1.1 Gives the patients that are in need for a medical consultation the best and optimal medical management needed with the continuity of care.
1.2 Relieve the medical oncall team from the consultations responsibilities so they can focus and concentrate on the medical patients that are in need for medical attention in the emergency department, medical wards and critical care settings.
2.0 DEPARTMENT THAT ARE RELATED TO THIS SERVICE
2.1 Service provider:
2.1.1 Internal medicine department at Farwaniya hospital
2.2 Service receivers:
2.2.1 Surgical department and it’s subspecialty
2.2.2 Obstetrics and Gynecology department.
2.2.3 Cardiology unit
2.2.4 Nephrology unit
2.2.5 Intensive care unit
3.0 STRUCTURE
3.1 The team consists of
3.1.1 Four to five MOD registrars rotate two months.
3.1.2 Four to five MOD senior registrars rotate every two months.
3.1.3 One attending doctor (specialist or above) rotate every two or three weeks.
3.2 Daytime working days.
3.2.1 7:30 - 8:00am Morning meeting.
3.2.2 8:00 – 8:30am oncall handover for all the oncall consults and then the oncall.
3.2.3 8:30am the oncall MOD senior will distribute the cases and distribute the list. We encourage to keep the list as an electronic/soft copy to utilize the resources in an optimal way.
3.2.4 8:30 -10:00am: all team members will see the follow-up assigned cases (old and new cases from the day before)
3.2.5 10-11am: the MOD Seniors/Specialist will round on all the follow-up patients list.
3.2.6 11am-2pm: the oncall MOD senior will distribute the new consults.
3.2.7 Notes:
3.2.7.1 Each registrar is supervised by a senior.
3.2.7.2 There is a cap of 4 consults per registrars during the daytime working hours and if exceeded, the seniors will write for the new consults.
3.3 Oncall Time
3.3.1 There will be one MOD registrar and senior doing the oncall every fourth or fifth day.
3.3.2 The oncall will be from 1:00pm till next day 8:00am.
3.3.3 Coverage distribution:
3.3.3.1 1:00pm till 8:00pm: MOD senior will evaluate and see all the consults (urgent and non-urgent).
3.3.3.2 8:00pm till second day 8:00am the MOD registrar oncall will cover all the consults (urgent and non-urgent).
3.3.4 Both oncall MOD registrar and senior registrar are expected to fill the follow-up sheet on google docs in a timely fashion and keep it uptodate after their shifts.
3.3.5 The MOD senior registrar is expected to inform the attending by the end of his shift about the consults that have been seen.
3.3.6 The MOD senior registrar oncall is required to respond and support the registrar oncall whenever is needed.
3.4 Weekend Time
3.4.1 During the weekend, there will a weekend follow up round done by the MOD registrar and senior over the cases that are agreed by the attending to be seen during the weekend.
3.4.2 New consults will be divided between the MOD registrar and senior till 1:00pm then the division will the same as the daytime division (1:00pm to 8:00pm by the MOD senior registrar, 8:00pm till 8:00am by the registrar).
3.4.3 Every Saturday, the attending should do weekend round with the oncall MOD team over the indicated cases.
3.5 Takeover protocol
3.5.1 If indicated, the transfer of patient from other departments to inpatient medical teams is decided exclusively by the consult team and the decision is final.
3.5.2 Disposition of the transferred patient is decided based on date and time of the patient’s admission and only after an approval from the head of department.
3.5.2 CCU patients:
3.5.3.1 The consult can receive only a “take over” consults for the patients in the CCU.
3.5.3.2 The patient can be shifted to medical unit only under all the following circumstances:
3.5.3.2.1 Deemed fit for discharge from the cardiology side.
3.5.3.2.2 Seven days have passed since the cardiac insult.
3.5.3.2.3 The patient has active ongoing medical problems.
3.6 Backup Plan
3.6.1 In case of the emergency leave of the MOD oncall registrar and/or senior, the next day MOD team should cover this day oncall, while the excused team will cover the next day oncall (switch).
3.6.2 In case of the emergency leave of the attending, the most senior doctor in the team (period of being senior registrar) will oversee the team during that working day.
4.0 FUNCTIONS
4.1 To provide comprehensive preoperative medical consultation (risk assessment and management) to medically optimize the patient for the planned surgery.
4.2 To provide high quality education to housestaff in the approach to and management of problems in the below-mentioned situations.
4.3 To establish a research forum from which important clinical questions arising from these consults may be investigated.
