Infectious Diseases Playbooks

Infectious Disease Service  Rounding Principles

Prepared by Frederick Southwick

Protocols provide uniformity and efficiency
–    Reporting responsibilities (seamless up & down)
–    Initial and follow up presentations (content & time limits)
–    Dictation and follow up notes (uniform organization and content)
–    Efficient communication to the primary team critical for high-quality care horizontal care (Development of new methods for communication)
–    Establishment of Criteria for timing of follow-ups, sign off, referral to clinic
–    Proper documentation of discharge outpatient treatment recommendations

Goals
–    The highest quality care for our patients
–    Timely rounds (AIM for 3 hours) 1-4PM (Allows fellow to see late cases)
–    Meaningful teaching – emphasis on differential diagnosis, basic approaches to common infections, use of the literature using search engines
–    Appropriate supervision of all trainees (concept of tiered supervision) combined with appropriate autonomy
–    Coordinated care that relays recommendations efficiently to the primary teams both as inpatients and outpatients
–    Seamless communication among team members

Team Communication expectations
–    During rounds – Attending, fellow, residents,, 4th year students, nurse practioner continually communicate about each case.
o    All questions should be fully discussed. The more ideas the better. Patient care is collaborative and interdependence is required for ideal care.
o    Going it alone is potentially dangerous and should be discouraged. Independence in thought and creation of new hypotheses to improve patient care is always encouraged and is expected.
o    New diagnostic and treatment plans can arise from anyone’s ideas not just the attending.
–    After rounds – specific communication channels need to defined to eliminate confusion.
o    Students will report patient findings to the fellow
o    Resident report findings to the fellow and attending
o    Fellow closely communicates with the Attending

Consultation workup must be efficient and of consistently high quality

What is the question that is being asked?
Clarify by speaking directly with the resident or attending.
Tailor your consult to specifically address the question asked by the referring team.
* Four types of consults
1. New unknown case (requires careful history and review of prior hospital data)
2. Antibiotic management or simple infection (appropriate for nurse practioner)
3. Settle a controversy with another service (beware)
4. Assist in diagnostic workup of a patient deteriorating in the hospital.

* First review the electronic records and paper charts
Review the admission note, and quickly review the progress notes.
Usually need to document the fever curve
WBC with differential counts
ESR in some cases
LFTs in some cases
Antibiotics used (call the ID pharmacist for complicated cases to obtain an accurate accounting)
Cultures:
Radiology: Personally review the CXR and head CTs with the attending on rounds

* Next see the patient

* For unknown cases a very complete history should be obtained:
Specific epidemiology history is important
Review all symptoms associated with illness, do not simply rely on the previous doctors’ workups, a complete review of systems is helpful in unknown cases. The fellow should not simply read the admission workup, but add to and modify this document based on his/her own history and physical exam.
* If the specific diagnosis has been made and is clearly documented. A more directed history is appropriate
* In other cases extent of history will depend on the question you are being asked to answer.
* Routine parts of the workup such as PMH, PSH, FH, pertinent medications such as immunosuppressants, or drugs that can cause fever can be obtained from the medication sheet or the ID pharmacist.
* Next Physical exam:
* Needs to have a thorough physical exam including a funduscopic exam on patients with unknown diagnosis or suspicion of fungemia.
* Remember to palpate nodes, palpate for the spleen,
* Careful cardiac exam
* Careful skin exam
* Look for embolic phenomenon on unknown cases or cases suspected of  bacteremia or endocarditis

Use of Rounds and Admission protocols to maximize quality of care and efficiency

Communication Protocols
A. Follow up of cases (5 min/pt)
o Hospital course since original consultation (order by time) include antibiotic regimens, complications
o Subjective complaints:
* List Positive ROS
* Emphasize complaints relevant to the current problems
o Objective findings:
* Vital Signs
* Positive physical findings
o Focus on findings related to the patients active complaints
o What findings were positive on admission (be sure to include these)
* Abnormal laboratory findings
o Usually include CBC, Electrolytes.
o Results of new diagnostic tests
– For Each Active Problem Give (Most important section for learning):
Impressions
* When appropriate give your differential diagnosis
* Is this problem improving, worsening, or staying the same?
o Plans
* What new diagnostic tests do you recommend?
* List blood tests
* Radiologic tests
* Other tests
o Treatment
* What changes In antibiotics do you recommend
* What other modalities are you instituting
* Do you anticipate home iv therapy (need to inform primary team yes or no to enhance discharge planning and to avoid unnecessary PICC lines)

New Consultation Presentations (Duration 10 minutes, very complicated 15 min)
– Age, sex, race, job and Reason for the consultation
– Chief Complaint: What brought you into the hospital. Duration of the complaint or complaints
– Present Illness: Time line.
o Mr L. has suffered with X disease for 10 years, but was doing well until
o 10 Days PTA x complaint
o 7 Days PTA additional complaints or symptoms worsenting
o Day of admission – x symptom caused him to seek medical attention
o Hospital course up to consult date
– PMH pertinent to the present complaint do not repeat the facts about PMH already described in the PI
– PSH: do not repeat facts about PSH already described in the PI
– FH – if not relevant to the PI say noncontributory, hx of recurrent infections
– SH – habits, where do they live, what job do they have, other epidemiologic facts including pets and travel are often pertinent to the PI
– Allergies (All antibiotic allergies critical) antibiotic allergies should be fully characterize, ie indigestion (not true allergy); macular papular rash delayed hypersensitivity:
– Medications (antibiotics, Immunosuppresants, drugs that commonly cause fever, drugs that effect liver metabolism)
– ROS: only positive complaints not described in the PI, do not repeat facts given in PI
– Physical exam: Vital Signs Pulse, BP, Resp, Temp
o HENT – fundi, dental exam (often not described, but very important)
o Neck – stiffness, JVD
o Lungs – rales, e to a changes
o Heart – describe all murmurs
o Abdomen – describe bowel sounds
o Extremities and joints (look for arthritis, edema, cellulitis), pulses for patients suspected of endocarditis
o Skin very important (embolic phenomena, vasculitis rashes, decubiti)
o Neuro exam what is their mental status, focal deficits
– Laboratory findings
o CBC, ESR
o Electrolytes (S. creatinine, LFTs, albumin)
o U/A
o CXR, CT scans, MRI (have available when on the floor to review)
o Culture results with sensitivities
o Other diagnostic tests (titers, urine antigen etc)

