Harbor:ED follow-up options

REFER TO

  • File:AED followup flowchart 8-23-21.pdf
  • File:PED followup flowchart 8-23-21.pdf
  • Outpatient Follow up is based on patient’s insurance network
  • Out of Plan (OOP), means the patient has Non-DHS insurance network, Private insurance, Other Medi-Cal HMOs, or could be out of County/Country.
  • MHLA, MyHealthLA, are > 18yo, “uninsurable,” community clinic PCP that can e-consult to get subspecialty & inpatient care through DHS
  • DHS means LA County Department of Health Services network eligible

Same/Next Day Specialty Clinic Follow up

  • Sending or discharging directly to specialty clinic

RESULTS/SYMPTOM FOLLOW-UP

  • OOP, MHLA, DHS can all have phone follow up for results (labs or imaging), symptoms checks
  • Adults results/symptom phone follow up
  • Peds results/symptom phone follow up
  • Follow-up of outpatient labs/imaging
    • Any imaging/labs requested by a consultant in the ED that will NOT be resulted during the patient's stay in the ED should be ordered by the consultant making the request.
    • Follow-up of outpatient tests can be either performed by the consultant OR by the CCC

OOP follow up options

DHS eligible patients

Urgent Specialty Follow-up for DHS or MHLA Patients

NERF

Patient wants to switch to Harbor

Instructions for clerk requesting/booking an appointment

Pediatrics CCS Follow up

CCC

  • Bridges DHS eligible patients to primary care until empaneled (still need to NERF)
  • Refer all DHS patients with substance use disorder (SUD) started on medication assisted treatment (MAT) to CCC for enrollment in Dr. Brown's addiction clinic

MAT/BUP/Opiate Withdrawal

Follow up In Other Clinics

For DHS eligible patients only: Clerk will book into appointment slot, or if unable, will place a request into the scheduling queue for Patient Access Center/Call Center to take over. Patients can also call PAC to schedule appointments (Rather than calling the clinic directly)


DHS Patients Lost to Follow-up

  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange for routine follow-up for the patient:
    • HAR-OP-Anesthesiology: Pain Management-Clerical
    • HAR-OP-Cardiology: Anticoagulation-Clerical
    • HAR-OP-Cardiology: General Cardiology-Clerical
    • HAR-OP-Cardiology: HFDMP-Clerical
    • HAR-OP-Cardiology: Pulmonary Hypertension-Clerical
    • HAR-OP-Dermatology-Clerical
    • HAR-OP-Endocrine: Diabetes-Clerical
    • HAR-OP-Endocrine: General-Clerical
    • HAR-OP-Endocrine: Pituitary-Clerical
    • HAR-OP-Endocrine: Thyroid-Clerical
    • HAR-OP-Endocrinology: Diabetes Specialty-Clerical
    • HAR-OP-Endocrinology: General Endocrinology-Clerical
    • HAR-OP-Gastroenterology-Clerical
    • HAR-OP-Hematology/Oncology-Clerical
    • HAR-OP-Infectious Disease-Clerical
    • HAR-OP-Neurology-Clerical
    • HAR-OP-OB/Gyn: Gyn Oncology-Clerical
    • HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical
    • HAR-OP-OB/Gyn: Reproductive Endo/Infertility-Clerical
    • HAR-OP-OB/Gyn: UroGyn-Clerical
    • HAR-OP-OB/Gyn: Women's Health-Clerical
    • HAR-OP-Pulmonology-Clerical
    • HAR-OP-Renal: General Nephrology-Clerical
    • HAR-OP-Renal: Renal Hypertension-Clerical
    • HAR-OP-Renal: Renal Transplant - Clerical
    • HAR-OP-Rheumatology-Clerical
    • HAR-OP-Surgery: Bariatric Surgery-Clerical
    • HAR-OP-Surgery: Breast Surgery-Clerical
    • HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
    • HAR-OP-Surgery: Colorectal Surgery-Clerical
    • HAR-OP-Surgery: Dentistry-Clerical
    • HAR-OP-Surgery: Neurosurgery-Clerical
    • HAR-OP-Surgery: Ophthalmology-Clerical
    • HAR-OP-Surgery: Oral and Maxillofacial Surgery-Clerical
    • HAR-OP-Surgery: Orthopedic Surgery-Clerical
    • HAR-OP-Surgery: Otolaryngology-Clerical
    • HAR-OP-Surgery: Plastic Surgery-Clerical
    • HAR-OP-Surgery: Surgical Oncology-Clerical
    • HAR-OP-Surgery: Trauma Surgery-Clerical
    • HAR-OP-Surgery: Urology-Clerical
    • HAR-OP-Surgery: Vascular Surgery-Clerical