5.1Orientation: including discussion of the learning objectives, functions and responsibilities, and team requirements will take place on the first day of each rotation.
5.2Curriculum:
5.2.1 A list of required reading articles and other guidelines and management tips will be provided and should be read during the rotation.
5.2.2 Literature searches are encouraged when the answer to a problem is not apparent and when further information is desired.
5.2.3List of the topics:
5.2.3.1 Overview of the principles of medical consultation and perioperative medicine
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5.2.3.2 Preoperative medical evaluation of the healthy adult patient
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5.2.3.3 Perioperative Medication Management
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5.2.3.4 Perioperative Management of blood glucose in adults with diabetes
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5.2.3.5 Perioperative Management of hypertension
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5.2.3.6 Evaluation of cardiac risk prior to noncardiac surgery.
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5.2.3.7 VTE Prevention in Surgical Hospitalized Patients
5.2.3.8 Should we stop aspirin before noncardiac surgery?
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5.2.3.9 Perioperative management of patients receiving anticoagulants
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5.3.1 Definition of a Consult: “a procedure whereby, on request by one physician, another physician reviews a patient's medical history, examines the patient, and makes recommendations as to care and treatment.
5.3.2 The medical consultant often is a specialist with expertise in a particular field of medicine
5.3.3 Consults cannot be refused once issued without patient assessments.
5.3.4 Tenants of a consults should be met & fulfilled before a consult is declared to be completed. These tenants include:
5.3.4.1 Attendance of the consulted service to the source of consult & respective patient
5.3.4.2 Assessment of the patient by the MOD consulted service. Assessment includes History, Physical examination, File review and Follow up on ordered investigations necessary to formulate the final diagnosis & management plan.
5.3.4.3 Documentation by the consulted service of the impression, plan of management and disposition. Disposition includes Sign-off or Transfers of care (Take-over).
5.3.4.4 Cases being followed by the MOD consult service thereafter are expected to be provided with the serial assessment, management plan & documentation by the MOD consulted service until takeover, discharge or signing off is documented.
5.3.5 Sign off: is a term used to when the consulted service deems the patient consulted for is not for active management and or follow up at the time of the consult for the reason of the consult and may refer to follow up at a later date”.
5.3.6Consult report - consult templates for documentation
5.3.6.1Reason for Consultation (& planned procedure, if preoperative) - REMEMBER: We DO NOT "CLEAR" anybody. We evaluate patients as to their surgical risk, whether they are in their optimal medical condition, and how to manage their medical problems
5.3.6.2 The primary reason for consultation should be the one(s) listed by the referring physician on the consult request, but any other pertinent problems should be noted in the past medical history
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5.3.6.3Pertinent Medical Problems - Try to limit the list to <5 in order of importance. These are medical problems only - not surgical. They should be relevant to short term surgical risk. Qualifiers can and should be used (e.g., stable angina -NYHA Class II, mild hypertension - 5 years; type 2 DM - diet controlled - 1 year; etc,), Significant laboratory abnormalities can be included as problems as well.
5.3.6.4History and Physical Exam - This should be a directed H &P focusing on pertinent medical history and physical findings related to surgical risk. All consults should have important notation as to whether or not the patient has cardiac disease, pulmonary disease, diabetes, and hypertension.
5.3.6.4.1 Past surgical history should be noted including the type of surgery, type of anesthesia, when it was done, and whether there were any associated complications. The goal is to see whether or not the patient was able to undergo major surgery in the recent past or had any perioperative complications that may occur again.
5.3.6.4.2 Medication history (and reconciliation) is extremely important. Be sure to ask the patient about all medications (prescription, OTC, herbals) and go over the dose prescribed as well as the dose they are actually taking - also when they take the medication (AM or PM).
5.3.6.4.3 In the social history, be sure to phrase the questions properly - do you know or did you ever smoke, drink, or use drugs? Quantify the amount, duration, and when the patient last used the substance.
5.3.6.4.4 The relevance of the family history for perioperative risk lies primarily in the genetic nature of diseases -malignant hyperthermia (which is rare) and bleeding disorders. The only other pertinent item here might he a history of DM. Most other risk factors do not play a role in the patient's short-term surgical risk.
5.3.6.4.5 Presence or absence of chest pain and dyspnea and the patient's exercise capacity (activity level/physical fitness). Document how many blocks and flights of stairs the patient can walk without stopping or developing symptoms. Other potentially pertinent information must be sought as well - polyuria, polydipsia, significant weight change, bleeding tendency, cough, edema, etc.
