Subspecialty Admit Policies

Team cap of 16 patients

Daily admission cap of 5 patients

If the team caps at 16 patients at any point during the day, it will remain capped until 6:30pm, regardless of discharges.

1. Any patient in the Home Care practice or the Geriatric Ambulatory Practice whose primary care physician is a faculty member or fellow in the Section of Geriatrics.
2. Any long-term care nursing home patient whose primary care physician is a faculty member or fellow in the Section of Geriatrics.
3. Any patient at a nursing home for rehabilitation whose primary care physician is a faculty member or a fellow in the Section of Geriatrics.
4. Any patient admitted with a hip fracture whose primary care physician is a faculty member or a fellow in the Section of Geriatrics.
5. Any patient admitted with cardiac problems not requiring immediate specialist cardiac care (such as CCU, EP intervention, care of MI) whose primary care physician is a faculty member or a fellow in the Section of Geriatrics.
6. Any patient with BMCHP SCO insurance whose PCP is in Internal Medicine (not Family Medicine).
7. Any patient with a BMC PCP 80 years old or older, if the Geriatrics Inpatient Service is not at risk of being capped.
8. Patients aged 70 or older without any PCP (i.e. unassigned).
9. If the patient is at a nursing home for rehabilitation and a geriatrics physician is following the patient, and the patient originally came from a PCP not affiliated with BMC, the patient should be admitted to the Geriatric Inpatient Service.
10. If the patient is at a nursing home for rehabilitation and a geriatrics physician is following the patient, but the patient was followed by a non-geriatrics BMC provider, that patient should be admitted to a general medicine team.
11. Although BU Geriatrics patients should be admitted to the Geriatrics team, there will be times when this is not possible (i.e. team is capped). If this occurs, the patient should be cared for by the team to which they were admitted. Interservice transfers are at the discretion of the Geriatrics and primary team attending, and should not be systematic.

Heme/Onc Team A

Team cap of 16 patients

Daily admission cap of 5 patients

If team hits 16 patients at any point during the day, it will remain capped until 6:30pm, regardless of discharges.

Exceptions: can go up to a team cap of 18 for active chemotherapy pts who need admission. Team census can never exceed 18. If the team is notified of a patient being admitted from clinic, they may hold the 16th spot on the team for that patient.

Heme/Onc Team B

Team cap of 10 patients

Daily admission cap of 4 patients

If team hits 10 patients at any point during the day, it will remain capped until 6:30pm, regardless of discharges.

Exceptions: can go up to a team cap of 11 for active chemotherapy pts who need admission. Team census can never exceed 11. If the team is notified of a patient being admitted from clinic, they may hold the 10th spot on the team for that patient.

Triage Protocols

1. Patients will be paged to the hem/onc B resident, who should call back with the team assignment within 15 minutes; solid onc preferentially goes to team A, heme onc preferentially goes to team B, but teams should take either if the typical team is capped or markedly overloaded. Patients should stay on their assigned team once placed.
2. Sickle cell patients will be admitted to both teams, and should roughly alternate between them, with adjustment for the other admissions coming in & the overall census
3. GIM admits to hem/onc B do not require a code yellow and can occur anytime the GIM teams are busy (not necessarily capped). The team can defer taking a GIM patient to reserve their 10th spot for a heme/onc or sickle cell patient.

Admission Details

1. The highest priority for admission to the MEN 6E Heme-Onc Inpatient Team are heme-onc patients with active hematologic/oncologic management issues, ongoing chemotherapy, or patients undergoing bone marrow (stem cell) transplantation. Every attempt should be made to admit these patients to the heme-onc service. If the service is capped, transfer of less active patients to a general medicine team should be considered.
2. The second priority for admission should be heme-onc patients requiring chronic medical care, palliative care, end-of-life care, and other non-acute care.
3. The third is sickle cell patients. Sickle cell patients should be distributed between both Heme/Onc teams.
4. In general, heme-onc patients with active medical problems unrelated to their hematologic/oncologic illness that are outside of the scope of expertise of the Heme-Onc subspecialty attending staff should be admitted to a general medicine service. Examples of such problems might include suspicion of acute MI, DKA, CHF exacerbation. The heme-onc consult team should be notified of their admission and asked to consult if their care is impacted by their underlying heme-onc disease.
5. If there are any questions about the suitability of admission to the heme-onc service, please page the heme-onc fellow or attending on service or Dr. Tapan.
6. For both teams their final slot should be saved for hem/onc and sickle cell pts (defer GIM admits to hem/onc B)
7. When there is a scheduled chemo admission, the accepting team should contact admitting and hold one admission slot for that planned admission (including overnight if known the day beforehand as is often the case) – if the admission is canceled, that slot would then open

Patients Usually Requiring Heme-Onc Team Management

1. Patient requiring inpatient treatment for their heme-onc disease, e.g. acute leukemia.
2. Patients with direct side-effects of treatment
3. Fever and neutropenia
4. Chemo-specific side effects including nausea, vomiting, diarrhea, dehydration, mucositis
5. Chemo-induced pancytopenia
6. Tumor lysis syndrome
7. Other oncologic emergencies
8. Transfusion reactions or immunotherapy reactions
9. Patients on clinical trials or protocols requiring specific evaluation and treatment of disease or complications.
10. Patients undergoing bone marrow stem cell transplant.
11. Patients requiring an inpatient heme-onc diagnostic evaluation that is deemed most appropriate for the heme-onc service by a heme-onc attending.
12. Patients with complications from their disease that are deemed best managed on the heme-onc service by the admitting attending.
13. Patients requiring management of cancer-related pain.

