Common Inpatient Admissions
Acetaminophen Overdose
Please contact Alaska Poison Control (1-800-222-1222) which is based at OHSU in Oregon. They are very helpful and have access to a toxicologist if needed.
Our initial contact with these patients is usually through RMT. Oral mucomyst is in the village clinics and can be given every 4 hours until the patient arrives in the ER where blood levels are available and IV mucomyst, as needed, can be administered. Once admitted (see the Raven Tylenol PowerPlan), these patients complete their IV treatment with lab monitoring. Once medically cleared, BH should evaluate for suicide risk and appropriate discharge planning.
Acute Abdomen
Often, the ANMC on-call surgeon will ask us to admit and monitor an acute abdomen patient (often partial small bowel obstruction) when appendicitis has been ruled out by CT. If the patient does not improve, they can be transferred to ANMC in consultation with Surgery.
Acute Cholecystitis
If the common bile duct appears patent, the ANMC on-call surgeon will sometimes ask us to admit and monitor these patients while on antibiotics. If the patient improves clinically, they can then be scheduled for non-emergent surgery.
Altered Mental Status (AMS)
AMS patients with normal vital signs and no overt etiology for symptoms may be monitored inpatient in consultation with ANMC Internal Medicine.
Alcohol Hangover/Withdrawal
See YKHC Clinical Guidelines-p.20 as well as the Raven PowerPlan (also includes our Ativan Protocol) for this type of admission. Anyone hallucinating following cessation of alcohol ingestion should be admitted for Withdrawal and placed on the Ativan Protocol.
Anemia
If an anemic patient is symptomatic, they can be admitted for a blood transfusion.
Behavioral Health / Title 47 Hold
See YKHC Clinical Guidelines as well as the Raven PowerPlan for this type of admission. BH manages these four closed-circuit monitored beds in two rooms which are cohorted by gender and behavior. The Title 47 part is a special Alaska law which allows a police officer, physician or psychologist to temporarily take a person rights away (for good cause) if there is perceived threat to self or others. There is an outpatient form that is generally signed to transport the patient to the ER prior to admission and a required pre-checked order sentence in the Power Plan for T-47 (that allows up to get paid for the admission) before the patient will be allowed on NWing. WE as the physician admit and discharge the patient while the BH Clinican generally deals with the BH aspects works with the patient to move them where they need to go to for the best care. Physician-BH Clinician communication is essential for the best care of these patients.
Also, if a higher level of care is considered best for the patient, the BH Clinician will make the initial arrangements with the referral facility and if involuntary, obtain the necessary “exparte” from the local Judge.
Cerebral Vascular Accident (CVA)
Direct transfer of an acute CVA patient from the ER to ANMC should always be considered as these patients have better chance at rehab as the rehab-queue for Alaska Regional starts at ANMC inpatient.
That being said, non-hemorrhagic, non-brain stem and stable stroke patients can be monitored inpatient for 1-2 days to assure there is no clinical worsening. On a cardiac-respiratory monitor emboli-producing arrhythmias can be screened while Physical Therapy can help assess for rehabilitation potential and ability to swallow can be grossly assessed.
Neurology and/or IM at ANMC should be consulted and the patient transferred there if rehabilitation is a possibility. YKHC inpatients can only go to rehab via ANMC inpatient. Otherwise, YKHC patients are discharged home with an ANMC IM follow-up appointment for an MRI, echocardiogram and carotid duplex (if latter not done in Bethel).
Chest Pain
No MI patients are admitted to Northwing unless they are DNR/DNI and decline transport to Anchorage. A patient can be admitted for non-ischemic chest pain with cardio-respiratory monitoring to clarify the chest pain etiology.
COPD
See YKHC Clinical Guidelines for this as well as the Raven PowerPlan. RT should be consulted on all such patients regardless of supplemental oxygen needs. RT has been encouraging us to use Spiriva (tiotoprium) in favor of ipratropium as well as adding Advair on all such patients inpatient (and out outpatient as well). Albuteral nebulized orders for less than Q4hrs should be a rarity and CPAP use is very much an exception and if used at all, should only be for short periods. Patients requiring BiPAP cannot be admitted to NW.
Congestive Heart Failure
See YKHC Clinical Guidelines for this as well as the Raven PowerPlan. RT should be consulted on all such patients regardless of supplemental oxygen needs. Also be cognizant that, like pneumonia above, this is one of CMS’s “high profile” illnesses and the CMS discharge recommendations for this diagnosis-includes EF and weight monitoring-is posted in the NWing Doc’s Office (important for billing). The known LV function (Ejection Fraction [EF]) for these patients is very important to document and if not available in Raven is often hiding in the old soft chart, RPMS-HIS Patient Chart, or online through ANMC. If this is a new CHF patient or no recent echocardiogram is in the record, a referral to Cardiology either through YKHC Specialty Clinic or at ANMC should be sent. Feel free to directly call the cardiologist at ANMC most familiar with the patient as needed or sometimes, especially during the weekend, IM will have to do.