5.3.6.4.6 The physical exam must include the vital signs and should be a directed exam. The airway and thyroid gland should be evaluated; evidence of lymphadenopathy, bruits, JVD, murmurs, adventitious sounds, organomegaly, and edema should be sought. Any patient with a history of a CVA must have a detailed neurological exam documented with any residual deficit documented.
5.3.6.4.7 Laboratory results, especially if done as "screening tests", Tardy yield useful information that alters management or affects risk. Specific tests should be done only as indicated (refer to the UPAC guidelines for Preop Testing), and the results of any pertinent information (particularly cardiac workup) should be documented. Initial any outside records you reviewed and include the pertinent results in the chart
5.3.6.5Discussion - This should include a brief summary of the pertinent history, physical exam, labs, and explanation of recommendations. For all preoperative consultations, be sure to document presence or absence of cardiopulmonary disease and symptoms, including a statement concerning exercise capacity. Be specific but avoid giving percentages concerning risk. You can state that the patient is at low/intermediate/high risk clinically and is scheduled for a low/intermediate/high risk procedure, or that the patient is medically stable and not at (significantly) increased risk for the planned surgical procedure.
5.3.6.6Impression - Is the patient in his or her "OPTI MAL. (or acceptable) MEDICAL CONDITION" for surgery? Do not say that a patient "is cleared" for surgery or anesthesia. If there are no recent laboratory values available, you can state that the patient is clinically in his optimal medical condition (pending results from preadmission testing).
5.3.6.7Recommendations – Try to limit to <5 (if possible) including perioperative Management of medications, prophylactic measures (for DVT, SBE, surgical Wound prophylactic measures, etc.), diagnostic tests required, and other instructions. Factors Influencing or Improving Compliance with Consultant Recommendations:
5.3.6.7.1 Prompt response (within 24 hours)
5.3.6.7.2 Limit number of recommendations (< 5) if possible
5.3.6.7.3 Identify crucial or critical recommendations (vs. routine)
5.3.6.7.4 Focus on central issues
5.3.6.7.5 Make specific relevant recommendations
5.3.6.7.6 Use definitive language
5.3.6.7.7 Specified drug dosage, route, frequency, duration
5.3.6.7.8 Frequent follow-up including progress notes
6.0 Consultation Guidelines (adapted from Goldman's “10 Commandments")
6.1 Determine the question--no question produces any answer. Know for whom you are providing the service, why you are being consulted, and answer the question. Try to give them what they want.
6.2 Establish urgency and provide timely response.
6.3 Look for yourself. Don't believe it until you see it, independent data facilitates new conclusions. Confirm and check labs yourself.
6.4 Be concise with your note and specific with your recommendations. The longer your note and list, the less likely the compliance.
6.5 Support your impressions and recommendations with appropriate discussion and references.
6.6 Teach—with tact, for both the specific case and general problem.
6.7 Attempt personal communication. Talk is cheap—and effective.
6.8 Provide contingency plans and follow up. Monitor to assure results.
6.9 Be accessible, acceptable, and accountable.
6.10 Avoid the don'ts - don't argue, don't be rigid, don't write orders without permission, don't take sides, don't criticize except to correct danger, and don't specify the type of anesthesia, CONSULT -- DON'T INSULT!
7.0 LEAVES AND EXCUSES
7.1 The MOD team is a very crucial team and missing one team member will disturb the dynamics and flow of the teamwork.
7.2 All MOD registrars, seniors and attending are encouraged to arrange their leaves ahead and away from their MOD block as leaves can’t be provided during this block.
7.3 Emergency excuses should be approved by the attending and should be communicated to the team.
7.4 Sick leaves should be informed to the oncall senior so he can redistribute the cases based on the new numbers.
7.5 Official sick-leave form should be provided the day after to the medical department secretary.
8.0 SERVICE EVALUATION
8.1 The service will be evaluated every 3 months based on the consultation team, medical teams, and other departments feedback.
8.2 In Oct 2020, we aim to get approval from the KBIM to provide senior residents (R3, R4 and R5) to the consultation service.
9.0 SPECIAL THANKS TO
9.1Dr. Faridah Redha, internal medicine
9.2Dr. Laila Alanzi, internal medicine
9.3Dr. Naela Al-Mazeedi, internal medicine and endocrinology
9.4Dr. Ammar Alkhateeb, internal medicine
9.5Dr. Sultan Alqaderi, internal medicine
9.6Dr. Fatema Al-Yatama, internal medicine and endocrinology
