Small Animal Emergency Service Patient Transfer to VTH Services SOP

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Purpose/ Applicability: 

The Small Animal Emergency Service Patient Transfer to VTH Services SOP is intended to provide guidelines for the management of patients that present to the Small Animal Emergency Service of the VTH.

Scope:

This SOP applies to all services providing clinical care for small animals within the VTH.

The primary purpose of the Small Animal Emergency Service (SAES) is for clinical personnel to detect emergent problems in veterinary patients and treat these as quickly as possible.

 

Definition(s):

• Emergency Patient – a patient exhibiting clinical signs that require immediate action to maintain life.
• Non-Urgent Patient – a patient that does not have a life-threatening condition and that is stable.
• Small Animal Emergency Service – The clinical service of the VTH that provides scheduled and walk-in care for small animals with emergent and urgent conditions.
• Urgent Patient – a patient that should be assessed and treated within hours to days but cannot wait for the next available appointment.
• Veterinary Teaching Hospital – The clinical services associated with the Small Animal Clinic, the Large Animal Clinic, the Veterinary Medicine South Clinic, and Midwest Equine at Illinois.
  
  

Equipment: NA

Procedure:

Patients presenting to the SAES will be triaged into three categories emergent, urgent, and non-urgent.

Monday through Thursday 10 am-6 pm, patients with urgent or non-urgent presentations should be rerouted to the Urgent and Convenient Care (UCC) service.

Patient Disposition

Patients seen by SAES will have one of three dispositions: discharge to the owner, hospitalized and transferred to a different specialty service, or humane euthanasia/death.

1. Discharge to owner:
   1. These patients will generally be those that were triaged into the “non-urgent” category.  The presenting problem has 1) been resolved, 2) the patient is stable and follow-up care was recommended with a referring veterinarian or an alternative specialty service within the VTH, or 3) the client has declined further care due to cost or other reasons. These patients need to be sent home with Outpatient Discharge Instructions listing all recommendations for treatment and follow-up. Follow-up may include referral to VTH service for specialty care.
2. Humane Euthanasia or Death: 
   1. These patients can be those from the “emergent,” “urgent,” or “non-urgent” categories.  No documentation is provided to the owner, but the rDVM should be notified within 24 hours and a full discharge report is written.
3. Transfer to VTH Service: 
   1. These patients will generally be those that were triaged into the “emergent” or “urgent” categories.  These patients need diagnostics and treatment, as well as 24-hour nursing care, prior to the next available appointment or being sent home.

 

Specialty Service Support of SAES Patients Not Transferred

If the patient will not require hospitalization but requires emergent or urgent procedural care from a VTH service (gastroscopy, cesarian section), the patient will stay the responsibility of SAES until discharged from the VTH with the following caveats:

• SAES will call the personnel from the service being requested to perform the procedure and advise them of the need for the procedure.
• SAES will call the personnel from the anesthesia service to respond as needed and to determine and address any necessary pre-anesthetic stabilization.
• The VTH service performing the procedural care will take over patient care for the duration of the procedure. However, the SAES clinician will remain the point of contact for the owner, communicating additional needs and/or requests (e.g., need for surgery following an endoscopic procedure, consideration for euthanasia, etc.).
• Post-procedure, the patient will be returned to the ER for monitoring and discharge. The SAES clinician will assume full patient oversight once the patient has returned to the ER.
• The VTH service performing the procedural care will 1) provide a student for patient monitoring until the patient is fully recovered and 2) document the procedure and findings in an appropriate format in the patient record and provide client information for home care and follow-up in the draft discharge summary prior to leaving the VTH.
• The student will confirm with SAES clinical staff that the patient has fully recovered prior to leaving the patient. SAES clinical staff will confirm patient status and release the student.
• The SAES will complete the discharge summary/patient visit report, communicate with the owner, and discharge the patient. Patient discharge may be performed by any SAES personnel, including clinical year students, and does not require that the SAES clinician receiving the patient be present.
• If the patient requires hospitalization post-procedure, the VTH service performing the procedural care will assume oversight of the patient as per the case transfer protocol.
• If the VTH service performing the procedural care elects to delay the procedure until normal receiving hours, barring adverse impact to the patient, the patient will be transferred to the VTH service as per the case transfer protocol.

Diagnostic Testing and Estimate Generation

Diagnostics performed by the SAES will occur only when those results are needed to 1) direct appropriate emergency care and/or 2) to determine the need for transfer and to identify the most appropriate service to receive the transfer.

SAES will be responsible for establishing the patient care cost estimate and acquiring the appropriate client consent and payment prior to transfer. SAES will use a service cost reference to generate a reasonable initial estimate and inform the client that the estimate may change after transfer. The transfer receiving service may change the cost estimate and collect an additional deposit after the transfer, based on the assessment and plan and after speaking with the client.

