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Neurosciences Admission Agreement

Page history last edited by Kali Graham 1 month, 4 weeks ago

January 1, 2024

**FINAL DRAFT**

Interservice Agreement for Non-ICUNeuroscience patients

Departments of Internal Medicine, Family Medicine, Neurology, Neurosurgery and Surgery

Purpose:

To define the proper admission criteria and consultation expectations for floor level patients with neuroscience diagnoses across the departments listed above.

Background:

This document was developed to guide practitioners in determining appropriate service assignments for patients with neurologic and medical problems and to outline consult expectations from the above departments.

This guideline applies to adult patients being admitted to UNMH (from the Emergency Department or via the Transfer Center) or being transferred out of one of the Intensive Care Units

For patients with criteria for admission to more than one service (ex: Trauma and Neurology), service assignment should be based on which diagnosis has a higher level of acuity and is the presumed precipitant of the hospitalization.

In general, the algorithm guides which service to call, and the first service called should assume care of the patient within reason. If residents/APPs are unable to determine the appropriate service, they should quickly involve their attending.  Disagreements regarding appropriate service assignment should be resolved at the attending level with both services agreeing to transfer patients if an assignment was made in error. Disagreements at the attending-to-attending level will be quickly escalated to the Clinical Affairs on call physician.

Readmissions: if a patient is discharged from UNMH and returns within 30 days, the patient will be readmitted to the appropriate prior service, unless the reason for the admission has changed (e.g. post-op craniotomy patient returns to the hospital on day 29 with pneumonia, that patient should go to Medicine). 

Admit to Neurotrauma (Trauma Verde)

Any patient with an acute traumatic injury (including spine trauma) is appropriate for admission to the Neurotrauma service. Please note that initial admits to floor are rare and patients are usually placed in the ICU as primary admitting location. In these situations, Trauma is the primary team for ICU trauma patients with ICU service consulting.

Diagnostic Categories to admit to Neurotrauma (Trauma Verde):

In general, the Neurotrauma team (Trauma Verde) takes both isolated and poly-system TBI and spine patients including Isolated head trauma, traumatic cortical SAH, traumatic intraparenchymal hemorrhage, head trauma with non-depressed skull fracture, head trauma status post craniectomy with no further active neurosurgical issues, subdural hematoma not requiring or status post neurosurgical intervention, spine trauma.

please note: chronic subdural hematomas or other non-acute trauma-related issues (will be admitted to a medicine team

Readmissions for floor level patients previously on the Neurotrauma team (Trauma Verde) will follow the medicine admission pathway. Individual case concerns will be addressed at the Trauma Verde and IM Triage Hospitalist attending level.

ED floor Admission process:

For patients with neurological trauma (spine or brain) needing admission from the ED, the Trauma team will assess the patient and, if appropriate, admit to the Neurotrauma team (Trauma Verde).

ICU downgrade process:

The Trauma service usually is primary for most patients in the ICU and will follow through downgrade to floor status. The Trauma team will internally assign patients to the Neurotrauma (Trauma Verde) team if appropriate. For ICU patients without Trauma involvement, please contact the Trauma team to evaluate for ICU downgrade to the Neurotrauma (Trauma Verde) team.

Admit to Neurosurgery:

The Neurosurgery attending will direct which patients are admitted to Neurosurgery and which patients are admitted to a different team. For ICU downgrade patients, the Neurosurgery attending will verify that the patient is ready for floor status before the transfer request is sent to the floor team by the ICU primary team.

Planned Elective surgical cases in patients with minimal medical comorbidities requiring postoperative hospitalization will be admitted (or downgraded from the ICU) to the Neurosurgery team for the specific attending.

Planned Elective surgical cases in patients with multiple medical comorbidities requiring postoperative hospitalization will be admitted (or downgraded from the ICU) to the Internal Medicine/Sound Service.

Readmissions for both elective and non-elective neurosurgical patients:

Patients readmitted with need for urgent/emergent operative procedure will be admitted by Neurosurgery and taken to the OR. Post-operatively will follow the above pathway.

Readmissions that do not require urgent/emergent operative procedure will be admitted to a Sound Physician team

All other cases (including incoming transfers from outside facilities) that require Neurosurgical assistance or intervention (and are not more appropriate for another specialty service in this agreement) will be admitted to Internal Medicine/Sound with Neurosurgical co-management during the hospital stay.

Neurosurgical Co-management is defined as:

Daily patient evaluations and progress notes (including bedside evals for acute patient decompensation or concerns for needing ICU transfer)

For ICU upgrades of floor patients, the Neurosurgery APP will coordinate with the NSI re: transfer

Placing orders for Neurosurgical-related needs (ex: imaging, anticoagulation, dietary orders)

Being available and taking primary floor nursing and provider calls for Neurosurgical-related needs (ex: drain management or anticoagulation questions)

Sign-off will only occur once the Neurosurgical problem has been stabilized and an attending-to-attending conversation has resulted in agreement to this plan. Neurosurgery remains available for any subsequent call or re-involvement at any time for the remainder of the hospitalization.

