Service Agreements & Protocols

This agreement outlines the collaborative pathway between the Emergency Department and Pediatric Surgery for children (ages 0–13) presenting with suspected appendicitis at a GMC without an inpatient pediatric floor. The local Surgeon on Duty (SOD) is called first to confirm suspected appendicitis, then contacts PTAC to coordinate surgeon-to-surgeon transfer to the STMC — with age determining the accepting surgical service (Pediatric Surgery for ages 0–5, Adult General Surgery for ages 6–13). If the local SOD is unavailable and CT confirms appendicitis, the ED physician may initiate transfer directly through PTAC. The Pediatric Appendicitis Score (PAS ≥7 highly suspicious, <5 less likely) and pediatric CT protocol guide imaging decisions, and the accepting surgeon creates an OR case at STMC immediately upon transfer confirmation to reduce time to surgery.

This agreement defines a four-tier ED disposition pathway for urologic conditions: Tier 1 (call Urology immediately) covers true emergencies such as testicular torsion, persistent priapism, penile fracture, Fournier's gangrene, obstructing stone with fever >38°C, and refractory gross hematuria; Tier 2 (admit to Hospital Medicine, no overnight Urology call 7 PM–7 AM) applies to non-febrile obstructive stone pain, controlled hematuria on CBI, and septic epididymo-orchitis without abscess; Tier 3 (outpatient Urology referral, no ED consult) covers stones >3 mm without fever, successful urinary retention with Foley placed, incidental renal masses, and testicular masses on ultrasound; Tier 4 (PCP follow-up only) applies to stones ≤3 mm without fever, uncomplicated UTI/pyelonephritis, balanitis, and benign hydroceles. The tier category must be documented in every ED note, and any presentation that does not cleanly fit a tier should be escalated via attending-to-attending discussion.

Once a hip fracture patient arrives in the ED, both Medicine and Orthopedics are to be consulted simultaneously — Medicine to arrange admission and Orthopedics to begin expedited surgical planning. This dual-consult approach has been shown to move patients out of the ED sooner, reduce time to surgery, decrease medical complications, shorten overall length of stay, and free up hospital beds for other patients.

This agreement defines which service admits for common surgical presentations: biliary disease with confirmed gallstones (acute cholecystitis, gallstone pancreatitis, choledocholithiasis with cholelithiasis) goes to General Surgery, while biliary pathology without gallstones, post-cholecystectomy stones, or surgical refusal goes to Internal Medicine. Bowel obstruction with an incarcerated hernia or CT transition zone goes to General Surgery; ileus, carcinomatosis, impaction, or refusal of surgery goes to Internal Medicine. For diverticulitis, free air or abscess requiring intervention goes to General Surgery; all other cases go to Internal Medicine. Any post-operative complication (wound infection, dehiscence, abscess) goes to General Surgery, while non-surgical post-op issues (PE/DVT, pneumonia, MI/CHF) go to Internal Medicine. Necrotizing fasciitis and large abscesses requiring surgery go to General Surgery; all other cellulitis goes to Internal Medicine. For trauma, multisystem or wound-care cases go to General Surgery, while patients transferred from outside hospitals with only active medical issues go to Internal Medicine. Pediatric surgical patients 14 years and older may be admitted to FMC or OMC; those under 14 must go to FMC.

This agreement between Emergency Medicine, Hospital Medicine, Care Without Delay (CWD), AAMD, and Area Medical Director (Ontario and Fontana) provides a consistent pathway for non-admitted ED patients with LOS ≥24 hours who cannot be safely discharged due to disposition barriers — not medical acuity. All such patients are discussed in the daily morning CWD huddle; if no disposition is secured within 12 hours of the 24-hour mark, the case is escalated to the CWD physician who, if criteria are confirmed, authorizes a Hospital Medicine consult. Hospital Medicine accepts the patient as the primary team and admits to observation, while the ED physician signs off but remains available for acute decompensation (airway emergency, code blue). AAMD and AMD are notified during daytime hours; the pathway is valid 7 days a week with on-call CWD coverage on weekends.

• Secure Chat Alerts: ED physicians will receive notifications for patients requiring authorization.
• One-Hour Rule: Health plan must respond within 1 hour; if no response, authorization defaults to admit.
• Transfer Timeframe: Maximum 2–3 hours wait for a bed at an outside facility; if no bed, admit locally.
• Scope: Managed Care Commercial, Managed Medicare, Managed Medi-Cal.
• Go-Live: April 13
• Pilot Duration: 4–6 weeks with weekly check-ins.

Defines the consultation and referral agreement between Adult Primary Care and Emergency Medicine, covering shared-care expectations, follow-up routing, and escalation pathways for complex patients.

Establishes the service agreement between OB-GYN, Urgent Care, and Emergency Medicine for managing OB/GYN presentations, including triage criteria, on-call consult expectations, and transfer guidelines.

ED patients with a viable pregnancy who need monitoring should be sent to Labor & Delivery — not discharged from the ED first. Discharging from the ED ends the encounter and forces L&D to re-register the patient, which was the root cause of recent workflow confusion. This is the current FMC policy; OMC is mirroring the same process.

1. ED identifies a viable-pregnancy patient needing L&D monitoring.
2. Patient is physically moved to L&D while still on the ED trackboard / encounter.
3. When the patient arrives in L&D, the L&D clerk calls down to the ED.
4. ED then removes the patient from the trackboard, which allows L&D to create the new encounter.

• Discharging from the ED first closes the encounter and can cause the patient to be lost to the L&D workflow.
• Keeping the ED encounter open until L&D confirms arrival preserves continuity of care and documentation.

Outlines the service agreement between Psychiatry, IM Hospitalists, and Emergency Medicine for psychiatric patients in the ED, covering hold criteria, psychiatric consultation timelines, and disposition planning.

Defines the transfer criteria and escalation process between the ED and Neurosurgery, including criteria for emergent neurosurgical transfer, on-call notification expectations, and documentation requirements.

Establishes the agreement between SNFs and Emergency Medicine governing appropriate ED referrals, return-to-SNF criteria after ED evaluation, and communication requirements between SNF staff and the ED team.

Defines the consult and referral agreement between Ophthalmology and Emergency Medicine, including on-call response expectations, triage criteria for urgent vs. emergent eye conditions, and after-hours management.

Outlines the service agreement between Hospitalists, Intensivists, Cardiologists, and Emergency Medicine for critically ill and high-acuity patients, including ICU admission criteria, cardiology consult thresholds, and shared-care responsibilities.

Defines the inter-facility transfer process for pediatric patients between Ontario Medical Center (OMC) and Fontana Medical Center (FMC), covering transfer criteria, transport coordination, and receiving team expectations.

Establishes the service agreement between Internal Medicine and Emergency Medicine for Code Sepsis activations, including sepsis bundle responsibilities, ICU escalation criteria, and shared documentation expectations.

Defines the shared patient care and information-sharing framework between San Bernardino County Sheriff's Department (SBCSD) and Kaiser Permanente for detained/incarcerated patients presenting to the ED, including custody notification requirements, documentation standards, and coordination of care responsibilities.