SERVICE AGREEMENTOCTOBER 1, 2010

HOSPITALIST, ORTHOPEDIC SURGERY, PALLIATIVE MEDICINE, AND EMERGENCY MEDICINE-

INITIAL CARE, CONSULTATION AND ADMISSION OF PATIENTS WITH HIP FRACTURES

PURPOSE: To expedite Emergency Department (ED) patient flow of patients with hip fractures from initial evaluation to admission to the appropriate in-patient service with appropriate primary patient care responsibility or consultation

  1. All patients who present to the Emergency Department with signs and symptoms of a hip fracture will be expeditiously evaluated in person by the Orthopedic Surgery Section and the Medicine Service.
  1. All patients diagnosed with a hip fracture seen in the Emergency Department will have an expeditious evaluation by the Orthopedic Surgery Section and the Medicine Service. A consultation to both the Orthopedic Surgery Section and the Medicine Service will be placed into CPRS by the Emergency Medicine provider treating the patient. As a significant majority of VA patients meet the ACS level 3 guidelines for complexity, the Medicine Service will admit all acute hip fracture patients from the Emergency Department and optimize the treatment of their medical conditions prior to surgery. The Orthopedic Surgery Section will evaluate the patient in the Emergency Department and ensure that the patient is scheduled for the earliest appropriate surgical intervention. If the Orthopedic Surgery Attending Physician believes that the patient has no complicating comorbidities that would preclude admitting the patient to the Orthopedic Surgery Section, the patient can be admitted directly to the Orthopedic Surgery Section and the Medicine Service will consult as appropriate.
  1. Communication: Immediately post-op the Orthopedic Surgery Attending Physician will contact the Medicine Service Attending Physician and communicate any pertinent findings at the time of surgery, intra-operative complications, and post-op instructions. The Orthopedic Surgery Section providers may write orders for their patients admitted to the Medicine Service, only after communicating those orders with the appropriate Medicine Team. Daily communication will also be important in regards to surgery specific issues, such as weight bearing, physical therapy, anticoagulation, and discharge planning.
  1. If the patient requires transfer to an ICU level of care post-operatively, the Orthopedic Surgery Section Attending Physician will communicate this to the Medicine Service Attending Physician and then the Orthopedic Surgery Section Attending Physician will contact the Intensive Care Physician to arrange transfer into the ICU. The medicine Service hospitalists do not have admission privileges to the ICUs.
  1. The Medicine Service will utilize the criteria developed by Palliative Medicine to order a palliative care consult on all appropriate cases.
  1. Palliative Medicine consultation prior to surgical intervention is recommended for: patients admitted from Community Nursing Homes and patients with Advanced Dementia (speaking 7 words or less, incontinent of bowel and bladder, cannot tend to activities of daily living such as eating, dressing, bathing). Referral should be considered in patients with a widely metastatic malignancy.