Patients Usually Appropriate for Management on a General Medical or Hospitalist Team

1. Patients with a history of a heme-onc disorder that is not considered active requiring admission for an unrelated problem.
2. Patients with an active heme-onc disorder requiring admission for a general medical problem felt to be better served by medicine (as above).
3. Patients admitted from home, hospice, rehab, or a nursing home with an exacerbation of disease for which no specific heme-onc intervention can be offered when the heme onc team is nearing cap.
4. Patients with amyloidosis admitted for management of a cardiac or renal complication of their disease not undergoing active treatment should be admitted to the respective inpatient subspecialty service in preference to the heme-onc service.
5. Patients with benign hematologic conditions (e.g pancytopenia of unclear etiology) when the heme-onc team is nearing their cap. Patients with cancer who do not require inpatient heme-onc treatment when the heme-onc team is nearing their cap.
6. Patients requiring chronic medical care who do not require direct subspecialty management (e.g. chemotherapy) when the team is nearing the cap.
7. Patients requiring palliative care only when the heme-onc team is nearing cap.

Team cap of 16 patients*

Daily admission cap of 5 new patients

If team caps at 16 patients at any point during the day, it will remain capped until 6:30pm, regardless of discharges.*

* Exceptions: Patients on peritoneal dialysis or s/p renal transplant, may be admitted to the renal service when the team census is between 16-18. The team census may never exceed 18 patients.

1. Any patient on dialysis (hemo or peritoneal) admitted for a medical issue (does not include ICU or surgical).
2. All renal biopsies.
3. Patients being admitted by a Renal attending to initiate dialysis (Stage V CKD patients from clinic).
4. Patients with prior renal transplant without acute surgical issues.

Team cap of 16 patients*

Daily admission cap of 5 new patients

If team caps at 16 patients at any point during the day, it will remain capped until 6:30pm, regardless of discharges.*

*Exceptions: Patients may be transferred to the general cardiology team from outside hospitals up to a team cap of 20 patients. The chief residents should be notified if the team goes above 18.

Patients with the following diagnoses may be appropriate for admission to the inpatient cardiology service:

1. Patients with a BMC cardiologist, who are presenting with a cardiac diagnosis
2. ACS that does not require the CCU
3. TIMI score > 3 (age >65 yrs, > 3 cardiac risk factors, > 2 episodes of angina in 24 hrs, known CAD, aspirin use in past 7 days, ST deviation, elevated cardiac biomarkers)
4. Elevated troponin
5. Surgical or percutaneous revascularization within the last year.
6. Rapid atrial fibrillation that is not controlled in the ED (patients with chronic or new onset afib that is controlled can be managed on the medical service with cardiology consult as needed)
7. Prosthetic valve endocarditis (other endocarditis should be admitted to ID)
8. Symptomatic but hemodynamically stable valvular heart disease
9. Patients with ICD discharges that do not require CCU admission
10. Cardiac amyloid patients admitted with HF, bradyarrhythmias, or tachyarrhythmia
11. Large pericardial effusion, without tamponade
12. Pericarditis requiring admission
13. Patients recently discharged from the cardiology service who are readmitted with cardiac problems.
14. Patients with other symptomatic arrhythmias (e.g., WPW, AVNRT, NSVT) especially if presenting with syncope.
15. Patients with heart failure who are not felt to be appropriate for non-cardiac teams, eg requiring dobutamine/milrinone (most HF patients can be managed on medical services with assistance from the HF Consult Service)

Team cap of 16 patients

Daily admission cap of 5 new patients

If team caps at 16 patients at any point during the day, it will remain capped until 6:30pm, regardless of discharges.

1. All HIV-seropositive patients unless they require dialysis, active management of a malignancy, active management of an acute coronary syndrome, or urgent surgery.
2. Any patient with possible, probable, or definite diagnoses of:
   •  HIV/AIDS
   • Sepsis (not septic shock or simple fever)
   • Infectious endocarditis (except patients with prosthetic valve endocarditis should be admitted to Cardiology)
   • Central line associated bloodstream infection (except patients with HD catheter infection should be admitted to Nephrology)
   • Other bacteremia
   • Meningitis
   • Encephalitis
   • Peritonitis (except patients with PD catheter infection should be admitted to Nephrology)
   • Cholangitis
   • Intraabdominal abscess
   • Infectious colitis
   • Osteomyelitis
   • Septic arthritis
   • Head and neck infection
   • Ocular and periorbital infection
   • Complicated pneumonia
   • Tuberculosis
   • Malaria
   • Complicated skin and soft tissue infection
   • Syphilis
   • Febrile rash illness
   • Vectorborne illness

The ID team will also take GIM patients when asked by admitting.

This does not require a Code Yellow.