Consultation

Aka: Consultation, Referral and Consultation

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II. Approach: Relationship

  1. Maintain a friendly, collegial relationship with consultants and hospitalists
    1. Approach as a longterm relationship
    2. Socially converse when time and situations allow
    3. Follow-up on shared patients
    4. Learn from their expertise
    5. Treat as partners working for the best interest of the patients (as opposed to adversarial relationships)
  2. Assist consultants when they need help from the emergency department or other consulting services
    1. Assist with order placement, procedure set-up, consent process
    2. Connect them with nursing staff or technicians who can assist them
  3. Acknowledge when "dumping on admitting or consulting services"
    1. Thank them for their help in particularly difficult situations

III. Approach: Consultation (example)

  1. Introduction
    1. Introduce yourself
    2. Write down their name and the time of the phone call
    3. Thank the consultant for their involvement
  2. Frame the Consultation (brief overview)
    1. Subjective
      1. 65 year old female with a history of diabetes and coronary disease
      2. Presents with a 5 day history of progressive exertional Chest Pain
    2. Assessment
      1. I suspect Unstable Angina and
    3. Plan
      1. I would like to transfer this patient to you for further evaluation
  3. Details (pertinent)
    1. Subjective
      1. Anterior, substernal Chest Pain with radiation to both arms, jaw
      2. Associated Shortness of Breath and Nausea. resolved prior to presentation
    2. History
      1. S/p PTCA with DES x2 to LAD in 2012, last echo 1/2013 with 45% EF, no WMA
      2. On Metoprolol, Aspirin, Plavix, Atorvastatin
    3. Objective
      1. Last BP 110/60, HR 95, O2 Sats 93% RA and unremarkable exam
      2. Normal Troponin, unchanged ekg, Chest XRay
    4. Plan
      1. Given Aspirin 325, oxygen, nitro-paste and Heparin
  4. Listen, clarify history and answer questions
  5. Ask specific questions when seeking consultant advice
  6. Summarize your understanding of next steps
    1. We will await RN report and will then obtain Ambulance transport to your facility
    2. I estimate one hour from that time to arrival at your facility
    3. Are there any other measures you recommend prior to transport
  7. Closing
    1. Thank you for your assistance with this patient's care

IV. Precautions

  1. Tribalism (or the specialty clique)
    1. Avoid using team cohesiveness (e.g. Emergency providers) to isolate other groups or consultants
    2. Avoid labeling other specialties with negative characteristics
    3. Encourage collaboration and mutual respect
    4. References
      1. Lin and Brazil in Herbert (2015) EM:Rap 15(12): 6-7
  2. Consultation Advice with which you feel uncomfortable
    1. Examples
      1. Delayed evaluation by a consultant (e.g. Acute Coronary Syndrome, Ectopic Pregnancy, surgical Abdomen)
      2. Potentially unsafe disposition (e.g. discharge home versus hospital observation or admission)
        1. Does the hospitalist believe admission is unwarranted? Ask them to examine the patient
        2. Is there disagreement about which service accepts the patient? Ask the services to speak with one another
        3. Is there Delaying admission for additional testing? Can admission and tests be ordered simultaneously?
    2. Present your reservations to the consultant
      1. Lay out specific and objective reasons for concern, and their potential complications
      2. Offer alternative options (e.g. keeping the patient in the emergency department until consultant evaluation)
    3. Consider alternative consultants
      1. Does the call schedule change in a few hours?
      2. Is there another consultant available with whom you have a good working relationship?
    4. Consult other colleagues
      1. Confer with your partners on shift or with department head
    5. Always follow what you believe to be in the best interest of the patient (best practice, safety)
      1. Employ Shared Decision Making when the best path is not clear
    6. References
      1. Mason and Swaminathan in Herbert (2021) EM:Rap 21(7):1-2
      2. Weinstock and Pensa (2024) Mailbag: Blocked Admission (2024) EM:Rap, 11/25/2024

V. References

  1. Sacchetti and Herbert in Herbert (2013) EM: Rap 13(9): 4

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