BMDH Admission Matrix – Version 3 August 2020

BMDH Admission Matrix

Admitting Team Based on Clinical Problem
VERSION 3 – SEPTEMBER 2020

1. This Matrix aims to assist in identifying which provisional diagnosis comes in under which team and, where any ambiguity exists, ED Senior Medical Staff will
determine the need for admission and allocate the patient to an inpatient team.
2. The decision to admit is made by ED senior medical officers (staff specialists, VMOs, Registrars and CMOs).
3. The allocation of each patient to an inpatient team should be consistent with the Admissions Matrix WHEN POSSIBLE
4. Patients who re-present to ED within 72 hours of discharge by an inpatient team with a syndrome similar to that in the prior admission, or likely complications
from treatment during the prior admission, should be referred back to the same specialty for admission.
5. ED operate under a ‘One Call’ principle where the first team contacted, appropriate to the matrix, should admit and manage the patient.
6. If the admitting team feel that the patient is better managed by a different team, then it is up to the initial admitting team to notify the appropriate team.
7. If an ED senior medical officer has determined that admission is required, the ED medical officer calling the inpatient specialty AMO or registrar should preface
discussion by stating: ‘I am calling to inform you of an admission under your specialty’.
8. No referral for admission may be refused unless it is agreed after discussion that either:
 The patient does not need admission; or
 The Admissions Matrix has been misinterpreted. The final decision about this rests with the ED Senior Medical Officer who has personally seen
the patient.
9. Lack of a need for surgery is not a reason for refusing a referral for admission unless either:
 After assessment by the relevant surgical registrar that surgery is not required, there is a recognized pathway in the Admissions Matrix for patients
with the condition who do not need a surgical procedure; or
 In the absence of a need for surgery, there is another medical condition (not just the age of the patient) that becomes the primary reason for
admission.
10. ED medical officers may also contact inpatient teams for advice on whether a patient needs admission or to clarify their understanding of the patient’s
presentation. In this case, the ED medical officer should preface the discussion by stating: ‘I am seeking your advice about this patient who may need
admission’.
11. There is an appeal process for any dispute about the allocation of an admission to an inpatient team. This is managed by the Director of Medical Services.
12. If, after assessing the patient, the inpatient medical team concludes that the patient’s care is more appropriately under another specialty, transfer of care may be
arranged by means of inpatient AMO to inpatient AMO discussion and agreement. This is not the responsibility of ED medical staff, and patients may not be
referred back to ED medical staff after a referral for admission. However, outside normal working hours, the ED medical officer may be asked to contact one other
specialty to request an early consultation.
13. If a complex imaging test is requested to further delineate the diagnosis of the patient, then the patient should be admitted under the initial team who the patient
was referred to whilst the complex test is carried out to further delineate the diagnosis.
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating
System admission
Proposed admitting Unit Notes
Any Any All Within each specialty, the on-call specialist will be the default
specialist to accept care. If a patient is under the active management
of another Blacktown specialist, it may be appropriate to contact the
specialist to give them the opportunity to accept care in business
hours
Acute single organ/system disease Organ specific specialty
Face & pinna Plastic Surgery
Neck & trunk General Surgery
Hand (Carpal Bones and below) Plastic Surgery
All other limb wounds/lacerations General Surgery Except degloving limb injuries and skin tears/flaps >5cm which
may require operative management – Plastic Surgery
Wounds/Lacerations

EXCEPT IN CASES OF:

Joint, muscle or tendon involvement Orthopaedic Surgery Except hand – admit Plastic Surgery

Tendon injury of wrist or forearm Plastic Surgery

Nerve involvement Plastic Surgery

Extensive skin loss/damage Plastic Surgery

Major vascular involvement Vascular Surgery Except vascular injury to hand – admit Plastic Surgery