Pre-Transfer Diagnostic Imaging Requested by a Specialty Service

If advanced imaging is requested by a specialty service for procedure planning (e.g., CT imaging prior to abdominal surgery) prior to the case transfer, the patient will stay the responsibility of SAES until transfer with the following caveats:

• SAES will provide an estimate for both the imaging and recommended procedure and obtain client consent for the imaging.
• SAES will call the personnel from the anesthesia service to respond as needed and to determine and address any necessary pre-anesthetic stabilization.
• The requesting specialty service will call the personnel from the radiology service and request imaging.
• The requesting specialty service will take over patient care for the duration of the diagnostic procedure. However, the SAES clinician will remain the point of contact for the owner, communicating additional needs and/or requests.
• After diagnostic imaging, the requesting specialty service clinician will relay the results and recommendations to the SAER clinician, who will then communicate with the client.

• If the client elects to pursue the recommended procedure, the SAER clinician will obtain a deposit for the procedure. The patient will be immediately transferred and the service receiving the transfer will assume patient oversight and case communications.
• If the client does not elect to pursue the recommended procedure, the patient will not be transferred and SAES will assume full patient oversight for follow-up, including client communication and continued patient care/discharge or euthanasia.
  
  

Hospitalization and Patient Transfer

Patients will be hospitalized in the Intensive Care Unit (ICU) or Intermediate Care (IMC) if deemed necessary by the SAES and transferred to the appropriate service in the VTH based on the most urgent condition or significant problem identified. 

The SAES will notify VTH services of transfer cases through the dissemination of the daily transfer list. The transfer list will be finalized by 5:30 AM each day. Prior notification of the receiving service is not required, although the SAES personnel may consult with other services as deemed appropriate by the SAES following consultation with the supervising SAES clinician. Service consultations must not be used to redirect a potential transfer from the consulting service to another service. VTH services will be notified when a patient presents to the SAES that is currently under care. The SAES clinicians remain responsible for patient care and treatment decisions until the patient is transferred or discharged. All transfers will occur at 7 AM unless the case has already been transferred to a VTH service. Case transfers may occur prior to 7 AM when a patient requires emergent or urgent care provided by a specialty service.

 

Patient Transfer Guidelines are established below:

In general, patients should be transferred to the specialty service best able to provide definitive therapy for the primary, underlying disease process. Secondary or pre-existing problems should be managed by the that service in consultation with other, relevant services, as needed.

CARDIOLOGY

• Suspected or known cardiac disease causing clinical signs
• Arrhythmias suspected to be associated with primary heart disease requiring treatment

CRITICAL CARE – Cases will be transferred appropriately to alternative VTH services when Critical Care Service is non-operational.

• Environmental emergencies (alternate – SAIM)
• Non-surgical sepsis (alternate – SAIM)
• Polytrauma (alternate – STS)
• Toxicosis requiring monitoring or inpatient treatment (alternate – SAIM)
• Consider co-management for:
  • High flow nasal oxygen
  • Mechanical ventilation
  • Severe acid/base or electrolyte derangements
  • Vasopressor therapy

 

DENTISTRY

• Jaw fracture and severe dental disease (check availability of faculty first)

 

DERMATOLOGY/OTOLOGY

• Severe skin, ear, anal sac disease

 

NEUROLOGY

• Cluster seizures/status epilepticus
• Myelopathy (see separate schedule for details)
• Neurologic signs (unless known to be secondary to metabolic disease)
• Spinal fractures (check availability of faculty first)
• Patients presenting with predominantly neurologic signs should be transferred to Neurology even when other non-specific signs are present (e.g., inappetence, mild clin. path. abnormalities)

 

ONCOLOGY

• Known or suspected neoplastic disease-causing clinical signs or prompting referral
• Clinical signs requiring hospitalization secondary to administration of chemotherapeutic agents or radiation therapy

 

OPHTHALMOLOGY

• Ocular disease where vision is likely to be lost if not treated (check availability of faculty first)

 

ORTHOPEDIC SURGERY

• Appendicular or pelvic fractures requiring surgical intervention
• Myelopathy (see separate schedule for details)

 

PRIMARY CARE

• Injured or sick unowned/stray animal
• Patients with urgent conditions that don’t require specialty care AND that don’t have a referring veterinarian

 

SHELTER MEDICINE

• Post-operative complication from surgery performed by Shelter Medicine

 

SMALL ANIMAL INTERNAL MEDICINE (SAIM)

• Patient has infectious or immune-mediated disease with predominantly non-neurologic manifestations
• Non-surgical/non-neoplastic diseases of the respiratory, urinary, GI/pancreas, hepatobiliary, endocrine, or hematological systems
• Patient has unexplained fever
• Patient has unexplained anorexia without evidence of surgical or significant neurologic, oncologic, or cardiac disease
• Patient has unexplained effusion without evidence of surgical or significant oncologic or cardiac disease

 

SOFT TISSUE SURGERY (STS)

• Known or suspected to need a surgical procedure
• Post-operative problem (surgery at VTH or rDVM)
• Patient was referred for surgery by rDVM and surgical need is confirmed by SAES
• Complicated or severe wounds requiring on-going/daily wound care or surgery

 

ZOOLOGICAL MEDICINE

• Zoological species requiring hospitalization