss when the procedure can be done. If the patient is stable and procedure is not urgent, accept the patient to come either the night before or the day of the procedure. If the patient is unstable/needs procedure in short order, the patient should be accepted for immediate transfer.

Advice is desired:

We can give general medical advice, but if the OSH provider is calling for subspecialty advice, direct AC to call the appropriate subspecialist.

Information to collect:

A) Vitals and mental status to assess level of service.

B) Appropriate labs and diagnostic studies. Try to avoid getting bogged down into asking

for all labs.

C) It is okay to ask the outside provider what they think is going on with the patient but

try to avoid asking too many questions such as "Did you think of X?". There are times

when outside providers are asking to transfer due to diagnostic uncertainty.

D) What information/recommendations (if any) were made by other UW specialists?

Acceptance:

If a patient is accepted it may be a good idea to ask the for following:

-reciprocity if a patient is an inpatient and may have ongoing inpatient needs once the

issue we've been asked to address has been appropriately addressed.

-discharge summary, labs/radiology reports to be sent with the patient. Imaging done at

OSH should be pushed through to our PACS system.

When accepting, the access center would benefit from knowing:

- what service (will likely be a medicine service; if accepted to a subspecialty service, then that attending should be the one accepting)

- what level of care

- what hospital (there may be patients that are appropriate for acceptance to EMH, UPH-M, and/or UH)

If an OSH ED patient's care level is unclear (general care vs IMC vs ICU), it may be reasonable to consider ED evaluation to determine appropriate level of care.

Denial:

There may be times that a patient does not need to transfer and acceptance is not appropriate. For instance, the patient may be able to be managed at the referring, the requested procedure may not need to be done in the inpatient setting, the subspecialist to which they are being sent to see does not feel the patient needs to be seen by them. In these cases, it can be appropriate to decline to accept. However, keep in mind the requirements imposed by EMTALA on accepting patients who are referred from an ED and for whom the referring claims medical necessity for capabilities they do not have and that we do.

Practice pearls for AC calls:

-If it seems clear at the beginning of the conversation with the OSH provider that the patient

should go to another service (e.g. type 1 NSTEMI, massive PE with unstable vitals, sepsis and has already been given 3L IVF with continued marginal BP, etc.), it is best to a) ask for the

appropriate service to be called and end the call (if completely clear that the patient is better

served on another service and explain your reason to the OSH provider) or b) if it's not entirely

clear which service a patient would best serve their needs, ask that the appropriate

subspecialist join the call and discuss with them the patient's situation.

-If you have already taken all of the information, are near the end of the call, and think the

patient needs to come to UH but be admitted to a subspecialty or surgical service, tell the OSH

provider we will take the pt and then talk to the staff from the other service off-line. Avoid

making the OSH physicians speak to multiple services.

-If you think another service should be on the line while you are talking with OSH (e.g.

hepatology, surgery, etc), ask the Access RN to connect a 3-way call. This is helpful in situations in which a patient may benefit from being admitted to a subspecialty service, need a procedure that may not be able to be scheduled for a few days (no need to transfer a stable patient until prior to procedure-e.g. double-balloon enteroscopy), or if a patient may not need transfer but a telephone consult only.

-If a patient sounds tenuous and may require ICU level care or surgical evaluation prior to being

admitted to a medicine service, the patient can be routed through our ED for a bedside

assessment. In this case, either have the AC RN add the ED physician in charge to the call or end the AC call and call the ED physician in charge directly at 262-2398 to discuss this. If the patient is routed through the ED, the ED will call Hos triage for patient assessment when the patient arrives.