UWHC Division of Hospital Medicine Consult Service

Structure & Duties

The Hospitalist Consult service will consist of a hospital medicine physician who will manage the consult service and provide Infusion Center coverage. They will work in a collaborative effort with communication throughout the day with the triage hospitalist regarding patient transfers from all non-ICU, non-GMED services to a HOS service. Please direct ICU transfer requests (CCU, Neurosurg ICU, etc) to route through Triage.

The hospitalist consult is, in a sense, the Department of Medicine's ambassador to the hospital, and thus must strive to provide excellent and timely care while always maintaining a service-oriented attitude. In general, consults should be seen as soon as possible and very rarely should a consult be refused.

Duty Hours:

Monday-Friday: 7am-5pm

Saturday-Sunday and holidays: 7am-2pm

Consult Hospitalist Duties:

The consult hospitalist will work the hours as listed above. Duties are as follows:

  1. Provide all necessary follow up of patients on the consult list. Some patients may be appropriate to follow peripherally to monitor vitals, labs, etc.

  2. Meet with ortho APPs in B6/487 on Monday-Friday at 9:00 AM to discuss mutual patients. Sign into the treatment team as a consultant for ortho patients.

  3. Provide medical consultation on all new consults called prior to 30 minutes of end of shift.

    a. For example, if a consult is called at 4:25pm during the week, the consult hospitalist should see the patient unless they are busy with other follow up issues. Should the consult hospitalist be unable to see a new consult prior to the end of their shift, they are to contact the triage hospitalist to discuss.

    b. Ask the primary service to place a specific order for "Hospitalist consult".

    c. Of note, we do not consult on patients who are ICU level of care.

  4. Evaluate all non-ICU, non-GMED patient transfer requests. When another service calls for a patient transfer, the consult hospitalist will review the patient's chart for appropriateness for transfer.

    a. If a transfer to a medicine service is in the best interest for the patient, the consult hospitalist is to contact the triage hospitalist to discuss the patient re: Hos service assignment. The consult hospitalist will then complete the patient transfer orders and note and hand off verbally to the appropriate Hos service provider who will be following the patient.

    b. If the patient is more appropriate for medical consultation, the consult hospitalist will discuss the patient with the requesting service to offer medical consultation.

    c. See below for transfer requests for established consult patients.

  5. Cover Infusion Center reaction calls during working hours (5-7pm M-F will be covered by admitter 2). The Infusion Center is located in C5/350 and hours are: M-F: 8am-8pm (last infusion typically initiated at 6pm with nearly all reactions occurring by 7pm). Sa-Su: 8am-2pm.

    a. The first call is an FYI page that the Infusion Center protocol has been initiated (If a patient has a critical reaction a Code Blue is called and hospitalist page is bypassed). A second page is sent 15 minutes later of either \"All clear" or "Come to the Infusion Center".

Orthopedics Consult Requests and Follow up:

For all Orthopedics consults, it is important to be aware of the agreement that exists between Orthopedics and Hospital Medicine (see additional document). When we are called by Orthopedics for a preop consult, they are typically also requesting medical co-management. Rarely, they may ask for a preoperative risk assessment only.

  1. Preoperative risk assessment: determine perioperative cardiac +/- pulmonary risk and make recommendations regarding perioperative medication management. If a patient is >65yrs old with medical comorbidities and/or has a hip fracture, they should be seen at the very least again on POD#1.

  2. Medical co-management: order and manage all the patient's preadmission medications. The consult hospitalist will also order any pertinent labs needed for the patient's medical care. Please see below for guidance from the Hospital Medical Consultant/Orthopedic Surgery Co­-Management document:

Orthopedics is responsible for the following:

- Activity

- PT orders

- Anticoagulation: please defer to Orthopedics if called by RN

- Transfusions

- Pain management

- Wound Care

- Diet

- Perioperative Antibiotics: at least initial order, then per discussion between providers

Hospital Medicine is responsible for the following:

- BP control

- IV fluids

- Respiratory issues/Chest pain

- Electrolyte management

- Telemetry (if needed)

- Arrhythmias

- DM management

- All other medical issues that may arise (AKI, drug rash, etc.)

  1. Communication: Daily communication is expected between the consult hospitalist and the ortho primary team for mutual patients. The consult hospitalist will sign into the treatment team for the patients they are following and meet with the ortho APPs at 9 AM M-F in B6/487. For new consults, recommendations should be given to the requesting ortho provider verbally, especially if timing of surgery needs to be delayed for additional medical workup.

Communication with non-Orthopedics requesting services:

The consult hospitalist is expected to clearly communicate any new recommendations to the primary service on initial consultation and whenever there are new recommendations on follow up visits on non-Orthopedic patients (we write any necessary medical orders on Orthopedic patients as noted above). This should always be accomplished via closed loop communication via secure chat (need a response from the consulting svc after sending) or verbally via phone.

Transfer of existing Hos Consult patients to a Hos service:

There may be times when an existing Hos consult patient becomes more appropriate for transfer to a Hos service due to new/worsened medical problems. If this occurs, there are two ways to handle the transfer:

  1. Transfer to a Hos service with new Hos provider (most cases): If a consult patient is known to the consult hospitalist for a short (\<2d) period of time [or]{.underline} the patient requires close follow up or frequent visits, transfer to a Hos service may be appropriate. If this occurs, the consult hospitalist is to notify Triage for a service assignment and then verbally hand the patient off to the accepting Hos service. In most cases, the consult hospitalist should provide patient care for the remainder of their shift.

  2. Transfer to a Hos service with consult hospitalist remaining as primary: If the consult patient is well known to the consult hospitalist, the consult hospitalist can choose to continue as primary provider. If this occurs, the consult hospitalist is to notify triage for a Hos service assignment. The consult hospitalist is to then enter a 'nursing communication' order to notify nursing staff of who to call while they remain on consults. When going off service, the consult hospitalist is to sign out to the oncoming hospitalist and APP on the corresponding Hos service.

  3. Consult transfers to IMC level of care: Nearly all Hos consult patients who require transfer from general care to IMC should be transferred to a Hos service unless the primary service specifically requests to remain as primary while the patient is in IMC level of care. We have agreements with family medicine and orthopedic surgery that patients will transfer to hospitalist when IMC level of care, with transfer back to the initial service when the patient is no longer IMC level of care.

Process for signing off consult patients:

If a patient no longer has active medical issues the following process should be followed:

  1. Contact the requesting service directly via page and verbal discussion or closed loop secure chat.

  2. Once the requesting service has been notified that we will be signing off and are agreeable, please enter documentation into that day's consult note that outlines the reason for signing off and the conversation with the requesting service provider (best to use the provider's name in the note for future reference).

  3. For ortho patients, the threshold to sign off should be higher. Do not sign off before POD1. It is ok to peripherally follow patients and just check the chart if no changes are recommended. Prior to signing off, include discharge recommendations (e.g., changes to medications, follow up labs).

Sign out:

All sign out that requires follow up between 5-7pm on weekdays and 2-7pm on weekends should be made known to admitter 2 either verbally or via secure chat prior to leaving. All sign out tasks should be documented using [ ] prior to the task to be followed and, if known, the time that the study (lab, x-ray, etc) should result.

Consult Night Cross Coverage 7pm-7am:

Overnight cross coverage of Hospital Medicine Consult Service patients will be done by the Subspecialty Night Cross Cover hospitalist.

-AW 6/7/24

-small edits made by SMB 11/26/24 (changed TLC to "ICU")