Diabetic foot ulcers Vascular Surgery

Ischaemic limbs/ulcers Vascular Surgery

Pressure area wounds General Surgery Surgical Team to contact Plastic Surgery only if needing skin graft
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem Specific Condition/Disease necessitating
or System admission Proposed admitting Unit Notes
Infectious Diseases & Hospital in the
Uncomplicated Cellulitis Infectious Diseases, if requires admission
Home (HITH) – non admission

Cellulitis with collection (except

General Surgery
hand/forearm)

Skin/Bone/Joint infections
Skin and soft tissue abscess General Surgery Admit under General Surgery, even if abscess has been drained

Hand infections Plastic Surgery

Other upper limb infections Orthopaedic Surgery

Osteomyelitis/Septic arthritis/Bursitis Orthopaedic Surgery

Dermatological emergencies Dermatology Westmead Hospital Must discuss with Westmead Dermatology on-call

Major Burns State Burns Guideline Concord Hospital (Adult); Children’s Hospital (Paediatrics)
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or System Specific Condition/Disease
necessitating admission
Proposed admitting Unit Notes
Multi-trauma State Trauma Unit Refer to Westmead Trauma Unit
Toxicology Team to organize Mental Health when need for in-patient
Overdose/poisoning/drug intoxication Toxicology
medical care complete

Toxicology Envenomation Toxicology

Drug & Alcohol withdrawal syndromes Drug & Alcohol

Alcohol intoxication Drug & Alcohol

Orbital/Peri-orbital Cellulitis with Globe Certain groups may be admitted under Max Facs in WMH. Please check
Ophthalmology Westmead Hospital
involvement WMH roster
Ophthalmology
Infectious diseases BMDH
With NO Globe involvement
Some subspecialty conditions refer to Tertiary children’s
Age less than 16 with medical conditions Paediatrics hospital after local paediatric consultation

Age 5 and above with surgical conditions Appropriate surgical team as per adults +/- paediatric medical consultation as appropriate

Refer tertiary children’s hospital Isolated injuries: Orthopaedics or Plastics if Age > 2
Paediatrics Age less than 5 with surgical conditions +/- paediatrics review as needed In emergency life-threatening situations consult paed & surg teams

Discussion with CONSULTANT psychiatrist and CONSULTANT

Mental health less than 16 years Psychiatry paediatrician to be had between the teams

Post tonsillectomy bleed ENT CONSULTANT Westmead Children’s ENT CHW

Obstetrics Pregnancy related illness or complications Obstetrics

BMDH Admission Matrix – Version 3 August 2020

Presenting Problem or Specific Condition/Disease necessitating Proposed admitting Unit

System admission Notes
Haematology Acute haematological conditions and
haematological malignancies Febrile Neutropenia secondary to chemotherapy in other oncology patients
Febrile Neutropenia in a haematological Haematology admit under Medical
patient
Specialist palliative management is
required for complex end-stage It is important to note that Supportive and Palliative Medicine inpatient beds are
conditions where acute/curative reserved for patients requiring specialist Supportive and Palliative Medicine input
treatment is no longer Supportive and Palliative Medicine Team
Palliative Care possible/appropriate or the patient is BMDH
known to and/or accepted by the
Supportive and Palliative Medicine
Systemic toxicity while on Cancer
service
therapy,
for end of life care Including Silverchain
Eg Febrile neutropaenia,
services Diarrhoea, Medical Oncology
Hypotension, Neurological or
Immunological complications
Patients who have included
been referred to
Neurological deterioration
Palliative with known
care for further Palliative care
management andmalignancy
intracranial or Silver chain Radiation Oncology
Bone pain
and from
have notmetastatic
been seendisease
yet Radiation Oncology
Symptoms suggestive of malignant Radiation Oncology
Cancer superior vena caval obstruction
Malignant spinal cord compression Radiation Oncology
Toxicity secondary to Radiation & or
symptom in area of Radiation Radiation Oncology
(NOTE: febrile neutropenia should not
be admitted under Radiation Oncology)
Cancer related symptoms Admission under the patients primary
Oncology team (Rad Onc or Med Onc)
Cancer patients who present with a
complication requiring a procedural Under relevant subspecialty for further
intervention (Pericardial effusion differentiation (Cardiology,
requiring a pericardiocentesis, Gastroenterology etc.)
obstructive jaundice requiring ERCP
First presentation of a CLEARLY
etc.)
disseminated malignancy and the Medical Oncology
primary source is unclear
First presentation of “Unsure” of Under relevant sub-specialty for further
malignancy based on limited diagnostics differentiation

