VA MEDICAL CENTER INPATIENT CONSULTATION
A. GOALS AND OBJECTIVES
1. Fellows will gain a broad experience in the evaluation and management of hospitalized adult patients with a comprehensive array of acute and chronic infectious disease problems.
2. Following this rotation, fellows will be able to formulate a basic approach to the evaluation of acutely ill patients with potential infectious diseases including pertinent history and physical exam, appropriate utilization and interpretation of diagnostic tests, and development of a prioritized differential diagnosis based upon history, exam and diagnostic studies.
3. Fellows will develop an increased understanding of the pathophysiology of common infectious diseases in hospitalized adult patients. The emphasis is on case-based bedside teaching.
4. Fellows will recognize and treat common infectious disease problems requiring hospitalization including pneumonia, osteomyelitis, skin/soft tissue infections, endovascular infections, osteomyelitis/septic arthritis, central nervous system infections, intraabdominal and genitourinary infections.
5. Fellows will recognize indications, side effects and drug interactions of diverse classes of antimicrobials utilized to treat hospitalized adult patients.
B. METHODS, PATIENT MIX, PROCEDURES
Fellows will have daily bedside rounds with the Infectious Diseases attending and participate in the diagnosis and daily management of acutely ill patients with a variety of infectious diseases.
Fellows are required to attend TB clinic (weekly usually every Thursday morning) and manage patients presenting with either tuberculosis or positive PPD reactions. The TB clinic experience is precepted by a Pulmonary attending with ID attending backup.
All HIV patients will be staffed in the comprehensive patient care model incorporating the expertise of the ID attending, Clinical Nurse Specialist, Pharm D, and other appropriate personnel. Outpatient continuity and follow-up will be stressed.
Didactic discussions that are case-based will be undertaken by the Infectious Diseases attending physician and generally occur daily as each patient is presented. Fellows will attend the weekly ID Clinical Case Conferences, fellow’s didactic lectures and the bi-monthly ID Journal Club held at University Hospitals.
The mix of patients will include the entire spectrum of adult patients with infectious diseases problems managed in the inpatient setting. Fellows will encounter patients in all departments including Internal Medicine, Surgery and surgical subspecialties, Neurology, Psychiatry, and Dermatology. The number of patient encounters will emphasize on teaching and service so that educational goals are met. The fellow is also available for Emergency Department consultation and for consultation (by phone) for acute patient related problems that arise at Brecksville and Community Based Outpatient Clinics (CBOCs).
The principle ancillary educational material will include "classic" and recent medical literature, which will be applied in each specific case. Fellows are strongly encouraged to contribute educational material to our current library.
Fellows are responsible for notifying the primary team of each positive blood culture and each positive sterile fluid culture (cerebrospinal fluid, joint, ascites, pleural fluid, etc.). Positive blood cultures (excluding coagulase negative staphylocci and diptheroids) require a consultation. This may be a simple point of contact note or a formal consultation depending upon the nature of the problem.
Each formal consultation is recorded in the ID Consult book.
Fellows will be required to familiarize themselves with the current needle stick protocol and HIV prophylaxis. Appropriate material to be read will be available from the Infection Control Section. Counseling of patient source when Infection Control is not available for this task. ID fellows will also be available for advice regarding post-exposure prophylaxis (PEP).
Each patient placed in respiratory isolation to exclude TB also requires formal ID consultation. It is strongly encouraged that in cases where TB is highly suspected, each ID fellow review AFB smears with the attending. The decision and rationale to remove a patient from isolation must be clearly documented in the medical record.
The ID Fellow is responsible for informing Infection Control of notifiable diseases (e.g, syphilis, Group A b-hemolytic streptocci, invasive Streptococcus pneumoniae, Legionella, Hepatitis A, CJD, West Nile, etc.) so that Public Health is appropriately notified by Ohio law.
The ID fellow and Attending will be responsible for decisions regarding the use of restricted antibiotics or biologicals. Often the decision will require formal ID consultation or point of contact note.
C. EVALUATION
1. Formal ongoing feedback by the Attending Physician is required. Fellows will receive evaluation at the end of the month and will be part of the fellow’s permanent file. Also, at mid-month, attending physician will give feedback to the fellows. Fellows will also anonymously complete an end-of-month evaluation form which is available for the attending and program director to review. Specific comments are relayed to the Division Chief.
2. At the end of the month, fellows assigned to the ID Consultation Service, will have a feedback session with the Fellowship Program Director to discuss strengths and weaknesses of the rotation, the service load, the Attending physician and other issues affecting the educational experience of the service.
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