– IMPRESSIONS AND RECOMMENDATIONS
(most important for fellow learning)
o List by problem when appropriate
o When appropriate give your differential diagnosis
o Describe the pathophysiology of the disease when appropriate
o Whenever possible include recent literature from PubMed
–  RECOMMENDATIONS
o Diagnostic
* List blood tests
* Radiologic tests
* Other tests
o Treatment
* Does the patient require antibiotics? If so what antibiotics are you going to choose and why?
* What other modalities do you recommend?

Written note

REQUESTING SERVICE: (whichever team called; may be important for
billing/justifying that the consult was officially called by someone)
REASON FOR CONSULTATION: some of the fellows have not been doing a good
job with this!
– Age, sex, race, job
– Chief Complaint: What brought the patient to the hospital. Duration of the complaint or complaints
– Present Illness: Time line.
o Mr L. has suffered with X disease for 10 years, but was doing well until
o 10 Days PTA x complaint
o 7 Days PTA additional complaints or symptoms worsenting
o Day of admission – x symptom caused him to seek medical attention
o Hospital course up to consult date
– PMH pertinent to the present complaint do not repeat the facts about PMH already described in the PI
– PSH: do not repeat facts about PSH already described in the PI
– FH – if not relevant to the PI say noncontributory, hx of recurrent infections
– SH – habits, where do they live, what job do they have, other epidemiologic facts including pets and travel are often pertinent to the PI
– Allergies (All antibiotic allergies critical) antibiotic allergies should be fully characterize, ie indigestion (not true allergy); macular papular rash delayed hypersensitivity:
– Medications (antibiotics, Immunosuppresants, drugs that commonly cause fever, drugs that effect liver metabolism)
– ROS: Please perform a full ROS and state this fact in the dicatation (A full 12 point ROS was performed) only positive complaints not described in the PI should be included here, do not repeat facts given in PI. Say “please see PI for pertinent positive. In addition the patient complained of:
– Physical exam: Vital Signs Pulse, BP, Resp, Temp
o HENT – fundi, dental exam (often not described, but very important)
o Neck – stiffness
o Lungs – rales, e to a changes
o Heart – describe all murmurs
o Abdomen – describe bowel sounds
o Extremities and joints (look for arthritis, edema, cellulitis), pulses for patients suspected of endocarditis
o Skin very important (embolic phenomena, vasculitis rashes, decubiti)
o Neuroexam what is their mental status, focal deficits
– Laboratory findings
o CBC, ESR
o Electrolytes (S. creatinine, LFTs, albumin)
o U/A
o CXR, CT scans, MRI (have available when on the floor to review)
o Culture results with sensitivities
o Other diagnostic tests (titers, urine antigen etc)

– IMPRESSIONS AND RECOMMENDATIONS
o Summarize the case in a single sentence including all the key points in Hx, PE, Lab (illness script)
o When appropriate give your differential diagnosis
o It is important that the assessments reflect of the assessments in the attending and fellow summary note in the chart. Please explain the reasoning behind the recommendations. When discussing the case use “we” rather than “I”.
– RECOMMENDATIONS
o Diagnostic
* List blood tests
* Radiologic tests
* Other tests
o Treatment
* Does the patient require antibiotics? If so what antibiotics are you going to choose and why?
* What other modalities do you recommend?
– Teaching statement: (very important).  The case was presented to and discussed with Dr. X, who also examined the patient and obtained a history.

Other Important Protocols

Triage Protocols: How do we decide who requires follow up and how often? When should we sign off?  Attending in consultation with the team decides on follow up
o Initial follow up
* Attending puts first follow up date in his/her original billing sheet and office adds this to the followup sheet
o Subsequent follow up
*  Attending decides on a new follow up date and includes it in his/her follow-up bill. Assigns follow-ups to second attending when one is assigned
o Sign off
* Attending in consultation with the team decides on discharge from the service
* Critical that discharge planning be dictated at that time
* Office will keep track of bounce-backs

Transition from Inpatient to Outpatient
– A major problem
– One solution does not fit all (ie. all patients seen as consultations do not need an appointment to clinic)
– Need to carefully define the therapeutic plan for discharge
– Separate dictation once the diagnosis and treatment plans are verified.
o Lost in the handwritten chart, label dictation as ID follow up consultation note
– Need to make sure we do not sign off cases before all issues are clarified

Criteria for Sign off
– No new active problems
– Progress notes are repeating the same suggestions and findings over and over
– The plans for care are fully outlined and there are no future problems or complications anticipated
– Requires a careful discussion Attending makes this decision in consultation with the team (fellow, residents nurse practioner, and students.

Criteria for Clinic Referral
– Unable to predict outcome and duration of therapy without physically seeing the patient
– Intellectually challenging case that provides excellent teaching opportunities
– A very sick patient who requires close outpatient follow up
– Not simply to monitor the duration of antibiotic therapy.
– Issue of monitoring antibiotics as outpatient, who is responsible?
– What happens when an iv comes out? Do we see them in clinic for this problem? NO
HANDOFFS NEED TO BE ABSOLUTELY DEFINED