Consults v1

Medicine Consult Service, Attending Responsibilities:

This role serves as attending for the Medicine consult service, providing Internal Medicine care to improve the outcomes for patients on other services. Make sure you are carrying pager 123-0746 (Medicine Consult Attending) on all weekdays and on weekends the Magnolia APP pager as well (123- 7088). There is a potential need on Saturday/Sunday to see acute/co-management patients that remain on the Magnolia APP service and provide cross-coverage to the long-term patients. The Consult pager will be carried by the Night 1 Attending overnight.

Expectations and Responsibilities: - This is a teaching service with teaching and feedback expectations. You should meet with the MDM resident the first day to set expectations and work with the Procedure attending to manage the resident workload. - The MDM resident assists with both Medicine Consult and Procedure Service responsibilities. - The resident is responsible for covering the 123-7076 pager and discussing patients first with the referring service. - Residents are not expected to return to the hospital following afternoon clinics - On weekends, there is down staffing of housestaff and it is likely only one resident will be there on the weekend. In order to keep workloads manageable, for senior residents, ideally, they see no more than 5 consults in the day (up to three new, remainder followups) and for newer interns no more than 3 consults (1 new, remainder followups) - It is expected on weekends that Med M attendings will likely be seeing many followups and potentially new consults independently - Since August 2022, we are now placing orders on behalf of referring services to ensure proper care is delivered in a timely fashion with the exception of Psychiatry for whom we pend orders. It remains important that we communicate with the primary team what we are ordering and why. - Non-urgent consultations received in the late afternoon and evening may be deferred to the next day. - Urgent Consult Requests: These are rare, but every effort should be made to staff urgent requests ASAP. Overnight, urgent consultations will be performed by the covering night float resident and staffed with on-site hospitalist, including pre-operative evaluations. - Perioperative consultation is an important role for the Consult attending. Please see Paul Ossman’s helpful framework on Perioperative Consultation in the Common Clinical Conditions document. - The Consult attending should also help facilitate transfers, when appropriate, to medicine services. We, in general, do not transfer patients to Medical Services for disposition issues only. See Medicine Transfer guidelines below. - Some patients may be appropriate to assign to the co-management service if foresee prolonged hospital stay and requires daily Internal Medicine management. Please reference the Co-Management Agreement. Medicine consults is NOT for co-management patients. We do encourage discharge med rec review for medications we have recommended be started or discontinued while in the hospital. - Document and code for all services: (phone consults, curbsides, quick follow ups, lab reviews, etc.) - When transferring patients/interacting with other services, please remember the Golden Rule: “Interact with your colleagues as you would like them to interact with you.” - Please make sure to have a verbal conversation with consulting services prior to “signing off” to ensure they have no additional questions.

Service specific issues: - Fall from standing with a stable head bleed patients: In an effort to improve care for these patients, they will be generally admitted to the neurosurgery ICU for the first day with a medicine consult and then transferred to medicine if they cannot be discharged. These transfers should be facilitated to MDH without conflict. - Psychiatry: Medicine consult is of particular use to psychiatry as many of their patients come to the hospital without a PCP and have poorly treated, untreated, or undertreated medical comorbidities. Please facilitate care for those medically complex patients on the Psychiatry service when requested. For these patients, we may pend but not sign orders. - Trauma surgery: Trauma surgery may request routine medical consults for floor/stepdown trauma patients > 65 years old with 2 or more significant medical co-morbidities (CHF, DM, COPD, HTN, ESLD, CAD or on anticoagulation for other causes). These consults should be evaluated and cared for even without a specific consultation question. - Orthopedics- Please follow these patients post-operatively for 48-72 hours before signing off as this is the period when the majority of complications arise.

Medicine Transfer Guidelines: - The Medicine consult attending is responsible for triaging and assessing transfers and transfer requests to most DOM services including MDH, MDU/L/W/K/B/A. Transfers to Cardiology or Hematology/Oncology services should be determined by the respective fellows. - Transfers are appropriate for patients with ongoing medical needs that require ongoing inpatient care but whose surgical issues have resolved or become secondary to their medical requirements. - Requests for transfer on floor patients are never urgent but an urgent consultation can be requested for an acutely ill patient. - The requesting service attending or chief resident will need to directly communicate with the Consult attending who then facilitates the transfer. - Transfers based on difficult disposition should, in general, be strictly avoided. - If a transfer to medicine is felt to be most appropriate, the consult team will discuss patient with MAO and accepting medicine service. - If accepted, a team should be assigned and transfer completed within 24 hours. - If the transfer request is accepted, an updated "Hospital Course” placed in the appropriate section of Epic is required.