Diabetes
It is reasonable to admit a diabetes patient with out of control blood sugars for glucose monitoring, medication adjustment, and education.
Frostbite
Any frozen body part should first be thawed in the ER. Wound Care Nursing and ANMC Orthopedics should also be consulted prior to admission and throughout admission. There are also YKHC Clinical Guidelines to cover this and a Raven PowerOrder set. Severe frostbite involving digit loss tend to be long admissions as ANMC advises “auto-amputation,” which in the long run has shown to reduce tissue loss, prior to a definitive surgical procedure.
GI Bleed
These patients can generally be admitted for blood transfusions, IV PPI and monitoring if the are “stable” and the ANMC surgeon is consulted. Emergency endoscopy is sometimes available at YKHC for further evaluation. Please also see the YKHC Clinical Guidelines and Raven PowerPlan for this.
Hospice
In consultation with the “Palliation Team” and because no Hospice service is available locally in Bethel of the surrounding villages, sometimes NWing is the best place for a person with a terminal ailment to comfortable and respectfully die.
Inflammatory Bowel Disease
Both ulcerative colitis and Crohn’s Disease are not common but we do admit these patients occasionally. We now have a GI specialist at ANMC to help us. Also, endoscopy can assist in making a new diagnosis and is often available M-F at in the YKHC Surgery Department. Contact the Surgery Case Manager or the endoscopy physician if your patient might be a good endoscopy candidate.
Pain Patients
Pain alone is a reason to admit a patient when outpatient treatment is inadequate. This could include acute low back pain, chronic abdomen pain or cancer with bone metastases.
Pancreatitis
The lipase level and the clinical situation usually make the diagnosis. The main reason for admission is usually the need for “gut rest” = IV hydration along with IV analgesia. Inpatient treatment usually consists of advancing the diet while switching to oral analgesia.
Feel free to consult with ANMC IM for both clinical help and any f/u needs. Follow-up with their PCP is also key to preventing re-admissions.
Pneumonia
See YKHC Clinical Guidelines for this (includes PSI-Pneumonia Severity Index to guide on who needs admission) as well as the Raven PowerPlan. RT should be consulted on all such patients regardless of supplemental oxygen needs. Also be cognizant of CMS discharge recommendations for this diagnosis posted in the NWing Doc’s Office (important for billing).
Pyelonephritis
All pregnant patients with a kidney infection should be admitted for initial treatment. Additionally, any patient who fails outpatient therapy or is unable to tolerate oral intake is a good candidate for admission.
Skin and Soft Tissue Infection
See YKHC Clinical Guideline for Abscess/Cellulits *link here and the IDSA MRSA Guidelines.
A Raven PowerPlan is available on Adult Admit Orders and Wound Care is automatically consulted as is Pharmacy for vancomycin management. Lower extremity abscess and/or cellulitis patients should have a VERY LOW threshold for admission.
Tuberculosis (TB)
If you suspect Active PULMONARY TB, then the patient should already be on Airborne Precautions* prior to arrival on Inpatient. This is also true if you order an AFB smear. Please see the YKHC Clinical Guidelines for TB, the Tuberculosis Book in the Doc’s Office and the Raven PowerOrders for this.
As a general rule, do not order a tuberculin skin test (TST) as most elders have either been treated for active TB or currently have a Latent TB Infection-treated or not. In addition to our medical record system, Bethel Public health Nursing (543-2110) has the best records for past TST results and treatment history.
It is unnecessary to admit a reliable Bethel resident for suspicion of TB if they are clinically stable. This is not true for village patients in Bethel who may become a community infection risk if they travel home by airplane.
Until the rapid TB assay (Xpert® MTB/RIF) is implemented sometime this year in 2015, it will take between 3-7 days to receive 3 AFB reports from the State Epi Lab (907-334-2100) to effectively rule-out infectious pulmonary TB depending on a number of factors. Generally, seek advice from one of our fine YKHC TB Control Officers (currently Elizabeth Roll, Ron Bowerman, Cindy Mondesir or Mien Chyi) or the State TB Officer, Dr. Michael Cooper (or his associated mid-level provider), before initiating therapy. T rapid TB sputum assay mentioned above will give more certainty and speed in clinical decision-making.
