Consults

Medicine Consult Service (MCS):

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 or when there is no Magnolia APP, the Magnolia APP pager as well (123- 7088).  There is a potential need to see 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 Medicine Consult resident(s) the first day to set expectations. Starting June 2024, service will be staffed by one attending and one senior resident (NO LONGER PAIRED WITH PROCEDURES) The resident is responsible for covering the 123-7076 pager and discussing patients first with the referring service. The resident on service can see up to 14 consults daily (including old and new consults) Typical daily flow: - 9 AM – 10:30: Residents + Attendings round on old consults and overnight news - 10:30 – 3 PM: Resident sees new consults through the day - Attending may see some on their own - 3 PM: Touch base with attending to staff new daytime consults - 4 PM: Cut off time for new consults (depends on urgency) - 3 – 5:30 PM: Work on orders, communicate with primary teams, notes Residents are not expected to return to the hospital following afternoon clinics On weekends, the resident should have one day off, alternating based on call schedules. It is expected on weekends that the Medicine Consult attending will likely be seeing follow up visits 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 after discussion with primary team. 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 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. See Medicine Transfer guidelines. We, in general, do not transfer patients to Medical Services for disposition issues only. Some patients may be appropriate to assign to the co-management service if the patient is expected to require daily Internal Medicine management.  Please reference the Co-Management Agreement. The Medicine Consult service 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.