Acute Care Surgery (ACS) Observation

Approved- Carter, Supino 7/26

Inclusion:

Simple potentially surgical condition with clear end-point:

  • Possible appendicitis
  • Symptomatic cholelithiasis vs cholecystitis
  • Rule out bowel obstruction
  • Soft tissue infection awaiting definitive incision and drainage and/or debridement
  • Post-operative pain amenable to oral analgesics and likely discharge
  • Post-operative wound issue amenable to local care and likely discharge

OR

Simple surgical condition with plan for trial of non-operative management with clear end-point (ex: pain control, defervescence, tolerating oral intake, decreased leukocytosis, etc.)

  • Anticipated discharge within 24hrs
  • Stable vital signs
  • Normal mental status unless due to known, easily treatable condition (e.g., intoxication)
  • Concurrent stable chronic medical problems are OK (e.g., HIV, DM, HTN, etc.) as long as they do not require active management aside from prescribing home medications.
  • Patient is adequately resourced for the condition being treated (i.e., no barriers to discharge that will require additional hospital resources)
  • ACS consultation with plan of care

Exclusion Considerations:

  • Unstable vital signs
  • Complex medical condition(s) requiring active inpatient management
  • Definitive operative plan (patient to be admitted to ACS)
  • Multiple consultations required to coordinate care
  • Altered mental status not due to a known cause that is easily treatable or reversable
  • Low probability of discharge within 24 hours
  • Complex discharge process (e.g., placement, rehab, etc.)

Observation Management:

  • Use ED OBS Generic NOS or ED OBS Abdominal Pain PowerPlan
  • NPO status unless otherwise determined by ACS
  • Analgesics
  • Anti-emetics
  • Use caution resuming home medications such as ACE inhibitors and oral antihyperglycemics which are typically held in perioperative period.
  • Additional imaging as recommended by ACS consultants (HIDA scan, MRI abdomen, MRCP)
  • Care coordination/social work consultation
  • DVT prophylaxis in discussion with surgical team (SCDs for all patients; consider home antiplatelet/anticoagulation use or any coagulopathy, typically okay to start DVT chemoprophylaxis while awaiting possible general surgical intervention although additional consultants including IR or GI/E4 may ask for chemoprophylaxis to be held prior to percutaneous drain placement or ERCP. Default dosing is enoxaparin 40mg daily or heparin 5000U SQ TID if renal insufficiency.)
  • Antibiotics in discussion with surgical team
  • Notify ACS team via Tiger Connect of any change in abdominal exam or patient condition.

Disposition:

Home:

  • Patient satisfies discharge criteria as specified by surgical team
  • No indication for inpatient admission

 

Admission:

  • Ongoing treatment or evaluation required after 24 hours of observation
  • Definitive need for operative intervention (admit to ACS)
  • Development of new or acute condition requiring further management

Inclusion:

Simple potentially surgical condition with clear end-point:

  • Possible appendicitis
  • Symptomatic cholelithiasis vs cholecystitis
  • Rule out bowel obstruction
  • Soft tissue infection awaiting definitive incision and drainage and/or debridement
  • Post-operative pain amenable to oral analgesics and likely discharge
  • Post-operative wound issue amenable to local care and likely discharge

OR

Simple surgical condition with plan for trial of non-operative management with clear end-point (ex: pain control, defervescence, tolerating oral intake, decreased leukocytosis, etc.)

  • Anticipated discharge within 24hrs
  • Stable vital signs
  • Normal mental status unless due to known, easily treatable condition (e.g., intoxication)
  • Concurrent stable chronic medical problems are OK (e.g., HIV, DM, HTN, etc.) as long as they do not require active management aside from prescribing home medications.
  • Patient is adequately resourced for the condition being treated (i.e., no barriers to discharge that will require additional hospital resources)
  • ACS consultation with plan of care

Exclusion Considerations:

  • Unstable vital signs
  • Complex medical condition(s) requiring active inpatient management
  • Definitive operative plan (patient to be admitted to ACS)
  • Multiple consultations required to coordinate care
  • Altered mental status not due to a known cause that is easily treatable or reversable
  • Low probability of discharge within 24 hours
  • Complex discharge process (e.g., placement, rehab, etc.)

Observation Management:

  • Use ED OBS Generic NOS or ED OBS Abdominal Pain PowerPlan
  • NPO status unless otherwise determined by ACS
  • Analgesics
  • Anti-emetics
  • Use caution resuming home medications such as ACE inhibitors and oral antihyperglycemics which are typically held in perioperative period.
  • Additional imaging as recommended by ACS consultants (HIDA scan, MRI abdomen, MRCP)
  • Care coordination/social work consultation
  • DVT prophylaxis in discussion with surgical team (SCDs for all patients; consider home antiplatelet/anticoagulation use or any coagulopathy, typically okay to start DVT chemoprophylaxis while awaiting possible general surgical intervention although additional consultants including IR or GI/E4 may ask for chemoprophylaxis to be held prior to percutaneous drain placement or ERCP. Default dosing is enoxaparin 40mg daily or heparin 5000U SQ TID if renal insufficiency.)
  • Antibiotics in discussion with surgical team
  • Notify ACS team via Tiger Connect of any change in abdominal exam or patient condition.

Disposition:

Home:

  • Patient satisfies discharge criteria as specified by surgical team
  • No indication for inpatient admission

 

Admission:

  • Ongoing treatment or evaluation required after 24 hours of observation
  • Definitive need for operative intervention (admit to ACS)
  • Development of new or acute condition requiring further management