Cancer
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease Proposed admitting Unit Notes
System necessitating admission
Psychosis (incl. drug
Mental Health
induced)/mania/depression/suicidality
Deliberate self-harm or overdose after Mental Health PECC admissions are for 24-48 hours and after that time are
medical care complete discharged or transferred
Altered mental state after delirium Mental Health
excluded not
Behavioural disturbance Mental Health
caused by underlying medical
condition
Mental Health Challenging behavior secondary to Age ≥ 70yrs : Admission under Geriatrics Involvement of Geriatric and Psychiatry team. Please note that there is
dementia, depression or other organic no inpatient Psychogeriatric service in BMDH. Geriatric team to liaise with
cause in older person Psychiatry team

Challenging behavior in <70 due to an Neurology

underlying organic or other cause
Admission under relevant Neurology and/or Other admitting team to liaise with Psychiatry Team
Adult Mental Health patient presenting medical/surgical team with Psychiatry directly
with an acute organic Issue input

Undifferentiated abdominal pain General Surgery All Non Pregnant (lower) abdominal pain admissions under surgery
Appendicitis General Surgery
Cholecystitis/biliary colic General Surgery if uncomplicated biliary colic
Pancreatitis in patients with Gall bladder General Surgery Gastroenterology consultation for ERCP if cholangitis or CBD stones
Pancreatitis in patient who have had contributing. The Surgical Team to liaise directly with the
cholecystectomy Gastroenterology Gastroenterology team
Diverticulitis General Surgery
Intra-abdominal collections General Surgery
Abdominal Pain/Surgical Bowel obstruction General Surgery
Ischaemic enteritis/colitis General Surgery
Likely perforated stomach/intestine General Surgery
(free gas on x-ray)
Fournier’s gangrene General Surgery
Renal colic/ureteric obstruction Urology
Pyelonephritis with calculi Urology
Testicular Torsion Urology
Leaking / Abdominal Aortic Aneurysm Vascular Surgery Westmead
Pregnancy related pathology Obstetrics All Pregnant lower abdominal pain admission under O&G
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or System Specific Condition/Disease necessitating
admission Proposed admitting Unit Notes

Pathology of the female genital tract Gynaecology Including PV bleed as per EPAC guidelines, severe lower abdominal
Abdominal Pain/Surgical pain secondary to ovarian cause, Menorrhagia requiring blood transfusion

Gastroenteritis/vomiting/diarrhoea Gastroenterology

Inflammatory Bowel Disease Gastroenterology

Gastroenterology
Iron deficiency anaemia of unknown cause Gastroenterology

Upper GIT bleeding Gastroenterology

Lower GIT Bleeding Gastroenterology

Primary liver disease Gastroenterology

BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating
System admission Proposed admitting Unit Notes
Dyspnoea in patient with both respiratory Respiratory or Cardiology To be reviewed by senior ED MO who will determine which team the patient
and cardiac components (e.g. COPD and depending on predominant acute will be admitted under, at which point a Single phone call is be made to the
heart failure) component, 1st team. Cardiology if Acute Coronary Syndrome present.

