presentations and consultations workshop · npo, iv ppi, bloodwork (e.g. type & screen, cbc,...

HandoutPackagecompiledbyKatieLinandAnthonySeto,LastUpdatedDecember2017

PresentationsandConsultationsWorkshop

HandoutPackage(WorksheetsandReferenceMaterials)

SessionLearningObjectives:

1. Practiceastructuredprocessforpresentingclinicalcasestoapreceptor(F-SOAP)

2. Identifytoolsthatsupportaclinicalconsultationrequest(e.g.RAAPID,ROCA)

3. Practiceastructuredprocessforcommunicatingwithconsultants(5Cs)

4. Listelementstoincludeinwrittenclinicalconsultation


CasePresentations:F-SOAPMODEL

Component Notes

FRAMEStable/Unstable

IDCC

RelevantPMhx

STORYHPI

Pertinentpos/neg

OBJECTIVEDATA

VitalsPhysicalExam

Ix

ASSESSMENT

DDX(workingdx,

dangerousddx,commonddx)

PLAN

SymptomaticTxIx/ManagementDisposition

PatientEducation


CasePresentation:PracticeCasePrompt

69yoFintheED.Shetellsyouthatshecameintotheofficetodaybecauseshehasbeenhavingsomechestdiscomfort.Itstarted3hoursagowhileshewassittingwatchingWheelofFortune.Itdoesn’tgetworsewhenshetakesadeepbreathinorradiateanywhere,butshehasbeenfeelingalittlenauseousoverthepast3hourswithit.Shedescribesitasmoreofapressuresensationandratesit6/10presently.She’sneverhadthisbefore.Shedoesn’thaveanyinfectioussymptomsandshehasn’tfeltlight-headedorfainted.Shedeniesanypalpitations,sweats,positional,orexertionalchangetothechestpressuresensation.Shealsohasn’ttravelled,hadsurgery,orsufferedanyrecentinjuries.Shetellsyouthatshesmokes,butdoesn’ttakeanyrecreationaldrugsoralcohol.Herfatherhadaheartattackatage70andhermotherhadasthma.SheisonmetforminforDM,RamiprilforHTN,andatorvastatinforDL.Shehasnoallergies.She’sneverhadaheartattackbefore.Onexam:

• Vitals:Temp37.3,HR90,RR22,Sats94%RA,BP110/77• Neuro:GCS15,pupilsequalandreactive,normalstrengthtoallfourlimbs• CVS:JVPnormal,S1/S2normal,nomurmursorextraheartsounds,strongandregular

pulse• Resp:lungsareclear,noincreasedworkofbreathing,herchestpainisnotreproducible

onpalpation.Whenaskedtopointtothelocationofherchestdiscomfort,shepressesonhersternum.

• Abdo:Soft,non-tender,non-distended,shehasoldscarsforpreviousappendectomy• Extremities:nocalfswellingortenderness


CasePresentation:F-SOAPFeedbackChecklist

Learnerachievesthefollowing:

FRAME:c Stable/unstablec Age&genderofpatientc Chiefcomplaint

STORY:

c EasytofollowHPI,whichpaintsaclearpictureofwhat’sgoingonc FocusedPMHx,Meds,All,SocHx,FamHx(includedonlyifitcontributesto

narrowingdowntheddxforthechiefcomplaint)

OBJECTIVE:c Startswithvitalsignsc Focusedreportofsignificantphysicalexamandinvestigationfindings

ASSESSMENT:

c Sharesmostlikelydiagnosis(es)basedonencounterc Includesaddx(3minimum)thathasdangerousddxandotherddxalternatives

PLAN:

c Symptomatictreatmentc Furtherinvestigationsandmanagementplanc Considersadispositionplanc Patienteducation

STYLEPOINTS:

c Organizedflowtopresentationc Sign-postsimportantsectionsofpresentation(e.g.“Myoverallassessmentis__)c Deliveryisataneasy-to-understandpacewithappropriatepausesandvolume


Consultations:5CModel

Component Notes

ContactIdentifyparties

CoreQuestionE.g.Follow-up,

furtherevaluation,admission,definitive

management.

CommunicateF-SOAP

What’sdonesofar

CollaboratePlannextsteps

ClosetheLoop

Clarifyresponsibilitiesandsummarizeplan


Consultations:PracticeCasePrompt

ID:Stablecondition52yoMadmittedtoMTUformildpancreatitisCC:Newlydevelopedmelenastoolsx2episodesHPI:AdmittedtoMTU3daysagoforconfirmedmildpancreatitis.2episodesofmelenastoolstoday,butotherwisenonausea,vomiting,diarrhea,orfever/chills.PMHx/SHx:ETOHabuse(noliverdiseaseorvarices),pepticulcerdiseaseFHx:Non-contributoryMeds:NoneRelevantExamFeatures:

Vitals:Temp37.3,HR90,RR22,Sats94%RA,BP110/77Mildepigastricdiscomfort,butnon-peritoniticabdomenandrectalexamsignificantforsmallamountofmelenastoolonly.

