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Consult Medicine and Green Medicine

Page history last edited by Sarah Burns 3 months, 1 week ago

Consult Medicine/Green Medicine

 

Purpose

The purpose of this Consult Medicine (Green Medicine) rotation is to provide medicine consultations to non-medical services, to directly care for cystic fibrosis patients and to co-manage geriatric hip fracture patients admitted to Orthopedic Surgery. We strive to take excellent care of these patients in a timely manner.

 

Goals and Objectives

The goal of this rotation is to learn consult medicine and to apply this knowledge to subsequent consults. 

By the end of this rotation, the resident will be able to:

  1. Evaluate and appropriately assess a patient for perioperative management
  2. Evaluate and appropriately assess a patient for medical issues
  3. Demonstrate professional communication between healthcare providers and non-medical services
  4. Demonstrate clinical reasoning skills in making recommendations for consult

 

ACGME Competencies

As delineated by ACGME, residents on this rotation are expected to obtain competency in the following six areas:

1) Patient Care – Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

2) Medical Knowledge – Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this knowledge to patient care.

3) Interpersonal and Communication Skills – Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

4) Professionalism – Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

5) Practice-Based Learning and Improvement – Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.

6) Systems-Based Practice – Residents must demonstrate an awareness and responsiveness to the larger context and system of healthcare as well as the ability to call effectively on other resources in the system to provide optimal healthcare.

 

Rotation overview

  • One upper level resident is supervised by faculty from the Division of Hospital Medicine, Department of Internal Medicine
  • Primary responsibility is to cystic fibrosis patients (primary service), hip fracture patients and medicine consults
  • Will need to assist triage resident if needed throughout the day and triage attending or resident may request assistance in admitting
  • Plan to start pre-rounding at 7am (on CF, hip fracture, old/new consults), must be in house by 7am
  • Start rounds with consult attending at 8:30am
  • Consult requests will be taken between 7am-5pm, may hand off consults after 5pm to the overnight consult resident if deemed appropriate or if ok with consulting team, may wait until the next day (must obtain agreement that this is acceptable with the service requesting the consult) and inform your attending via Tiger Text.
  • For hip fracture co-management patients, plan to follow the hip fracture service line agreement as outlined HERE
  • If asked to transfer a patient that has already been consulted on by Consult Medicine/Green Medicine, then complete transfer to the team as determined by triage attending. Transfer requests must be attending to attending, prior to 3pm. Place transfer order, reconcile medications and orders and complete a transfer note (containing components of H&P, similar to MICU transfer notes)
  • Days off and clinic days already determined by your schedule on AMION
  • A medical student may be assigned to Consult Medicine for one week. Student may write one note for billing purposes (discuss with attending). This patient is seen and evaluated also with the resident and the medical student note must have addendum done by the resident the same day the patient is seen. The note must be sent to the attending by 5pm.
  • One afternoon report presentation required during the block, date assigned by the Chief Resident (see the AR calendar)
  • Resident should attend Grand Rounds and Thursday School. If paged with a consult request during this time, communicate with your attending about when to see/staff the patient. 

 

Documentation – Consults

  • Initial consults must include requesting service, requesting attending, consult question
  • Also ask if we (consult medicine) can place orders
  • If PCP is Family Practice (on UNM FP List on Wiki) refer them to FP team
  • In consult note, address primary question as well as any additional recommendations you and your attending discuss
  • Communicate new recommendations back to primary services verbally
  • If new orders placed, communicate this as well
  • When signing off, communicate this verbally and in progress note to primary team

 

Documentation – Transfers

  • Transfer requests to be attending to attending, before 3pm (the resident does not take the transfer request)
  • If consult team following this patient (for whom a transfer request is made), then the consult team will do the transfer and put the patient on the team as directed by triage attending
  • Documentation must include H&P components (use the H&P template in dynamic doc) in the transfer note
  • Must place transfer order (in PowerChart listed as “Transfer to:”)
  • Complete order reconciliation including medications
  • Update Cache

 

Readings, Modules and Calculators

Reading -  Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med 2007;167(3):271-275.  PDF here:  Principles of Effective Consultation.pdf

Reading - “The Admission Consult” The Hospitalist, 1 Dec 2007. http://www.the-hospitalist.org/article/the-admission-consult/

Reading - “Navigating the Nuances of Consult Coding” The Hospitalist, 1 March 2005. http://www.the-hospitalist.org/article/navigating-the-nuances-of-consult-coding/

Online Module - Perioperative Cardiac Risk Assessment – Society of Hospital Medicine Learning Portal (login required) - Perioperative cardiac risk assessment