Hospital follow up needs (ex: clinical appointments) are arranged by the Neurosurgical team.

Leads communication with Patients/Families re: Neurosurgical issues

Note: for patients needing Urgent/Emergent admission from the ED for prompt (usually within hours or the same day) operative management, Neurosurgery will complete the pre-operative History and Physical and place preliminary orders to prevent any delays in getting to the Operating Room. Post-operatively, if the patient is stable for the floor, the neurosurgery team will coordinate with the appropriate admitting service as outlined in this document to assume care of the patient.

Admit to Neurology:

The Neurology service will admit patients who present with primary neurologic disease. Examples of these disease types include: acute ischemic or hemorrhagic stroke, aneurysmal, non-traumatic SAH, cerebral venous sinus thrombosis, seizures without suspected secondary etiology, seizures due to inadequate anticonvulsant therapy, acute CNS demyelinating disease (i.e. Multiple Sclerosis, Neuromyelitis Optica spectrum disorder, Transverse myelitis), acute inflammatory demyelinating polyneuropathy (i.e. Guillain-Barre syndrome), Myasthenia gravis.

Lupus/vasculitis: Patients with Lupus or Vasculitis with neurologic manifestations from their illness should be admitted to the Neurohospitalist service with Rheumatology consultation. A patient with an exacerbation of Lupus or Vasculitis WITHOUT neurologic involvement should be admitted to an IM/FM hospitalist service.

In addition, meningitis, encephalitis, encephalopathy not due to toxic/metabolic etiology, or other primary neurologic diagnosis normally cared for by neurologists should also be admitted to the Neurology service. Please see notation below for process of initial admission to an IM/FM hospitalist service with Neurology consultation followed by transfer to Neurology for confirmed diagnoses.

Notes:

Some vascular Neurosurgical patients will downgrade from the ICU to the Neurology Cerebrovascular (Stroke) team. This downgrade plan will generally be identified during the ICU course of care.

Some epilepsy Neurosurgical patients will downgrade from the ICU to the Neurology Epilepsy Monitoring Unit (EMU) Team. This downgrade plan will generally be identified during the ICU course of care.

For patients admitted to a Neurology service who, after stabilization, are found to have their acute neurological issues resolved and remain hospitalized with management needs usually care for on a medicine service, please consider transfer to an IM/Sound/FM team after attending-to-attending discussion.

Admit to Internal Medicine/Sound/Family Medicine Hospitalists:

Patients with acute neurologic manifestations of systemic illness with minimal or stable other organ involvement should be placed on a medicine team as primary. Admit/transfer requests go through the IM Triage attending (place “ED Consult to Medicine” Cerner order for ED admissions or “Inpt Consult to Medicine” Cerner order for service transfers/ICU downgrades). The IM triage attending will help direct admission requests across the IM, Sound, and Family Medicine teams.

Seizures secondary to alcohol withdrawal or other toxic/metabolic derangement, hepatic encephalopathy, toxic overdose, delirium, uremia, other causes of toxic/metabolic encephalopathy, or any other medical problem normally cared for by IM/FM hospitalist service.

Patients with chronic disabilities due to a neurologic cause or a neurodegenerative disease (including but not limited to remote history of ischemic or hemorrhagic stroke, spinal cord injury, stable traumatic brain injury, dementia, cerebral palsy) who present with primarily medical conditions.

Meningitis: If primary meningitis or encephalitis is suspected but other, more likely etiologies have not yet been ruled out, initial consultation by neurology and admission by IM/FM hospitalist service is appropriate with subsequent transfer to the neurology service if a proven diagnosis of primary meningitis or encephalitis is made.

Lupus/vasculitis: Patients with Lupus or Vasculitis with neurologic manifestations from their illness should be admitted to Neurology with Rheumatology consultation. A patient with exacerbations of Lupus or Vasculitis WITHOUT neurologic involvement should be admitted to an IM/FM hospitalist service.

Non-elective, non-traumatic Spine disease with concerns for degenerative, infectious, or oncologic etiology

Chronic (non-acute) subdural hematomas should be admitted to a medicine team.

Elective Neurosurgical patients with multiple medical comorbidities (see above--Neurosurgery attending will decide if Sound vs Neurosurgery as admitting/ICU downgrade team).

Note—Elective Neurosurgery patients requiring a medicine service as primary will only be placed onto Sound Physician teams.

Admissions for Oncologic patients

Any non-elective confirmed or suspected mass or malignancy of the CNS will be admitted to IM/FM/Sound Hospitalists with Neurosurgery Consultation (ex: cancer of unknown origin).

CNS Cancer of unknown primary origin admitted to medicine team (with oncology consulting and managing the patient) to perform a complete metastatic work-up, including deciding whether tissue diagnosis can be obtained without subjecting the patient to cranial surgery.

Late-stage Neuro-Oncology patients who are frail/poor surgical candidates, or who have previously been designated as non-surgical, with or without a tissue diagnosis, should go to IM/Sound/FM hospitalists with oncology managing the patient.

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