The I.D. Consult team at the VAMC is comprised of an I.D. faculty member/attending physician, a clinical I.D. fellow, 1 medical resident when scheduling allows, an I.D. pharmacist, 1-2 fourth year medical students, and 1-2 pharmacy residents. The attending physician is responsible for the activities of the members of the consult team and directly supervises the work of the I.D. fellow. The I.D. fellow is responsible for supervising any residents or students assigned to the service, at the direction of the attending physician.
All consults must be seen by the I.D. fellow, although the fellow may delegate the responsibility for the consultative history, physical examination, chart review, and review of pertinent diagnostic tests to the residents and students. If the consultation is delegated to a resident or student, the fellow must review the work of the resident or student.
The I.D. consultations will include a history and physical examination, a review of the chart and all pertinent radiographs, microbiology, serology, and pathology. All new consults are presented by the team (usually by the team member who performed the initial consultation visit and review) to the attending physician, who is then responsible for seeing the patients and discussing the diagnostic and therapeutic recommendations, as well as instruction and education for the team about the infectious disease that is the focus of the consultation. The diagnostic and therapeutic recommendations must be conveyed to the primary care team by the fellow or the resident immediately after the consultation, either in person, by phone or electronically as appropriate. Top^
The I.D. Consult team makes daily rounds 6 days/week. The attending physician is responsible for the medical care provided by the consult team 7 days/week throughout the rotation. Rounds generally take place at a prearranged time daily, in consultation with the attending physician and the I.D. fellow. In general, the morning is set aside for followup of existing consult patients and initial new consult workups by the I.D. fellow, resident or student. The I.D. fellow is responsible for following all active patients on the service, and if followup is delegated to a resident or student, the fellow is responsible for reviewing each case briefly with the resident or fellow prior to attending rounds. In general, the I.D. attending physician on service will meet with the team in the early afternoon to review active cases and new consults. Rounds continue until all patients requiring consultation or followup have been seen and notes written as appropriate. After each new case is seen, the I.D. fellow is expected to review the pertinent literature regarding the case. This may be done after during free time before rounds or after rounds are completed. Top^
Instructions for dictations are provided as an appendix to this document. If the resident is unable to or does not dictate the initial consult note, the I.D. fellow is responsible for doing so. Medical students may not dictate consult notes in the medical record. If a medical student is assigned to perform the initial consultation encounter, the I.D. fellow must review the case and is responsible for the dictation for that patient. Daily progress notes may be written in the chart by the fellow, resident, medical student, or attending physician. If written by a resident or student, these notes must be reviewed by the I.D. fellow and countersigned by the fellow. If written by the I.D. fellow, these notes should be reviewed by the attending physician and countersigned as appropriate. The attending physician will be responsible for reviewing dictated or written consultation notes, making appropriate edits or additions, and either writing an additional attending physician note or tying into the fellow’s note and countersigning the note either electronically or in the hospital chart.
When the consult team deems the I.D. care of the inpatient completed, or the patient is sufficiently stable that care can continue under the supervision of the primary care team, the I.D. fellow can “sign off” the case. When an active consult patient is to be discharged, the team will make the determination whether or not post-hospitalization outpatient followup is required, and if so, will refer the patient to the I.D. Outpatient Clinic, and provide the patient with appropriate instructions for outpatient care and for making an appointment in the I.D. Outpatient Clinic (see below). A discharge note should be dictated into the electronic medical record either by the fellow or the resident responsible for the followup of the patient. The discharge note should be brief and state the I.D. diagnoses established at the time of discharge, the pertinent I.D. discharge medications including all antibiotics and doses, the duration of antimicrobial therapy planned, and the instructions for outpatient followup. A “discharge note” should be dictated into the electronic medical record even if the team is only “signing off” the case and the patient is expected to remain in the hospital for other chronic care or followup. This serves to inform the outpatient providers about the I.D. care and recommendations the patient received when a written record may not be available at the time a patient is seen in followup. Top^
An integral part of I.D. consult rounds at the VAMC is participation in Microbiology rounds 3 days per week in the Microbiology laboratory with the Microbiology Laboratory Director. Microbiology rounds are generally held from 11:00 a.m. – 12N. During Micro rounds, the laboratory director will review new positive blood cultures, interesting or rare isolates identified in the lab, microbiology results from patients on the consult service, and other critical results with the consult team. The purpose of this component of daily rounds is to provide clinical-microbiological correlations and to teach fellows how to use the information from the microbiology laboratory to improve patient care. A formal I.D. consult is required for patients identified in the Microbiology laboratory with clinically important bacteremias, and recommendations regarding antimicrobial therapy are required to be communicated to the responsible primary care team during this time. Top^
I.D. fellows will take after hours and emergency calls from home. If an emergency consult or followup visit is required, the fellow will return to the hospital as necessary. Fellows will contact the attending physician to present the case immediately after the consult is seen. The fellow on call is responsible for answering all pages and must be reachable by pager or prearranged phone number at all times when on call. The attending physician on service must be available by pager or prearranged phone number at all times as a back up for the I.D. fellow. Top^
I.D. fellows rotating at the VAMC will cover the service on weekends according to a prearranged schedule with the attending physician. The I.D. training program must meet the requirement of an average of one day off per week for the fellows. The schedule for the fellow’s day off will be arranged with the attending physician on service at the beginning of each rotation. The fellow on each service is responsible for signing out important clinical information to the fellow on call to assure continuity of care over the weekend. The attending physicians on service at Hillcrest and Thornton Hospitals will also cross-cover both institutions with the fellow on weekends, and will serve as on call back up for the fellows. Top^
The I.D. Outpatient Clinic at the VAMC meets on Monday mornings in the VAMC Outpatient facility and is staffed by I.D. faculty members. This clinic sees patients who are referred by other physicians for consultations and patients treated in the hospital who require further outpatient I.D. followup. The I.D. fellow rotating on the VAMC consult service is responsible for attending the VAMC outpatient clinic, and is generally assigned to see those patients referred from the VAMC inpatient I.D. consult service who require followup I.D. care after discharge. I.D. fellows make as initial assessment of the patients they are assigned and develop a treatment plan. The patient is then presented to the I.D. faculty attending physician staffing the clinic. In this clinic fellows gain experience managing outpatient antibiotics and central lines; tuberculosis; chronic systemic fungal infections; diabetic foot ulcers; performing lumbar punctures; management of syphilis, herpesviruses and other sexually transmitted infections, and other chronic infectious diseases. Top^