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Home | Articles | Admission | ‘Watershed’ Conditions

‘Watershed’ Conditions

Last updated 10th July 2024

Where to Send the ‘Watershed’ Conditions.

  1. This is not a list of all possible presentations, but aims to cover conditions where there may be uncertainty as to which team should look after the patient.

General Principles

  1. Post-procedure complications which occur soon after the procedure and are thought to be direct sequelae of that procedure should be referred to the specialty responsible.  Exceptions would include a new medical problem arising de novo.   
  2. Recurrent problems or patients already under specialty care for the same issue should be referred back to that specialty, unless there is reason to believe that is no longer appropriate.
  3. This document is a guideline, but there will always be exceptions.  All decisions about placement must be made with the patient’s well-being as the top priority.  Any deviation from this guideline should be agreed between teams directly at senior level, and not left for the referrer to resolve. 

Primary Care

  1. Suspected DVT – GPs should refer directly for USS

General Surgery

  1. Rectal bleeding (unless in context of bloody diarrhoea or suggestive of inflammatory bowel disease)
  2. Complete dysphagia due to obstruction/food bolus etc
  3. Biliary colic, biliary sepsis/ascending cholangitis
  4. Acute pancreatitis
  5. Painless Jaundice with obstructive LFTs
  6. Head injury including traumatic subdural bleeds (when head injury is significant and is the primary reason for admission); Medicine will take a subgroup where injury is thought to be due to a medical problem which precludes immediate discharge (eg recurrent falls, cardiogenic syncope) provided CT head is normal and there are no facial fractures.
  7. Abscesses (eg IVDU with injection site abscess, breast abscess)
  8. Bowel obstruction (even if not a surgical candidate)
  9. Complications of advanced bowel or hepatobiliary malignancy or treatment for these
  10. Bleeding from varicose veins
  11. Undifferentiated Abdominal pain
  12. Acute Constipation (if occurring as a primary problem and sufficiently severe to require admission).  The Palliative care team will be happy to review patients with constipation in the context of advanced malignancy on the surgical wards

Medicine

  1. Upper GI bleed.  Initial management, resuscitation, and ongoing care should be done by the Medical team, with referral to the Surgeons for urgent endoscopy if indicated.
  2. Acute pyelonephritis
  3. Patients with a fall due to a suspected medical cause.  This includes patients who have sustained a minor fracture or soft tissue injury as a result of their fall, but not those with a major fracture or injury requiring surgical intervention (eg # neck of femur).
  4. Patients with known osteoarthritis/osteoporosis etc. who have experienced a deterioration in their symptoms without any obvious precipitant and who are now unable to mobilise
  5. Cellulitis which does not meet criteria for orthopaedic admission (see below)
  6. Acute gout
  7. Thrombo-embolic complications following orthopaedic surgery

Orthopaedics

  1. Patients with fractures following a simple fall or trauma, even if they do not require surgical intervention eg pubic ramu fractures
  2. Patients with soft tissue injuries following a simple fall or trauma, who are now unable to mobilise
  3. Patients unable to weight-bear following hip trauma
  4. Patients with known osteoarthritis/osteoporosis etc who have experienced a deterioration in their symptoms as a result of a simple fall or trauma
  5. Cellulits overlying a joint, involving the hand, on the site of previous surgery, or in a limb with a joint replacement
  6. Septic arthritis

Urology (General Surgery out of hours)

  1. Renal colic
  2. Urinary retention and clot retention
  3. AKI secondary to obstruction of urinary tract (unless patient needs urgent dialysis)
  4. Frank haematuria (unless due to known UTI)
  5. Renal abscess/pyonephrosis

ENT (at weekends may be admitted to General Surgery after discussion with ENT)

  1. Acute tonsillitis/tonsillar abscess
  2. Complex ear/nose/sinus infections
  3. Epistaxis (with advice from Medicine/Haematology if needed)
  4. Stridor (after anaesthetic review)

The Diabetic Foot

  1. Acute diabetic foot sepsis should be admitted under care of surgeons in Dumfries for assessment by Surgical middle grade
  2. Patients with chronic diabetic foot infection patients may be admitted semi-electively for intravenous antibiotic therapy if unsuitable for OPAT; these patients will usually be admitted to AMU and then move to be under the care of the Diabetes team on D8.
  3. Click here for more detail and link to The Diabetic Foot

Acutely Ischaemic Limb

  1. Acutely ischaemic limbs should go to the Hairmyres on call vascular registrar who can be contacted through Hairmyres switchboard on 01355 585000
  2. Click here for more detail and for link to Vascular Referrals

Maxillofacial Surgery

  1. Facial fractures
  2. Dental abscess

Content by Dr Andrew Russell, (Clinical Director Medicine), Miss Maria Bews-Hair, (Clinical Director – Surgery) & Dr David Pedley, (Clinical Director – Emergency Department)