    • HAR-OP-Pediatrics: Allergy/Asthma-Clerical
    • HAR-OP-Pediatrics : Cardiology - Clerical
    • HAR-OP-Pediatrics : Child Development - Clerical
    • HAR-OP-Pediatrics : Craniofacial - Clerical
    • HAR-OP-Pediatrics : Diabetes - Clerical
    • HAR-OP-Pediatrics : Endocrinology - Clerical
    • HAR-OP-Pediatrics : Failure to Thrive - Clerical
    • HAR-OP-Pediatrics : Gastroenterology - Clerical
    • HAR-OP-Pediatrics : Hematology - Clerical
    • HAR-OP-Pediatrics : High Risk Infant - Clerical
    • HAR-OP-Pediatrics : Immunology - Clerical
    • HAR-OP-Pediatrics : Infectious Disease - Clerical
    • HAR-OP-Pediatrics : Medical Genetics - Clerical
    • HAR-OP-Pediatrics : Nephrology - Clerical
    • HAR-OP-Pediatrics : Neurology - Clerical
    • HAR-OP-Pediatrics : Nursery - Clerical
    • HAR-OP-Pediatrics : Oncology - Clerical
    • HAR-OP-Pediatrics : Rheumatology - Clerical
    • HAR-OP-Pediatrics : Surgery - Clerical

Anticoagulation (Coumadin) Clinic

  • Book without consultant approval
  • Book at 7d post initiation of anticoagulation
  • M-F 8am-4pm Ext. 5159, M-F after hours 4-9pm pager 9995, S- Sun 8am-8pm Pager 9995

Breast Diagnostic Center (Radiology)

Breast Surgery Clinic

  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Breast Surgery-Clerical

CARDIOLOGY

  • Daytime: Talk to CORE during the day, Afterhours: Talk to C-team Night fellow (listed on MedHub)
  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up. (Cards will message Mariedel Morales and Sheila Walters IC, the Cardiology clerks, to book).
  • For ZioPatch (holter monitor) - message empaneled PCP or CCC for cardiology
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Cardiology: Anticoagulation-Clerical
    • HAR-OP-Cardiology: General Cardiology-Clerical
    • HAR-OP-Cardiology: HFDMP-Clerical
Stress Testing

DERM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Dermatology-Clerical

ENT

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Otolaryngology-Clerical

Expedited Work-up Clinic (EWC)

GYN

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-OB/Gyn: Gyn Oncology-Clerical
    • HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical
    • HAR-OP-OB/Gyn: Reproductive Endo/Infertility-Clerical
    • HAR-OP-OB/Gyn: UroGyn-Clerical
    • HAR-OP-OB/Gyn: Women's Health-Clerical

Gyn UCC

  • Book without consultant approval
  • 3-4d f/up for ALL DHS PID patients (cervical motion tenderness or adnexal tenderness, empirically treated)
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-OB/Gyn: Gyn Urgent Care-Clerical