Dyspnoea needs to be admitted under relevant specialty

a. Respiratory – Predominant respiratory cause including those
requiring high flow oxygen or noninvasive ventilation.
Elderly patients with high level
functional and/or cognitive b. Cardiology – Predominant cardiac cause including those requiring
Cardiorespiratory impairment will be admitted
cardiac monitoring, serial troponins, inotropes
under the Geriatric Medicine Team
Gastroenterology / Haematology – significant anaemia

Geriatric Team to directly consult/liaise with Cardiology/Respiratory Team

Cardiology as per Pathway for Acute
Coronary Syndrome Assessment Cardiology – Predominant cardiac cause including acute coronary
syndrome and pericarditis
Cardiac Arrhythmia patients admission Conservative management plan is deemed appropriate for some patients
Possible Acute Coronary Syndrome
under Cardiology and this decision will need to be made by Cardiology in consultation with
Cardiac Arrhythmias requiring inpatient Geriatrics
care Respiratory – Predominant respiratory cause including confirmed or
Elderly patients with high level
suspected PE, pleurisy, lung cancer, and pneumothorax
functional and/or cognitive
Consultation with the secondary team needs to be organized by the
impairment - consider Geriatric
Medicine primary admitting team

Early Respiratory Physician consultation if PE suspected or other

respiratory cause confirmed
Chest pain work-up (Incl CTPA req) Cardiology

Cardiology

Elderly patients with high level

Syncope (not seizure)
functional and/or cognitive impairment -
consider Geriatric Medicine
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating Proposed admitting Unit Notes
System admission
PE, or Likely PE Respiratory
Hospital in the Home admission with
DVT (all ages) Haematology /HITH
Haematology

Pneumothorax - Spontaneous Respiratory

Pneumothorax - Traumatic Trauma service – Westmead Hospital Transfer to Westmead Hospital as per trauma transfer policy
Rib Fracture without pneumothorax, Respiratory
haemothorax or other complications (consider Geriatric Medicine if > 70 years
of age and with comorbidities)
Multiple rib fractures or flail WMH Cardiothoracic Surgery OR Refer to The District Trauma Transfer Policy
segment Trauma if patient fits Trauma Criteria for
Transfer
Elderly patients with high level functional and/or cognitive
Community acquired pneumonia Respiratory impairment - consider Geriatric Medicine and consultation with
Respiratory Medicine

Aspiration pneumonia Geriatrics ≥70 yrs

Respiratory <70yrs Aspiration pneumonia secondary to an acute or deterioration of a chronic
neurological condition. – Resp/Geri to consult Neurology as inpatient
Mobility problems/falls Geriatrics ≥70yrs
General Medicine - <70yrs
Undifferentiated or
multisystem illness Back pain with SUSPECTED Discitis and NO Infectious diseases
collection
Back pain with no red flags, chronic pain General Medicine

Blood transfusion, Iron infusion

Tropical diseases Infectious Diseases

Temperature/Infection of unknown cause <70 yrs Infectious diseases, ≥70yrs
Raised inflammatory markers Geriatrics

>

am
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating
System admission Proposed admitting Unit Notes
Diabetic Ketoacidosis (DKA)
Hyperosmolar Hyperglycemic State
(HHS) Where Diabetes is the dominant acute condition and acute metabolic
Persistent Hyperglycemia decompensation is present: e.g. Diabetic Ketoacidosis or
Hypoglycaemia Endocrine Hyperglycaemic non-ketotic Coma, or Hyperglycaemia and
dehydration requiring intravenous resuscitation

Metabolic
Thyrotoxicosis without cardiac problems Cardiology consult may be required. Endocrine to organize relevant
Endocrine
decompensation consults

Thyrotoxicosis with severe neutropenia Endocrine

Severe hypothyroidism - monitoring not Cardiology Consult may be required. Endocrine to organize relevant
Endocrine
required consults
Addison’s or suspected Addison’s Disease Endocrine

Hyper/hypocalcaemia without malignancy Endocrine

Malignant hypercalcaemia Oncology

Rhabdomyolysis Renal

Acute Kidney Injury (predominant problem) Renal

Hypernatraemia due to Diabetes Insipidus Endocrine

Hypernatraemia < 70yrs Renal

Hyponatraemia related to thiazides Renal

Hyponatraemia unrelated to thiazides Endocrine

Hypo/hypernatraemia in patients ≥70yrs Geriatrics

Hypokalaemia due to Conn’s syndrome or
Endocrine
Thyrotoxicosis (periodic paralysis)
Hypokalaemia from other causes Renal

