Diagnosis: Internal Medicine Education and Resources  

Medicine and Orthopedic Co-management Service Agreement




To establish an agreement between Internal Medicine, Emergency Medicine, and Orthopedic Surgery concerning the treatment of patients who are admitted though the emergency department with any acute fracture. Any questions regarding which service should be the primary team should be resolved by a conversation first between the respective residents, and if needed between the respective attendings. If a conversation between attendings is necessary, the residents on the service first consulted by the ED must initiate the conversation between attendings. The decision about which service will admit the patient should be made and communicated to the ED team within one hour of the first consulted service seeing the patient.

This policy also addresses the management of any inpatients with both medical and orthopedic conditions.


A) After admission to the orthopedic service, acute problems will be called to the orthopedic resident on call if related to a surgical problem, or to the surgical co-management (SCM) hospitalist if related to a medical problem. For acute medical problems overnight, the SCM hospitalist on call may choose to involve the Nocturnist. If the medical problems require frequent evaluation by the medicine team for active issues, the patient should be transferred to the medicine service or ICU, depending on the acuity of illness.

B) Discharge planning and follow up are the responsibilities of the primary team.


A) Medicine Service:

  • a) Medicine service will admit any patient with a fracture and any of the following
  • - Acute chest pain or EKG or enzyme evidence of ischemia


    - Dyspnea, or signs/symptoms of pulmonary edema


    - Decompensated Heart Failure


    - Uncontrolled arrhythmia or new arrhythmia with HR >110


    - DKA


    - Severe Valve disease


    - EF <30% on prior ECHO


    - Any complicated active infections (e.g. diverticulitis or pneumonia but not bronchitis or simple UTI), or evidence of sepsis


    - Acute renal failure


    - Acute loss of consciousness


    - Persistent/Recurrent Systolic BP >180 or diastolic >100


    - Persistent/Recurrent Systolic BP < 90 despite appropriate fluid challenge


    - Any signs of active internal bleeding (unless another service is more appropriate [eg, trauma, or ICU])


    - Any patient with acute change of chronic oxygen requirement


    - Acute alcohol intoxication with ethanol level >250

b) If consulted on a patient admitted to the orthopedic service, medicine service will see the patient within 3 hours (unless called STAT, in which case the patient will be seen within 1 hour)

c) Medicine service will accept in transfer patients who are initially admitted to the Orthopedic service but develop any of the major conditions listed above. This includes patients admitted for elective procedures such as joint replacement surgery. Orthopedic team will follow these patients in consult.

d) If patients originally admitted to medicine become medically stable but have continued orthopedic problems they can be transferred to the orthopedic service and followed by the orthopedic SCM hospitalist service.

e) For patients on the Orthopedic service, the SCM (Surgical Co-Management Hospitalist) service will write daily notes and orders for evaluation and management of medicine related problems (including labs, meds, etc.). Notes will include full risk stratification for intra-operative intervention and will recommend cardiology consult if needed.

B) Orthopedic service:

a) Orthopedic service will admit all patients with fractures except those with the medical conditions listed above.

b) If consulted on patients admitted to the medicine service, the orthopedic service will see the consult within 5 hours unless called STAT, in which case the patient will be seen as soon as possible.

c) Orthopedic consult service will write a note on patients on the medicine service with orthopedic injuries daily, and will write orders pertaining to evaluation of the fracture, anesthesia evaluation, OR scheduling, NPO status, anticoagulation, equipment orders, PT/OT, perioperative antibiotics if needed, wound care, activity level.

d) If patients become stable from an orthopedic standpoint but have ongoing medical issues that prevent them from discharge, these patients can transfer to the medicine service with an orthopedic consult if needed.  Placement (eg. to a SNF) is not an indication for transfer to a medicine service.

e) Orthopedic service will accept patients in transfer from the medical service in the post-operative period if the initial indication for admission to the medical service has resolved.

f) Once stable from an orthopedic standpoint the consult team may follow peripherally or sign off if orthopedic problems are resolved, if mutually agreeable to both teams. If the consult team signs off, final recommendations including follow up recommendations will be included in the final note.

g) Elective orthopedic patients: If none of the conditions under Medicine’s responsibilities section (3.A.a) above are present but a patient needs to be admitted for a surgical problem, that patient will be admitted to the orthopedic team.

h) If a patient comes to the ER with musculoskeletal injury (in absence of a fracture) that cannot be managed as an outpatient because of pain or debilitation but there is no surgical indication for admission, the patient should be admitted to the medical service and orthopedics will follow the patient as consult if needed.

C) Emergency Department:

a) Emergency department will review the above criteria and determine to which service the patient will be admitted and notify the proper resident.

b) Emergency department will not make above determination until an adequate workup is obtained to assess for the above criteria.

c) The service called by the Emergency Physician is responsible for admitting the patient if the above process has been followed. The respective residents or attendings can arrange for a transfer after admission if they do not agree with the initial placement, but this should not delay the admission.


This agreement will be re-evaluated yearly to see if any modifications will need to be made (or sooner, if deemed appropriate by the Service Chiefs).




Ahuja/Lowenberg/Shen/Weinacker- 4/2014