Interventional Radiology

Urgent Outpatient IR

Nephrology Clinic

  • For non-dialysis patients only: Don’t need Nephrology fellow approval per Sharon Adler, MD, Chief, Division of Nephrology and Hypertension, 7/28/17)
    • 3 slots a week specifically earmarked for ED use for Thursday morning Nephrology clinic (GN, diabetes, other CKD)
    • 2 “Discharge” slots for the Friday afternoon Hypertension (complex/resistant HTN, HTN with CKD, stones, PCKD, SLE)
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Renal: General Nephrology-Clerical
    • HAR-OP-Renal: Renal Hypertension-Clerical
    • HAR-OP-Renal: Renal Transplant - Clerical

Neurosurgery

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Neurosurgery-Clerical

Limb Salvage

  • Opting out of automatic 30-day automatic f/up consult
  • Weekdays 7a - 5p
    • If the patient seems stable for outpatient follow-up:
      • Page limb salvage p0847
      • After discussion with on-call resident/NP, initiate a TEAMS Chat with: ED attending, ED resident, LS on-call res/NP, LS on-call Attending and send a picture of the involved foot
      • The limb salvage team may respond with appropriate outpatient f/up timeframe or may notify you they will come see the patient in the ED if they feel it is necessary
  • Afterhours (5p - 7a weekdays, weekends, holidays)
    • Consult trauma if the patient needs surgical evaluation; trauma will liaise with limb salvage attending
      • Do NOT consult surgery for appointment
    • For appointment only, can directly contact limb salvage OR defer to PCP for e-consult to podiatry (at MLK) if appropriate (several weeks to f/up)
      • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
        • Clerk books directly into HAR Surg VASC -> Podiatry New


A. Wu, MD - ED Director of Ops & A. Miller, DPM - Director of Limb Salvage, Co-Chair of DHS Podiatry Workgroup 3/30/22

OB

  • For new desired pregnancy w/out anticipated complications: discharge patient with OB clinic intake phone number (424-306-7200) so they can schedule appointment. OB intake is a medical assistant appt, NOT a provider
  • For patients with needing serial beta HCGs, patient should follow with Gyn UCC w/in 2-4 days
  • For patients considering pregnancy termination or interested in discussing options: discharge patient with general Gyn clinic phone number (424-306-4061), they can request appointment with ROC (reproductive options clinic)

ONCOLOGY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up.
  • Newly diagnosed, metastatic cancer - discuss with oncology fellow p7862

OPHTHO

  • Book without consultant approval for next day follow up for orbital wall fractures w/o orbital injury concerns, ok per Dr. Prasad, Division Chief
  • All other cases: Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Ophthalmology-Clerical

ORTHO

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Orthopedic Surgery-Clerical


  • Orthopedic conditions that can be managed in the ED with Orthopedic follow-up (must be neurovascular intact; ED clerk can book into orthopedic fracture clinic):
    • ADULT:
      • Clavicle: <5mm mid-shaft; sling, ortho in 2 weeks
      • Shoulder dislocation: after reduction, place in shoulder immobilizer, ortho 1 week
      • Humerus:
        • Proximal: non-displaced; sling, ortho in 1 week
        • Shaft: non-displaced; sugar tong/sling, ortho 1 week
      • Radius:
        • Non-displaced distal or shaft; volar splint, ortho 2 weeks
        • Non-displaced head with good ROM: sling, ortho in 2 weeks
      • Ulna: non-displaced; volar splint, ortho 2 weeks
      • Occult Scaphoid: thumb spica splint, ortho in 3 weeks
      • Metacarpal: non-displaced shaft and neck
        • MCP 4&5: Ulnar gutter splint, ortho 3 weeks
        • MCP 2&3: Radial gutter splint, ortho 3 weeks
      • PIP/DIP dislocations: simple, no fracture; buddy tape with padding between digits/splint, ortho 1 week
      • Hand: Distal Phalanx - buddy tape/alumiform splint, ortho in 3 weeks
      • Metatarsal 2/3/4 with <2mm displacement and no rotational deformity: post op shoe, ortho in 2 weeks
      • Foot: non-displaced phalanx fracture - buddy tape, ortho in 2 weeks
      • Chronic or non-healing fracture: CCC for e-consult (call ortho if needs closer follow-up)
    • PEDIATRIC
      • Radius, ulna, fibula, clavicle, tibia fractures
        • < 5mm displaced and < 15 degrees angulation
        • Pain controlled by oral meds
        • Normal neurovascular status
        • 5 years and older
      • Proximal humerus fractures with minimal displacement – place in sling
      • Elbow trauma with elevated posterior fat pad, no visible fracture
      • Foreign bodies not in bone or joint space
      • Salter Harris 1 fractures that are not displaced
      • Distal phalanx fractures not involving joint space
      • Tuft fractures


