Fellow & Resident Responsibilities
Official vs. Unofficial Consults | Follow-up of Selected Positive Cultures
Sign-Off and Final Recommendations | Meeting Attendance | Order Writing | Lines of Responsibility
Teaching
vs Non-Teaching Patients Fatigue | Hours of Duty | Dictation | At-Risk
System Consults on ICU Patients
The ID fellow is responsible for the day-to-day operation of the consultation service at the hospital seven days a week, except on days off. S/he is the person to whom all new consults should be directed. On weekends or at night, the resident and fellow may elect to alternate call. At the beginning of the month the fellow(s) should generate a call schedule and provide it to the paging operators. The fellow(s) is responsible for dividing the new consults among members of the team and for the supervision and teaching of the medical students and house officers rotating through the service; the fellow(s) selects cases to be presented at attending rounds and conferences. All consultations must be entered in the EMR using the ID templates. Consultations written by students must be attended by fellows and include a brief HPI, exam and assessment and plan section composed by the fellow. All formal consults must be presented to the attending.
Official vs. Unofficial Consults ("The Curbside Consult")
Often the ID team is asked a question regarding diagnostic or therapeutic intervention in the absence of personally evaluating the patient--the "curbside consult." These should be discouraged as they frequently lead to errors on many levels. The team should ask to see the patient and can emphasize the teaching and learning potential for the students as a means to facilitate this. Curbside consults that do not generate formal assessment are strongly discouraged since they frequently lead to recommendations based on inaccurate or incomplete data.
Consults on ICU Patients
To provide better service to the ICU teams and to increase involvement of the ID team in the care of complicated medicine patients there should be regular (daily) contact between the ID fellow(s) and the ICU fellow. The ID fellows should contact the ICU fellow Monday through Friday, late in the morning (~ 11:30 am) to ask if there are patients with challenging ID issues for whom the ICU team would like an ID consult.
Follow-up of Selected Positive Cultures
The fellow or resident should follow-up ALL positive blood and CSF cultures in order to insure that appropriate therapy is being administered. The Microbiology Laboratory will inform you of these results. In addition, you may be asked on occasion to follow-up a patient with a positive culture for mycobacteria. In general, the medical students on the ID team can assist with the gathering of initial information on the patient. This follow-up is not a formal consult and often requires discretion in interacting with the patient's primary team. Occasionally, positive blood cultures will be obtained from outpatients (usually patients seen in the ER and sent home). The ID service is responsible for follow-up of such patients by phone or by arranging a clinic or ER visit to ensure that patients are receiving appropriate therapy. It is useful to enter a brief note in the EMR when such encounters occur, so as to leave documentation for the outpatient Infectious Diseases clinic in case the patient requires follow-up.
Sign-Off and Final Recommendations
Once the team is ready to “sign-off” on a consult, final recommendations should be left in the medical record including instructions for follow up in ID Clinic and lab monitoring (please see the UW Medicine guideline for lab monitoring while on long-term parenteral antimicrobial therapy), as indicated.
The ID clinic patient care coordinator, Rachael Murphy (744-2308), can assist with scheduling of follow up appointments.
Meeting Attendance
As part of the fellow’s education in infection control and infectious diseases from a healthcare system approach, the fellows are expected to attend the monthly infection control committee (ICC) meeting and other related meetings as communicated to the fellows by Tim Dellit, Medical Director of Infection Control.
Monthly IC meetings occur on the fourth Wednesday of each month at 9:00am in Maleng III. [link to calendar?]
Order writing on Infectious Diseases Consult Service
Infectious Diseases Consultants (fellows, residents, or attending physicians on the ID consult service) will not routinely write orders on patients. They can, however write orders on concurrence and by request of the primary team responsible for the care of the patients. These orders generally would be related to the ID consult itself, such as antimicrobial drug dosing and relevant diagnostic studies. Order writing by the ID team would not be indicative of assuming a primary care responsibility of the patient.
Lines of Responsibility between the Infectious Disease Fellows and other Subspecialty Fellows or other Residents
Residents or Fellows with primary care responsibility shall request ID consultations from the ID Fellow or Resident or Attending on the service. The primary feedback shall be the consultation note in the EMR by the ID service and the Attending Physician note. In addition, the ID team shall make every effort to also give verbal feedback of the ID consultation assessment and plan to the primary care team. If a subspecialty service requests ID input, the ID team shall seek approval from the team with primary care responsibility for the patient before seeing the patient and leaving a consultation note. The ID team will continue to follow the patient and leave notes when new developments dictate ID input until:
- the primary care team communicates that they no longer need their input;
- the consultation question was limited in scope and only a single consultation is required;
- the ID issues have resolved; or
- the patient is discharged.
Teaching vs. Non-teaching Patients
There are no non-teaching patients at this hospital; no patients are "private" patients or shall be seen without an attending physician.
Recognition of signs of fatigue and prevention and counteraction of the potential negative effects of fatigue
All faculty, residents, and fellows shall be educated to recognize fatigue and apply policies that prevent or counteract its negative effects. Annual training in this area is provided at ID Conference by the training program director. If faculty, residents, or fellows have not had training in this area, they should review slides from D. Dingess's presentation on "Sleep Deprivation, Fatigue and Effects on Performance" available on the web site: www.acgme.org.
