• A. General Workflow
• B. Consult Types

• A. Daily Schedules
• B. Day Off Policy
• C. Preoperative Evaluation Didactics
• D. EPIC Tips

A. Admission Workflow

• Team H is a 24-hour Medicine consult service. Team will be composed of hospitalist attending and two senior Medicine residents
• Daytime Consults
  • Team H residents will carry and receive consults via Team H consult pager during daytime work hours (6:30-5:00PM)
  • Resident will see and evaluate all new consults, formulate recommendations and document in Consult note. All recommendations will be staffed with attending physician before being communicated to primary service
  • Resident will see patients in follow-up and document follow-up notes with revised recommendations as appropriate, in discussion with team attending
  • Resident will discuss any consults deemed to be "inappropriate" with primary service resident to clarify consult question and need. If there is a disagreement, resident will discuss with Team H attending
  • Resident will not provide any "curbside" recommendations. All recommendations must be staffed with attending and documented in consult note.
• Overnight Consults
  • Medicine night float cross-cover resident will carry and receive consults via Team H pager overnight (5:00PM-6:30AM)
  • Night float resident will clarify with primary service resident if recommendations are required overnight ("Urgent Consults") or can be seen by daytime residents following day ("Non-Urgent Consults")
  • Urgent Consults
    • Night float resident will see and evaluate all urgent consults, e.g. preop evaluation for urgent surgery, time-sensitive questions, as soon as possible after receiving consult
    • Resident will staff all preoperative evaluations for hip fractures with the medicine nocturnist
    • Resident will staff all other urgent consults with on-call attending (p2112)
  • Non-Urgent Consults
    • Resident will obtain basic signout (patient info, primary service, consult question) from primary service resident
    • Resident will forward details to both daytime Team H residents of pending consult and place patient on Team H team list (see " EPIC tips" below)
• RRT/Code Blue Team
  • Team H residents will carry RRT/Code Blue pager during daytime work hours.
  • Residents will be responsible for responding to all RRTs and Code Blue events in hospital along with MICU team

B. Consult Types

• Specific Management Questions
  • May be requested by any non-Medicine service, e.g. General Surgery/surgical subspecialties, OB/GYN, Neurology, Psychiatry, etc.
  • Consult questions usually related to specific symptom-related, e.g. chest pain, dyspnea, etc., or disease-related issue, e.g. hypertension, diabetes, COPD, delirium
• Preoperative Evaluation/Optimization
  • May be requested by any non-Medicine service, e.g. General Surgery/surgical specialties, OB/GYN, etc.
  • Consult must be related to specific issue requiring evaluation, e.g. cardiovascular risk assessment, hypertension management, preoperative diabetes management, etc.
  • Patients will require initial consult note with preoperative recommendations, and post-operative follow-up note. (usually on POD #1). Additional pre/post-op follow up notes may be required for any active issues being managed, e.g. blood sugar control
• Geriatric Co-Management
  • May only be requested by Trauma Surgery service
    • Other surgical specialties may request consult for specific geriatric issues
  • ISAR criteria used to determine which patients qualify for this type of consult
    • Patients must be >70 years with 2+ of the following:
      • Takes >3 chronic medications
      • Hospitalized for > 1 night in 6 months prior to current admission
      • Serious problems with memory at baseline
      • Difficulty seeing at baseline
      • Prior to admission, required someone to help pt on regular basis
      • Since admission, requires more help than baseline
    • For patients being seen for co-management, Team H will generally manage:
      • All medical issues
      • Geriatric-specific issues, including
        • Cognitive issues, e.g. delirium, dementia, encephalopathy
        • Medication reconciliation, e.g. review Beer's criteria, evaluate for drug/drug interactions, polypharmacy
        • Gait/mobility issues, fall risks
        • Depression screening
        • Evaluation of capacity, as appropriate
    • All patients being seen for co-management will require daily progress note, even if no new recommendations
    • Team H residents may be able to directly place some orders for co-management patients. However, this should be clarified on patient-by-patient basis with primary service
• Insurance-mandated Co-Management
  • May be requested by any non-Medicine service as required by patient's insurance
  • Consult may be required even if no active medical issues requiring management
  • All patients being seen for Co-Management require daily progress note even if no new recommendations
• Medicine Transfer Evaluation
  • May be requested by any non-Medicine service, e.g. General Surgery/surgical subspecialties, OB/GYN, Neurology, Psychiatry
  • Required as part of any request to transfer patient to Medicine team. Outside of emergent situations, i.e. RRT, Code Blue, no patient may be transferred onto Medicine without approval from Team H attending
  • All patients require Consult note, regardless of decision to transfer to Medicine or not