  • Call Orthopedics for the following fractures
    • Displaced radius, humerus, ulna, tibia, fibula fractures
      • >5mm displaced or >15 degrees of angulation all ages
    • All elbow and femur fractures (unless only posterior fat pad)
    • Open fractures or concern for
    • Fractures entering a joint space or concern for
    • Suspected septic joint
    • Fractures with suspected neurologic or vascular injury or pain not controlled by oral pain meds
    • Excessive swelling or ecchymosis suggesting risk for compartment syndrome
    • Scaphoid fractures
    • All fractures in children less than 5 years
    • Any fracture > or = to 10 days that may need reduction
    • Anytime unsure of what to do or if fracture not included on any of this protocol


  • Peds Specifics
    • OK to Splint; DHS Eligible
      • Call ortho and ask for approval to book in clinic the next Tuesday for Pediatric fracture clinic.
      • Ortho does not have to see the patient or write a consultation
    • OK to splint; OOP (these will not qualify for CCS)
      • D/c patient with copies of films
      • Specific instructions to family to call and get ortho referral
      • Hand-out available with options for families (PMD, Shriner’s, Orthopedic institute)
    • Patients Seen at OH splinted and referred to Harbor; Call ortho if:
      • DHS eligible or empaneled
      • Believe urgent/emergent intervention needed
      • Needs a reduction
      • Patient having difficulty getting into empaneled orthopedist (can give hand-out of other options).
        • Ortho attempts to get CCS and if not able helps get care
          • Ortho and CCS (California Children’s Services)
            • Ortho has hired Anna Contreras ( Daisy) to help get CCS for many of the OOP ortho patients
            • If patient is OOP and ortho requests to see them after they splint or cast send a communication to Anna Contreras through Cerner and she gets back to families within 1 business day.
            • Instructions on each computer in PED doc box
            • If the patient doesn’t qualify for CCS, they will help the family get into their orthopedist

PEDIATRICS

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Pediatrics: Allergy/Asthma-Clerical
    • HAR-OP-Pediatrics : Cardiology - Clerical
    • HAR-OP-Pediatrics : Child Development - Clerical
    • HAR-OP-Pediatrics : Craniofacial - Clerical
    • HAR-OP-Pediatrics : Diabetes - Clerical
    • HAR-OP-Pediatrics : Endocrinology - Clerical
    • HAR-OP-Pediatrics : Failure to Thrive - Clerical
    • HAR-OP-Pediatrics : Gastroenterology - Clerical
    • HAR-OP-Pediatrics : Hematology - Clerical
    • HAR-OP-Pediatrics : High Risk Infant - Clerical
    • HAR-OP-Pediatrics : Immunology - Clerical
    • HAR-OP-Pediatrics : Infectious Disease - Clerical
    • HAR-OP-Pediatrics : Medical Genetics - Clerical
    • HAR-OP-Pediatrics : Nephrology - Clerical
    • HAR-OP-Pediatrics : Neurology - Clerical
    • HAR-OP-Pediatrics : Nursery - Clerical
    • HAR-OP-Pediatrics : Oncology - Clerical
    • HAR-OP-Pediatrics : Rheumatology - Clerical
    • HAR-OP-Pediatrics : Surgery - Clerical