Hyperkalaemia due to Addison’s disease Endocrine

BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating Notes
Proposed admitting Unit
System admission
Hyperkalaemia from other causes Renal
Acute Charcot’s Foot Endocrine
Metabolic Inborn Errors of Metabolism Endocrine Ideally transfer to Genetic Medicine at Westmead (Contact on-call person
through switchboard at Westmead)
Electrolyte disorders due to refeeding Electrolyte derangement managed by Endocrine only if care accepted by
Endocrine
syndrome(Eating disorders) Psychiatry
Ischaemic Stroke < 70yrs Neurology
Ischaemic Stroke ≥ 70yrs Geriatrics
Primary haemorrhagic Stroke As per ischaemic stroke if no Discuss with Westmead Neurosurgery Unit
neurosurgery intervention required
Consider Westmead Neurosurgery Unit. If non operative management
Subarachnoid Haemorrhage Neurosurgery
patient <70 under Neurology, Patient ≥70 under Geriatrics BMDH
Neurology Subdural Haematoma As per ischaemic stroke if no Discuss with Westmead Neurosurgery Unit
neurosurgery intervention required
Headache Neurology
Delirium in older persons ≥70yrs Geriatrics
Delirium <70yrs Neurology
Seizures (any age > 16yrs) Neurology
Geriatrics ≥ 70yrs
Vertigo (any age > 16yrs)
Neurology < 70yrs
Back pain with neurological signs or
abnormal Transfer to Westmead Hospital as per Spinal Unit roster at WMH
CT or MRI suggesting cord
Back Pain compression / cauda equina
compression Neurosurgery/Spinal Unit
≥70yrs - Geriatrics

<70yrs – General Medicine

Back pain without neurological signs or red
flags
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating
System admission Proposed admitting Unit Notes

Urosepsis with obstruction Urology

Urosepsis without obstruction, <70 years – Infectious Diseases

Uncomplicated Pyelonephritis ≥70yrs - Geriatrics
Complicated pyelonephritis e.g. with Acute
Kidney Injury or requiring HDU/ICU Renal
treatment

Acute Kidney Injury (predominant problem) Renal

Renal Chronic Kidney Disease complications

Renal
(predominant problem)

Renal transplant patients with complications Renal

Dialysis patients with complications Renal

Hypertensive emergencies Renal

Significant electrolyte disturbance

(predominant Renal
problem) – see ALSO under metabolic for
hypo/hypernatraemia and hypo/
hyperkalaemia

Eye Ophthalmology Westmead

Foreign Bodies ENT ENT Westmead

Gastro to Organize further referrals to ENT if post assessment they feel
Oesophageal Gastroenterology that ENT input required.
Hand Plastic Surgery
Upper limb Orthopaedic Surgery
Lower limb Orthopaedic Surgery
Foreign Bodies
Rectal General Surgery
BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating
System admission Proposed admitting Unit Notes

Upper limb – all operative fractures Orthopaedic Surgery

Non-operative upper limb fractures admission under Orthopaedics then Must be assessed by Orthopaedics before considering Geriatrics
requiring Hospital admission transfer to Geriatrics if ≥70yrs admission.
Orthopaedics < 70yrs Orthopaedics to then transfer to Geriatrics if ≥70yrs
Pelvis Initial admission under Orthopaedics and Must be assessed by Orthopaedics before considering Geriatrics
then transfer to Geriatrics ≥70yrs admission
Orthopaedics < 70yrs

Lower limb Orthopaedic Surgery If fracture suspected clinically, but requiring further imaging to
confirm/exclude, admit under Orthopaedics

