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Patient Populations Admitted to DHM

Hospital Medicine Patient Populations:

The following reflects a historical perspective and is meant only to help when there are disagreements. With the advent of regionalization and the MAO, many of these arrangements are of lesser priority. Please work with the MAO to determine the appropriate admission team for patients. Attached to the end of this document is the agreed upon “Pathway for Determining Appropriate Services for Complicated Patients Requiring Admission” and Escalation Pathway to help resolve disputes.

RESIDENT SERVICES: Resident services should generally be expected to use their daily admission capacity when possible.

We have traditionally encouraged the following patients to be directed to resident services: Patients with multiple consulting services HIV Transplant patients Patients with an EF <25% Complicated oncology patients

Traditionally ADMITTED to the MDH Direct Care Service: Unless was a compelling reason, these patients are typically admitted to MDH/MDX

Benign Hematology (ITP, sickle cell, etc) Uncomplicated patients with COVID-19 pneumonia. COVID+ patients who are otherwise complex (those meeting the teaching team criteria outline above) may still be admitted to the teaching services. Patient admitted for other reasons and found to be COVID-19 positive can remain on team/floor they are admitted to unless develop progressive pneumonia. Non-operative head trauma: Per UNC policy, these patients are generally admitted to the NSICU team initially but will be transferred to Hospital Medicine after 24 hours if stable and unable to be discharged. The consult team usually directs admission/transfer to appropriate medicine team. Dentistry and Ophthalmology (i.e. surgical services who do not have inpatient services) Dermatology (also no inpatient service)

Procedure admissions:

We have traditionally admitted several populations of post-procedure patients, including post-VIR patients out of the PRU after TACE, TIPS and other procedures requiring post procedure monitoring and GI patient after POEM and other esophageal and biliary procedures.

Most procedures are Observation or Extended Recovery appropriate (select this status in the ADT1 order). The exception to this rule is TIPS patients who are “inpatient” status and must be entered as inpatients in order for UNC to be reimbursed for their procedure. We should be called with the patient after they have completed their procedure and the patient is ready for admission. This page may be from the PRU nurse. Fellows/attending should contact us if there are any issues with specific patients. Find the encounter (it may be linked or not but should be same day) that says "ADMITTED". You should be able to enter orders here and they should follow the patient to their hospital bed.

Patients typically NOT ADMITTED to the MDH Direct Care Service: Consults – should be called to the MDM resident Intoxicated patients (unless they are otherwise ill Patients that are appropriate for psychiatric admission without active medical needs (geriatric or otherwise) Patients who presented to the ED as a leveled trauma. Patients with a Family Medicine PCP (admit to Family Med service at HBR).

Patient Admission/Transfer Disputes:

Disputes about the appropriate disposition of a patient in the Emergency Department who requires admission or an established inpatient who may require transfer are common in academic medicine. There are many factors in play: the role of residents and fellows, who are underpaid and overworked; the lack of direct incentive for increased clinical productivity; the sheer number and breadth of specialty services and attendings; the lack of the personal relationship and trust among providers.

Here are some general guidelines to assist these decisions:

  • The best interest of the patient should be the foremost consideration. Patients generally benefit from being cared for by providers who will be making decisions on the primary reason for their admission.
  • It is appropriate for a medically complex patient who requires an immediate or short-term surgical intervention or ongoing assessment to be admitted to a surgical service if the medical issues are not requiring acute intervention or interfering with the ability to perform the surgical treatment.
  • A patient should be seen and assessed prior to making recommendations about the appropriate disposition.
  • You can offer medical consultative support to facilitate placement on another service
  • When in doubt, remember the Golden Rule: Interact with your colleagues as you would ask that they interact with you.
  • Where dispute remains, an attending-to-attending conversation is recommended.
  • The MAOs are an invaluable resource/barometer for guidance in difficult situations.
  • Dave Hemsey (Chief), Andrew Donohoe/Emily Sturkie (Associates for Operations at the MC and HBR) and Beth Ann Brubaker (MDH Service Line leader) are available if needed for guidance.

Pathway for Determining Appropriate Services for Complicated Patients Requiring Admission - Medical versus Surgical Services - Dispute over appropriate admitting service (medical vs surgical) is an indication for attending to attending discussion. Utilize “UNC Provider Admission Escalation Pathway” noted below. At each level of escalation, if no response, wait 15 minutes then contact again. If no response, contact again and then move to the next level of escalation if no response after an additional 15 minutes.

  • Medical versus Social Issues
  • Initial contact to Medicine/Family Medicine who performs an assessment
  • Decision: Admit (clear medical indication for admission) versus further evaluation (no clear indication for admission other than safety)
  • Further evaluation
  • Case Management evaluation and escalation to CM/PA leadership
  • Physical Therapy evaluation
  • Occupational Therapy evaluation
  • Other services as appropriate (e.g. wound management)
  • If admission still indicated, Medicine/Family Medicine to admit

  • If admission not indicated, then discharge with resources

  • Failed Discharge

  • If patient returns within 7 days, then admit to previous responsible Department (Medicine, Surgery, etc.) unless there is a clear clinical contraindication designating another service is more appropriate.
  • If patient returns after 7 days, then admit to appropriate service.

UNC Hospitals Provider Admission Escalation Pathway

  • If disagreement between potential admitting service(s) and ED clinician which has already been elevated to an attending to attending discussion; each attending will self-identify the physician leadership contact for their service (example: Division Chief), discuss case with their leadership and then assist arranging a leadership to leadership discussion with the other services involved to achieve resolution.
  • If continued disagreement between potential admitting service(s) and ED; each physician leadership involved will self-identify the appropriate escalated physician leadership contact for their service below (example Vice Chair), discuss case with their leadership and then assist arranging a leadership to leadership discussion with the other services involved to achieve resolution.
  • If continued disagreement between potential admitting service(s) and ED; each provider will discuss case with their Chairs and then assist arranging a Chair to Chair discussion with the other services involved to achieve resolution.
  • If continued disagreement between potential admitting service(s) and ED. The Department Chairs involved will escalate to the CMO Office to achieve resolution.