Pediatric Adolescent Clinic

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up

Pediatric Cardiology

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Pediatrics : Cardiology - Clerical

PLASTIC SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Plastic Surgery-Clerical

PULMONARY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up


PROCEDURE CLINIC

  • For patient needing recurrent paracentesis
  • From Dr. Anshu Abhat:
  • only available for patients who are empaneled to Harbor-UCLA Internal Medicine or Geriatrics clinic.
  • If an ED provider thinks a patient could benefit from procedure clinic, they should include this in the ER note/documentation (ideal) or message the empaneled provider. Referrals to procedure clinic should only come from PCP's (not from ER providers).

RHEUM

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Rheumatology-Clerical

SURGERY

  • Book: with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Bariatric Surgery-Clerical
    • HAR-OP-Surgery: Cardiothoracic Surgery-Clerical
    • HAR-OP-Surgery: Colorectal Surgery-Clerical
    • HAR-OP-Surgery: Plastic Surgery-Clerical
    • HAR-OP-Surgery: Surgical Oncology-Clerical
    • HAR-OP-Surgery: Trauma Surgery-Clerical
    • HAR-OP-Surgery: Vascular Surgery-Clerical

UROLOGY

  • Nephrolithiasis
    • OK for clerk to book per Dr. Blumberg within 7-10d without calling urology consultant if meet below criteria
      • New Dx Nephrolithiasis
        • BMP, UA, consider CT for size/location/hydro (US if pregnant), have patients strain urine
      • Established Nephrolithiasis
        • BMP, UA, bedside US for hydro
  • CALL urology consult for patients with UTI (infected stone), h/o DM, solitary kidney, pregnancy
    • PCP follow-up if not already established, then can NERF when appropriate.
    • PCP for non-obstructive <5mm stones
  • Ureteral stent or percutaneous nephrostomy tube pain without concern for infection, otherwise uncomplicated course, follow-up in urology clinic in 7 days
    • Send Urine culture
  • Acute urinary retention
    • OK to book in Urology Clinic in 10-14 days WITHOUT consult approval per Dr. Blumberg if near baseline Cr, no significant electrolyte derangements, no evidence of post-obstructive diuresis, pain is controlled, and tolerating PO's
    • Place foley, send UA, BMP; do NOT sent PSA (falsely elevated with acute retention)
      • If <200ml output, remove catheter
      • If >400ml out, maintain catheter
      • Monitor for post obstructive diuresis. If >200ml/hr for 2 hours (not counting the initial output), consider further observation and IVF resusc
      • Discharge with tamsulosin 0.4 mg daily
  • All other Urologic conditions: book with consultant approval - write name of approving doctor, time frame, and reason for follow up
  • Epididymitis/orchitis just needs PCP f/up
  • If the patient has previously been followed at Harbor, but was lost to follow-up, you can message the following clinic-specific message pools and they will arrange follow-up for the patient:
    • HAR-OP-Surgery: Urology-Clerical

Per Dr. Blumberg (Urology) & Dr. Wu 2/8/22

FOLLOW-UP FOR OUT-OF-COUNTY/OUT-OF-COUNTRY (OOC) PATIENTS

Per DHS Policy 516.1, Out of County/Country Patients who need an urgent follow-up for an emergency medical condition may be provided such follow-up at Harbor

  1. Emergent Conditions:
    1. Places health in serious jeopardy
    2. Threatens serious impairment to bodily functions
    3. Threatens serious dysfunction to any organ or body part
  2. If they are from a county close by - consider referring them to their home county. Call 2-1-1 social services hotline.
  3. Do not arrange follow-up for NON-EMERGENT/URGENT issues
  • If patient is no longer Out of Country/County, they can go to Registration Rm 108, 1st floor main hospital), ext 8101 to change their address.

Dir AED, Dir OPS, DHS Policy 516.1 9/25/17

See Also