Reading - 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol. 2014;64(22):e77-e137.  PDF here: ACC-AHA Perioperative Cardiovascular Evaluation Noncardiac Surgery Guideline.pdf

Online Module - Periprocedural Management of Anticoagulants – Society of Hospital Medicine Learning Portal (login required) - Perioperative bridging anticoagulation therapy

Online Module - Perioperative medication management – Society of Hospital Medicine Learning Portal (login required) - Perioperative medication management

Online Module – Managing Diabetes and Hyperglycemia in the Hospital: Critically Ill and Surgical Patients – Society of Hospital Medicine (login required) - Management of diabetes and hyperglycemia in the hospital

______________________________________________________

 

ADDITIONAL CONSULTATIVE MEDICINE READINGS

 

Medical Consultancy

Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983;143(9):1753-5. PDF here: Ten Commandments for Effective Consultation.pdf

 

Surgical Geriatrics Patient Management

-ACS NSQIP 2016 Geriatrics Guidelines - outlining optimal care of geriatrics patients undergoing surgery. PDF here: ACS NSQIP Geriatric 2016 Guidelines.pdf

 

Glycemic Control

American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32(6):1119-31. PDF here: AACE-ADA Consensus Statement on Inpatient Glycemic Control.pdf

-The NICE-SUGAR Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360(13):1283-1297. PDF here: NICE SUGAR trial.pdf

Perioperative Cardiac Topics

2014 ACC/AHA guideline on perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation 2014; 130:2246-2264. PDF here: ACC-AHA Perioperative Beta Blockade Noncardiac Surgery Guideline.pdf

- Rosenman DJ, McDonald FS, Ebbert JO, Erwin PJ, LaBella M, Montori VM . Clinical consequences of withholding versus administering renin-angiotensin-aldosterone system antagonists in the preoperative period. J Hosp Med 2008;3(4):319.

- Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014;370(16):1494. PDF here: Aspirin in Patients Undergoing Noncardiac Surgery.pdf

- Garg AX, Kurz A, Sessler DI, et al. Perioperative aspirin and clonidine and risk of acute kidney injury: a randomized clinical trial.  JAMA 2014;312(21):2254-64. PDF here: Perioperative Aspirin and Clonidine and Risk of Acute Kidney Injury.pdf

- Horr S, Reed G, Menon V. Troponin elevation after noncardiac surgery: significance and management. Cleve Clin J Med 2015;82(9):595-602. PDF here: Troponin elevation after noncardiac surgery.pdf

 

Perioperative Anticoagulation Topics

- Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation [published online June 22, 2015]. N Engl J Med 2015. doi:10.1056/NEJMoa1501035. PDF Here: Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation - BRIDGE.pdf

 

Perioperative Pulmonary Topics

Smetana GW, Lawrence VA, Cornell JE  Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144(8):581. PDF here: Preoperative Pulmonary Risk Stratification ACP.pdf

Orthopedics

Hung WH, Egol KA, Zuckerman JD, Siu AL. Hip fracture management: tailoring care for the older patient. JAMA 2012;307(20):2185-2194. PDF here: Hip Fracture Management Tailoring Care for the Older Patient.pdf

- Flack-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis 9th ed: American College of Chest Physicians evidence based clinical practice guidelines. Chest 2012;141(2):e278s-e325s. PDF here: Prevention of VTE in Orthopedic Surgery Patients ACCP Guidelines.pdf

 

Various Surgical Topics

Surgical Care Improvement Project – Joint Commission http://www.jointcommission.org/surgical_care_improvement_project/default.aspx

- Surgical Care Improvement Project Core Measures - http://www.jointcommission.org/assets/1/6/SCIP-Measures-012014.pdf

 

 

SURGICAL RISK CALCULATORS

  

- Revised (Lee) Cardiac Risk Index – http://www.mdcalc.com/revised-cardiac-risk-index-for-pre-operative-risk/

- ACS NSQIP Surgical Risk Calculator – http://riskcalculator.facs.org/

- Duke Activity Status Index -  http://img.medscape.com/fullsize/migrated/578/141/mieres.fig3.gif

- Gupta Postoperative Respiratory Failure Risk Calculator -  http://www.jointcommission.org/assets/1/6/SCIP-Measures-012014.pdf

- Gupta Postopertative Pneumonia Risk Calculator – http://www.surgicalriskcalculator.com/postoperative-pneumonia-risk-calculator

- VSGNE Risk Index – http://www.qxmd.com/calculate-online/vascular-surgery

 

 

CONTACT INFORMATION

 

Director, Sarah Burns, DO, MS

Email: sjburns@salud.unm.edu

Pager: 505-380-1758

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