If ID residents or fellows show signs of fatigue that is having a potentially negative effect on their work, the Program Director, Wes Van Voorhis, should be contacted immediately (office 206-543-2447, pager 206-982-6384) to make arrangements for relief.
Hours of Duty
The purpose of this policy is to provide an optimal training environment for Fellows and Residents and comply with the ACGME requirements that fellows have 4 days off a month with no call (home or otherwise). The simplest way to comply with this is to make certain the fellows get 2 weekends off a month. The secondary purpose of this policy is to make certain there is backup coverage when emergencies or illness occur that lead to loss of a fellow's ability to cover a service.
We will establish a backup ("At-Risk") fellow to be responsible for covering weekends for each month. Each fellow entering the program will be expected to be responsible for coverage if it is needed for 1 to 2 months during their fellowship at the times when they are not on clinical service. If weekend coverage is needed or there is an illness preventing a fellow from working, the backup fellow assigned to be responsible during that month will provide service.
On services where there are both a resident and a fellow, weekend call will be split with the resident on the same service, such that the resident and the fellows each get at least 2 weekends off.
If there is not a resident at the VA and/or Harborview in a given month, the backup fellow positions will work out a shared weekend schedule such that each fellow has at least 2 weekends off.
At the UWMC, there are two fellows (General ID & SOT) and usually one resident (General ID) on the rotation. During such months, the General ID fellow and SOT fellow will alternate weekend call. If agreed by all, the weekend call will be shared between the fellows and the resident.
For the FHCRC/SCCA, Deb Mattson will continue to cover one weekend. The fellow will be given an option of having an additional weekend off or taking two consecutive weekdays off. If the latter option is chosen then the attending and Deb Mattson will cover the service for these two days. If the fellow desires to have the second weekend off, rather than two consecutive weekdays, then the attending will cover the service on the weekend.
The fellows, attendings, and residents should work out a weekend schedule at the beginning of the month and let all involved parties, including the paging operators and the Divisional Office (Lisa Allen) know in advance who is covering.
Dictation for Infectious Disease Fellows
In general, ID fellows are expected to electronically enter their notes. However, in order to comply with work hour duty limitation in the face of high volumes of complicated new inpatient consults (occasionally up to 10 new consults in a day) and the need for detailed chart review and documentation, the following criteria have been developed to allow limited dictation of new consult notes. These guidelines will allow a balance between patient care, education, and training on those days when the volume of new consults is high.
If the fellow chooses to dictate, he/she is still expected to call the team with oral recommendations as usual, leave a short typed note with the key recommendations, and then dictate the full note.
Medical students and residents will continue to type their notes as they are limited to only one of two new consults on a given day, during these situations:
- Written Note Cap on Busy Days: The first 3 fellow new-consultation notes of the day should be electronically entered and then the rest can be dictated. In general, all follow-up notes should be entered electronically with direct communication with the teams when there are changes in recommendations.
- Outpatient Clinic Days: If a fellow has a full panel of patients in clinic (at least 4), then all new consultation inpatient notes on those days can be dictated.
- Special circumstances: In some special situations, ID fellows will be allowed to dictate. For example, dictating notes may allow one fellow to cover two services at UWMC and avoid calling the at-risk fellow to cover. Again, new patient consultations should be the priority for dictation and whenever possible follow-up notes should be entered electronically. These special circumstance requests can be discussed with the Attending and the Program Head.
At-Risk Coverage
Guidelines
The At-Risk system is set up as coverage for fellows on clinical rotations for emergency situations when alternative coverage is not possible. To make the system function, every fellow is required to participate in At-Risk service for about two months during their fellowship at the University of Washington.
Reasons for calling At-Risk system:
- Family emergency
- Major illness
- Other reasons as deemed by the program director
Planned absences should not be organized through this system. These absences should be arranged 12 weeks in advance of the event with another fellow(s), and should be forwarded to the program director. If it is not possible to arrange 12 weeks in advance, options must be discussed with the program director and the absence may not be granted. Situations requiring coverage beyond what is discussed here should be discussed with the program director.
Typically the At-Risk system will be utilized for short time periods <1 week. If longer periods are needed due to extenuating circumstances, the fellow and the program director will try to find alternate coverage options.
To request At-Risk coverage the fellow should:
- Notify their attending on service
- Notify the program director or his/her designee
The program director will then contact the At-Risk fellow for coverage and will notify the attending on service. If a fellow believes he/she may need At-Risk coverage, they should call the program director as soon as possible to help organize coverage.
To assure continuity of care, efforts should be made for review of current / pending consults - either fellow to fellow, or from the attending on service.
Guidelines for At-Risk fellows:
It is the at risk fellow's responsibility to be available by phone or pager 24 hours a day for the entire At-Risk period. They should be within 1-2 hours of Seattle, so there will be no delay in service coverage.
Note: Fellows are responsible for forwarding any exchanges of At-Risk coverage time/months to the program director and coordinator.
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