Harbor:Neuro Obs & RLA Transfers

• Neuro Obs
  • Most frequently utilized for possible stroke (>24 hour onset) with negative CT pending MRI (complex migraine, vestibular syndromes)
  • Neuro should notify ED to “Place in Obs” (instead of “Request for Admit” as the official transfer of care to Neuro team)
  • Neuro will place all orders except “Admit to Inpatient”
    • Within 24 hours of “Place in Obs” order, decision must be made to admit or discharge

• Harbor to Rancho Neuro Transfer Process
  • ED
    • Patient identified as neuro patient requiring admission
      • IQ request/UM Teams chat
        • If stable and OOP, initiate transfer to home health network
        • If approved for admission at Harbor, Orchid consult to neuro team

• • Neuro
    • Staff case with senior resident or attending to ensure appropriate for potential transfer (vs admission)
      • Potential Transfer Diagnoses:
        • Vascular (Stroke, TIA)
          • Diagnostic evaluations required: head CT, CTA; CBC, BMP, troponin, EKG, Covid
          • If NIHSS>8 or cerebellar signs, then obtain MRI brain
          • Possible stroke pending MRI in AM can be placed on neuro OBS
        • Neuroimmunology (MS, transverse myelitis, NMO, optic neuritis)
        • Epilepsy
        • Neuromuscular (AIDP, MG, myopathies, neuropathies)
        • Vertigo
        • Movement disorders
        • Headache (status migranosus, IIH)
      • Exclusion criteria:
        • Acute intracerebral hemorrhage (may consider transfer if stable head CT at 48 hours)
        • Acute >2/3 MCA stroke or large cerebellar stroke (may consider transfer if stable for 7 days)
        • Needs ICP monitoring, catheter angiography, or is at-risk for needing emergent neurosurgical intervention (routine neurosurgical consultation is available)
        • Pregnancy
        • Psychiatric hold
        • Needs urgent dialysis
        • Needs a service not available at RLA: Cardiothoracic Surgery, Endocrinology (may be able to arrange for remote consultation), General Surgery, Hematology/Oncology, Ophthalmology (optometry available), Obstetrics, or Vascular Surgery

• • • If patient requires admission at HUMC:
      • Call ED with attending name and level of care for the “Request for Admit”
      • Place admission orders including “Admit to Inpatient” order

• • • If appropriate for transfer to RLA:
      • Notify ED to “Place in Obs” (instead of “Request for Admit” as the official transfer of care to Neuro team) and place all orders except “Admit to Inpatient”

• • • OOP Authorized for admission at HUMC
      • Neuro resident will call UR (x65093) who will re-contact health plan for specific prior authorization to admit to RLA (due to HUMC capacity constraints)
      • If denied, admit to HUMC by placing “Admit to Inpatient” order
      • If approved: same process as DHS Empaneled/Eligible patients (below)

• • • DHS Empaneled/Eligible
      • Initiate Transfer Process:
        • Harbor Neurology contacts RLA Neurologist to discuss case (6:30am – 9pm HUMC Neurology resident calls or Teams messages Rancho Neurology attending (AMION: login RLANRC)
          • If transfer denied by RLA neurology, place “Admit to Inpatient” order
          • If approved for transfer by RLA Neurologist:
            • Avoid further non-urgent diagnostic testing unless requested by Rancho attending (this delays transfer)
            • Neuro resident to place holding orders as needed (neuro checks, medications, notify physician parameters, etc.)
            • Complete EMTALA transfer form
            • Neuro resident orders, “Consult to Transfer Center” (open 7a-11p)
              • Need Level of Care, accepting Neurology Attending at RLA, “Neuro RLA” as reason for transfer, patient consented to transfer, HUMC Neuro Resident name and callback number
            • Transfer Center UM performs administrative functions (bed request, financial screening, relays bed assignment/phone number for nursing sign out and transportation instructions) and will call the Neuro resident back to confirm bed availability.
            • PFS clears case
            • Bed assigned by RLA bed control
            • Transfer Center calls HUMC ED clerk (x65001) to order county trans and provide phone number for RN sign out
            • Clerk gives sign out phone number to HUMC ED RN
            • RN to RN sign out
            • Pt transferred via county trans (BLS)
          • If the transfer has not occurred within 24 hours of the “Place in Obs” order, the patient should be admitted to HUMC (place the “Admit to Inpatient” order with plan for lateral transfer from the inpatient unit whenever a bed is available)

• FYI
  • Services Available at Rancho
    • Medicine: Cardiology (includes TEE, pacemaker), General Medicine/Family Medicine, ICU, Infectious Disease, Pulmonary, Nephrology (includes hemodialysis, peritoneal dialysis, catheter placement), Rheumatology
    • Surgical: Non-urgent Neurosurgery, Hand Surgery, Orthopedic Surgery, Otolaryngology (includes tracheostomy placement), Plastic Surgery, Spine Surgery, Urology Other: Dental, Optometry/Neuro-optometry, Interventional Pain, PM&R, Psychiatry, Psychology
    • Services Available on Part-Time Basis at Rancho
    • Dermatology, GI (includes PEG placement and non-emergent scopes), Gynecology, Vascular Surgery (includes IVC filter, lower extremity IR procedures)
    • Neuro-Related Procedures Available at Rancho
    • IVIg, PLEX, Rituximab infusion, Continuous Video-EEG, EMG/NCS, IR-guided LP, PEG placement, trach placement