Department of Internal Medicine and WRHA Medicine Program Consultation Policy
|Policy:||Department of Internal Medicine and WRHA Medicine Program Consultation Policy|
|Policy Nr:||Sec 03 - 01|
|Target Review Date:||2017-12-31|
|Main Stakeholder:||Executive Committee|
In-hospital consultations are an important component of patient care and an excellent vehicle for the education of hospital ward staff and trainees within subspecialties. A working group was established to identify the mechanism(s) and processes; the inpatient consult can be utilized to its maximum value.
Purposes of the Consultation
The purposes for submitting a consultation to a subspecialty service are:
- Requesting suggestions regarding patient care
- diagnostic advice/opinion
- therapeutic advice/opinion
- outlining treatment, monitoring and preventive treatment strategies
- Perform a procedure
- To transfer care
- all aspects of patient management
- specific component of patient management (e.g. dialysis orders or anti-rejection meds for transplant recipients)
- Triage for outpatient follow-up
- At request of consultative service
Mechanisms of the Consultative Process
A. Tertiary Care Centres
The consultative process begins with identifying that a patient requires a consult. In some cases the consultation should be considered mandatory (e.g. when specific antibiotics or a subspecialty-offered procedure is requested) whereas in others, the decision is the prerogative of the attending physician. In select cases, the consulting service can request consultations, most commonly, to satisfy teaching/educational requirements.
Of note, outside of medical emergencies, the house staff must first obtain the approval of the attending physician before submitting a consultation request. So called “courtesy” consultations should be discouraged and replaced with a “notification” to the consultant (and family) physician of a patient’s hospitalization. The notification can be carried out by the ward clerk in response to a written medical order by the house staff.
The second step consists of formulating a specific question(s) to be addressed by the consultative service. The question should be as specific as possible. For example, rather than “Diagnosis?” the question should read, “What findings or additional testing are required to establish the diagnosis in this case?”.
For “Educational” consultations, the house staff should indicate when they would be available for review. For non-urgent consultations, the ward clerk or house staff can notify the consultative service. For urgent consultations (those in which the patient must be seen same day) the attending physician or senior ward resident must personally notify the consultant or designated member of the consultative team.
Non-urgent consultations can be received by any member of the consultative service including the consultant, service fellow/resident, medical student or secretarial support staff. Urgent consultations must be conveyed to the attending consultant (if he or she were not initially notified) in a timely manner by those who received the consultation.
Ideally, the consultation should be submitted once the house staff has completed their evaluation and management plan (unless the clinical situation demands otherwise). Expedited consultations based on impending patient discharge are to be obtained only when necessary and should be mutually agreed upon by the two services.
The consult form itself should be completed by the consultant or a senior trainee (fellow). Junior trainees (rotating residents or medical students) should be discouraged from completing the consult form, but encouraged to provide their assessment in the progress sheets. All trainee entries (senior or junior) either on the consultation form or progress sheets should be countersigned by the consultant. Without such signatures the house staff will consider the entry/recommendations as unauthorized or not yet approved by the consultant. The exception to this should only include patients that can be discharged from the Emergency Room after hours where the attending physician is not on site. In this case it should be clearly documented when the consult was reviewed and by whom, and that the consultant agrees with the recommendations.
For sites that utilize an Electronic Patient Record, all members of the team may document on the same Clinical Documentation form.
B. Expectations of the Ward Staff Attending/House Staff
The attending/house staff initiate the consultation by filling out the consult form:
- check reason for consult
- fill out nature of problem in brief terms
- MUST specify question(s) the consultant is to address
- for audit and review purposes will note the time consult service was paged and answered, or if sent by fax
- emergency consults are to be seen without delay
- urgent consults are to be seen the same day and MUST be physician-to-physician notification
- other consults to be seen by the end of the next day and consult service notified by house staff preferable - however non-physician-based consults (e.g. physiotherapy) can be performed by the unit clerk
- patient to be informed of consult and reason for same by the attending/house staff
- attending to monitor/feedback house staff’s filling out form with appropriate information
- attending to monitor consult service response (timeliness, clarity of advice, etc.)
- where possible facilitate interaction between house staff and consult team when case reviewed (i.e. maximize educational potential)
C. Expectations of the Consultation Services
Emergency consultations should be responded to without delay.
Urgent consultations within 24 hours and non-urgent consultations (e.g. educational consults) prior to patient discharge or change in house staff.
If for some reason, “emergency” and “urgent” consultations can not be responded to within the time frame indicated, the consultant is obliged to offer and arrange for an alternative responder (other sub-specialist or consultative service).
Written Record of Response
Depending on the level of trainee, written accounts of their assessments and suggestion(s) must appear on the consultation sheet or patient progress notes. Entries into the progress sheets should be made at frequency dictated by changes/revelations in the patient’s course.
For “emergency” and “urgent” consultations the consultant should be available to review the case with their trainee within the time frame indicated for such consultations. For non-urgent consultations, the consultant should review the case within 24 hours of the trainee’s review.
For educational consults in particular (but not exclusively) the consultant should have the house staff notified (preferably 4 – 8 hours in advance) as to when they will be on the ward for the case review.
Written Record of Response
The consultant’s response should consist of:
- a summary of the salient features(s) of the case
- answer(s) to the specific questions(s) posed, and
- recommendations regarding further investigations and management.
The response should also indicate whether the consultant will take over the case and/or arrange for out-patient follow-up.
Recommendations should ideally be discussed with the patient’s attending physician/team prior to recommendations being outlined to the patient or family.
It is the consultant’s responsibility to identify when ongoing input and follow-up of the patient's course is no longer necessary and to indicate such with a note in the patient’s chart.
D. Community Hospitals
The specific components of the consultation process as they pertain to requests for General Internal Medicine and Medicine Subspecialty consultations for community hospital patients are essentially the same as those described previously in this policy pertaining to the tertiary care hospital setting.
However, consultation practices in the community hospital setting must reflect the fact that with some exceptions, full-time subspecialists are not routinely present or available on site.
- Attending physicians of community hospital patients are free to consult any licensed specialist or subspecialist of their choosing.
- In circumstances where a greater than a 24-hour delay is anticipated in completing the consultation or where a subspecialist is not clearly available, attending physicians are expected to consult the general internist on call for that site. At Concordia Hospital, Grace Hospital and Victoria General Hospital a general internist is available on site for a minimum of six days a week and is available 24 hours a day by telephone to respond to Internal Medicine consultations. Many consultations directed to subspecialists (e.g. endocrinologists, respirologists, infectious diseases specialists and cardiologists) can be competently and comprehensively responded to by a general internist.
- When the consultant general internist determines that a subspecialty consultation is appropriate, they should assist in facilitating the consultation either by identifying or even contacting appropriate subspecialists. This may entail:
- an over-the-phone consult
- a direct request to have an onsite assessment
- facilitating a patient transfer, or
- arranging a post-discharge outpatient assessment at another facility.
Policy Developed: January 2006 Approved: May 2006 Department of Internal Medicine Executive Committee Policy Amended: April 2007 Policy Approved April 11, 2007 Department of Internal Medicine Executive Committee Policy Revised: June 2017 Policy Approved: June 14, 2007 Department of Internal Medicine Executive Committee