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UNC Medicine/Orthopedic Surgery Co-Management Guidelines

General Principles:

  • For patients who require or will require orthopedic surgical intervention
  • In successful co-management, which provider serves as the primary attending should play a minimal role in determining the care provided.
  • Patients presenting with acute surgical problems and significant co-morbid medical issues may benefit from two specialty providers caring for them during an inpatient visit if care quality, patient satisfaction, length of stay and cost are improved.
  • Medical consultation is not indicated for medication reconciliation alone (can “curbside” if needed).
  • Effective communication to patients and family and between teams during transitions or when there are changes in clinical status is the foundation of successful co-management.

General Workflow:

  • Orthopedic evaluation of patients who present to the Emergency Department for orthopedic injuries.
  • Non-operative injuries requiring admission for pain control, mobilization, stabilization of other comorbidities will be admitted to the hospitalist service with support from SRO consult service.
  • Operative injuries will be admitted to SRO and placed on 5BT.
  • SRO to request medicine consult for operative clearance or management of comorbidities if necessary.
  • Patients with RCRI of 0 (no history/symptoms of CAD/CHF, Stroke/TIA, Cr < 2, no use of insulin use) OR patients with pre-op evaluation from their PCP/outpatient cardiologist
  • DO NOT require additional preoperative medical evaluation for cardiac risk
  • Should undergo direct screening by Anesthesia
  • Select patients with symptomatic pulmonary or liver disease may still require internal medicine evaluation for those conditions prior to an operation even without cardiac risk
  • Initial evaluation done by admitting hospitalist (2nd, Swing, Night1 provider). If patient felt appropriate for consult service, can make initial recommendations to surgical team and leave for consult team to see in AM. Patients appropriate for co-management should be seen and have initial consult note written by admitter. Assign Magnolia as treatment team. This should provide reliable coverage for “1st case” scenarios.
  • Admitting hospitalist to triage subsequent management strategy.
  • May sign off of patients felt to have low surgical risk and/or minimal comorbid conditions.
  • Patients with complex/ongoing need for medical management can be directed to the Medicine Consult service for follow-up of specified issue with anticipation of sign off once issue is resolved/addressed.
  • By agreement, Medicine Consult should follow these patients post-operatively for 48-72 hours before signing off as this is when the majority of complications arise.
  • Geriatric patients with significant comorbidities (including dementia) should be assigned to the Co-Management Service (Magnolia assigned as non-primary treatment team).
Care Phase Surgical Team Responsibilities Medical Team Responsibilities
Pre-OP Determine surgery is an appropriate option Identifies medical issues that affect perioperative risk
Pre-OP Conducts consent process Ensures optimization of underlying medical conditions
Pre-OP Provides education on surgical process /expectations Provides anticipatory guidance
Post-OP General postoperative care Manages chronic disease
Post-OP Surgery-specific postoperative recovery Surgical site care Acute decompensation not directly related to the operative intervention
Post-OP Routine pain management New medical conditions
Post-OP Discharge planning

Ongoing Care:

  • Co-management provider rounds on all patients daily and leaves Progress Note. Engage direct communication (Epic Chat preferred) for any changes to plan.
  • Co-management disagreements resolved by attending-to-attending discussion.
  • Both services will review orders daily.
  • Both services evaluate patient in person during rapid responses and acute deterioration.
  • Nursing staff encouraged to use Co-Management team pager for medical cross cover needs 24/7.
  • Co-management provider to review med rec prior to discharge.
  • Outside Hospital transfer to SRO:
  • Unless there is concern for stability, encourage to accept isolated orthopaedic injuries directly to the floor (bypass ED).
  • For medical stability concerns, SRO should involve MAP (Medicine Access Physician) PRIOR to acceptance.
  • Transfers to medicine.
  • Reserved for cases in which surgical intervention is complete/deferred and there is required management of new medical conditions or acute decompensation not directly related to operative intervention.