Respiratory
Rib Fracture without pneumothorax,
Fractures (consider Geriatric Medicine if > 70 years of
haemothorax or other complications
age and with comorbidities)
WMH Cardiothoracic Surgery OR
Multiple rib fractures or flail Refer to The District Trauma Transfer Policy
Trauma if patient fits Trauma Criteria for
segment
Transfer

Cervical Spine Spinal on call at Westmead Westmead

Skull Neurosurgery Westmead Westmead

Facial Bone Plastics/Maxillofacial Surgery Westmead Requiring fixation - transfer to Westmead Hospital
depending on roster
Orbital fractures +/- globe injury – admit to Westmead Hospital

Not requiring fixation – manage as outpatient

Sternal Fracture General Surgery With Cardiology as secondary admitting team for monitoring
 BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating
System admission Proposed admitting Unit Notes
Maxillofacial or dental at WMH; General
Dental Abscess/Infections
Medicine
Ear infections, sinusitis ENT at WMH; General Medicine
Tonsillitis without airway compromise General Medicine
Chest infection (including community Respiratory For community acquired pneumonia in elderly patients with high
acquired pneumonia and aspiration Aspiration pneumonia in <70 – Respiratory level functional and/or cognitive impairment - consider Geriatric
pneumonia) Aspiration pneumonia in >70 - Geriatric Medicine and consultation with Respiratory Medicine

EBV/glandular fever Infectious Diseases

Endocarditis Cardiology Cardiology Team to consult with ID Team Directly
<70: Infectious Diseases
Meningitis Geriatric team to consult Directly with ID Team
>70: Geriatrics
<70: Neurology
Encephalitis/confusion ≥70: Geriatrics with Neurology and/or
Infectious Diseases consult
Infections
Diabetic foot infection Vascular
Pulmonary TB Respiratory
Extrapulmonary TB Infectious Diseases
If presentation unrelated to HIV (especially
if procedures are required), admit under
HIV appropriate team with ID consult; if HIV
related admission, for ID

Source unclear, <70: Infectious Diseases

Bacteraemia recall Source unclear, ≥70: Geriatrics
Under team with primary responsibility
If source clear, admit under relevant team
Fever or sepsis in immunocompromised (e.g. Haematology, Immunology,
with ID consult
host Gastroenterology, Oncology) with ID
consult

Presumed sepsis – Infectious Diseases

Febrile neutropaenia without pre-existing
WITHOUT evidence of sepsis -
illness
Haematology
Fever in returned traveller or tropical
Infectious Diseases
disease
Pressure ulcer General surgery
Infections in pregnancy O+G

Uncomplicated cellulitis HITH + ID

 BMDH Admission Matrix – Version 3 August 2020
Presenting Problem or Specific Condition/Disease necessitating
System admission Proposed admitting Unit Notes

Pyelonephritis with calculi Urology

Urosepsis with obstruction Urology
Urosepsis without obstruction, <70: Infectious Diseases
uncomplicated pyelonephritis ≥70: Geriatrics
Complicated pyelonephritis (e.g. with acute Renal
kidney injury, or underlying renal disease)
Infections
Severe skin and soft tissue infection General surgery
(necrotising fasciitis not ruled out)
Cellulitis with collection General Surgery
(except hand/forearm)
Hand/forearm infections Plastic surgery

Other upper limb infections Orthopaedic surgery

Osteomyelitis/Septic arthritis Orthopaedics
Orbital/Peri‐ Ophthalmology
orbital Cellulitis with Globe involvement
Periorbital cellulitis Infectious Diseases
with NO Globe involvement
Back pain with suspected discitis/discitis Infectious Diseases
and NO collection
Back pain with suspected discitis/discitis Neurosurgery/Spinal Unit
and collection Contact Westmead Hospital Spinal Unit

Vasculitis Immunology
Rheumatological General Medicine
problem: Gout,
Arthritis flare

General Medicine
Rash (not infected)

Allergic reactions
Immunology