Atrial Fibrillation

Back Pain

Chest Pain

Syncope

Neurosurgery Admission

• Postoperative complications from recent surgeries
• Established patients sent to ED for expedited surgery/interventions
• The hospitalist team will consult and co-manage all patients.
• Surgical ACP hospitalists/ACP nocturnists can be utilized as surgical specialists to evaluate wounds and communicate with on-call neurosurgery ACP (i.e. pictures of wounds, dressing recommendations) for interim, stabilizing care until patient can be evaluated by neurosurgery following day.

Medicine Admissions

• Non-operative spine consults. (i.e. stable spine fractures such as compression fractures, chronic degenerative spine disease, herniated discs without neurologic deficits).  Neurosurgery to document no planned interventions this admission
• Non-operative downgrades from ICU (i.e. traumatic subarachnoid hemorrhages, small non-operative subdural hematomas).  Neurosurgery to document no planned interventions this admission
• Metastatic brain tumor patients
• Any documented neurosurgery consult that does not require urgent surgical intervention, or planned surgery during this admission

Transfers to Neurosurgery Service

• Any spine/cranial case initially admitted to medicine and following additional workup, surgical intervention has been recommended and agreed upon by patient/family

Case by Case Discussion and Escalation Process

• Newly diagnosed brain tumor patients in which there are isolated neurologic issues and no systemic issues requiring aggressive medical management
• Discussion regarding admission disposition shall occur between neurosurgery ACP/attending neurosurgeon and hospitalist group directly.  ED being used as intermediary for discharge disposition NOT advised
• If disagreement or discrepancy between neurosurgery ACP and hospitalist, discussion is escalated to neurosurgery attending

When the need for massive transfusion is identified, have the charge nurse call for “Code Fusion”. As you will be actively managing the patient, you will not have to enter orders or make any calls until products are no longer needed. The moment you are nearing hemostasis, you do need to call the blood bank and end the Code Fusion.

To meet the needs of the blood bank, the nurse has to fill in a provider’s name when they start the MTP.  That counts as the order.  Once they do that, an order goes to your inbox for you to sign after it’s all over.  There is no separate order for the providers to fill out.

MTP Protocol

MTP Policy

Parasternal Long Axis (PLAX)

The PLAX view establishes the long axis of the heart but is generally not the optimal view to assess the right ventricle. Nonetheless, comparing the LA, Aortic root and RVOT, which should be roughly the same size, we note the RVOT is more than double the size of the other “chambers”.

Parasternal Short Axis (PSAX)

Chamber size comparison is best assessed with the PSAX view as was done here or the Apical 4 chamber (A4C) view. Here we again find a dilated right ventricle closest to the peaked footprint of the phased array probe. Not only is the RV dilated (greater than LV size), but right sided pressure is flattening the septum, giving the LV a characteristic “D-shaped” appearance. In A4C, TAPSE < 17mm is consistent with pulmonary hypertension.

Any patient with significant acute pulmonary hypertension will have a plethoric IVC. This IVC is > 3cm at the level of the hepatic veins with to and fro venous flow noted.

These findings clearly show pulmonary hypertension — the next step is to decide whether this hypertension is acute or chronic. Certainly factors other than echo findings will be important. What is the patient’s history, is there thrombus on CT, and are there any distinguishing features of their thrombus that suggest acute vs. chronic PE.

On Echo a few factors can be easily assessed:

• Right atrial size – RA > LA size suggests chronic pHTN.
• Right ventricular wall thickness
  • Measure the RV free wall at end-diastole, perpendicular to basal third, just below tricuspid valve. Best subxiphoid.
  • Chronic pHTN > 5 mm
  • Normal / Acute pHTN wall thickness:  $$≤ 5 mm
• More advanced techniques using spectral doppler assessment (TRPG, 60/60) are available as well.

For this patient with PE on CT and acute right ventricular failure, PERT and / or the ICU should see the patient sooner rather than later.

The EMSL now has remote SBIRT resources available. They are open Mon-Sat 10a-8p. They are available to help with any issues including prescribing naltrexone, referring patients, friends, family or yourself, and setting up a health coach.

This course offered this summer by Northwell offers training from combined societies – SHM (the Society of Hospital Medicine) and CHEST (pulm critical care). The directors Linda Kurian and Harald Sautoff are longstanding point of care educators who teach with the national SHM/CHEST courses. I’ve taught with this group and they know how to put on world class ultrasound education. This will definitely be worth it if you are looking for a local course.

The charge nurse should tell the provider to enter the “Ambulatory Referral to the Emergency Department Order” instead of using the expected patient workflow.  There are several benefits to using this order:

1. The sending provider does not have to call the ED – which they hate doing because they usually wait on hold until the charge nurse can pick up the phone. The sending provider can enter whatever information they want into the order (the workup they are requesting, when they want a call back, etc.)
2. Saves the charge nurse from having to pick up the phone and fill out the expected patient workflow – which is not going to get the provider the information that they need anyway.
3. This order generates an OPA that opens as soon as the provider opens the chart and stays in the chart for the whole encounter as a reminder for the provider to contact the PCP when the workup is done. 
4. There is also an icon that appears on a trackboard column that lets the providers know that someone put in this order for the patient.

The Optum docs can enter the order from EpicCareLink – which is what they use in their office.