Treatmentstarted:

NPO,IVPPI,bloodwork(e.g.Type&Screen,CBC,INR/PTT)

ScriptforConsultantRoleinthepracticescenario

o Duringthecollaborationphase:o Promptthelearnerforcasehistoryifyoufeelnotenoughinformationhasbeen

giveno Askaboutinterventionsandinvestigationsdoneorstartedsofar(ifnotalready

providedbylearner)o Then:“Iagreewithyourassessment.Thissoundslikeanon-urgentupper

endoscopytoinvestigatefurther.Wecanorganizetheproceduretobedonetomorrowmorning.PleasekeepthepatientNPOandcontinuewithyourcurrenttherapy.Letusknowifanythingchangesorthepatientdeteriorates.”


Consultations:5CsFeedbackChecklist

Learnerachievesthefollowing:

CONTACT:c Identifiesname,rank,serviceforselfandconsultant

COREQUESTION:

c Leadswithclearlyarticulatedreasonforconsultc Includesurgency/timelineofrequest

COMMUNICATE:

c Communicatespatient’scaseinanorganizedfashion(e.g.F-SOAP)c Outlineswhathasbeendonesofar(intermsofinvestigationsandmanagement)

COLLABORATE:

c Workswithconsultanttodeterminenextsteps

CLOSETHELOOP:c Repeatsplanandconfirmsroles/responsibilities

STYLEPOINTS:

c Organizedflowtoconsultationc Deliveryisataneasy-to-understandpacewithappropriatepausesandvolume


WRITTENCONSULTATION:SAMPLETEMPLATE

To:Consultant<Contact>CC:Patient’sGP.Re:PatientXY,ID#Date:MM-DD-YYYYReasonforReferral:<TheCoreQuestionfortheconsultant>Patientcontactinfo:workingphonenumber(doublecheckthiswiththepatient)DearDr.XPatientXYisa__yoM/Fevaluatedat______onMM-DD-YYYYfor<ChiefComplaintorsuspected/confirmeddiagnosisifavailable>.<CommunicatewithF-SOAP><Remembertocommunicateyourinvestigationsandmanagementinitiatedthusfar><CollaborateandClosetheloopby:discussingwhatyou’rehopingthenextstepswouldbe,providingashortsummary,andthankingtheconsultant>Thankyouforyourassistance.Signed,XX,designation


RAAPID:SUPPLEMENTARYINFORMATION

RAAPID:§ Referral,Access,Advice,Placement,InformationandDestinationserviceinAlberta§ Callcentrethatcoordinatesconsultsandtransfersbetweenhealthcareprovidersand

centreswithintheprovince(ruralandurban)RAAPIDContactInformation:

§ RAAPIDNorth:everythingnorthofRedDeer(includingEdmonton):o 1-800-282-9911

§ RAAPIDSouth:everythingsouthofRedDeer(includingCalgary):o 1-800-661-1700

When you call RAAPID, youwill be greetedby anoperatorwho coordinates calls. There is astandardformattofollowwhencontactingRAAPID(don’tworry,ifyoudon’trememberthis,theRAAPIDoperatorwillpromptyouforthefollowing):

§ Stabilityofpatient§ Yourname§ Nameofyourstaff§ Siteyouarecallingfrom§ PatientsPHN(albertahealthcarenumber)§ Whoyouwanttotalkto(EmergDoc,Specialist,etc)§ Reasonforcallingconsultantandbriefstory

TheRAAPIDoperatorwillusuallyendthecallsotheycancontacttheconsultantandwillcallyoubackoncetheconsultantisonthelinesoyoucanpresentthecasetotheconsultingphysiciandirectly.Alternatively,theymaytransferyoutotheconsultantrightaway.Thisisusuallyastaff-to-stafforresident-to-staffservice,butyoumaybeaskedtohelpcontactRAAPIDifyouareworkingataruralsite.


ROCA:SUPPLEMENTARYINFORMATION

ROCA:§ RegionalOnCallApplicationinCalgary§ MostlearnerswillencounterthisduringMTUInternalMedicinerotationsinCalgary§ Thisishowyoulookupcontactsforon-callservicesinCalgary(eg.generalsurgery,

cardiology,etc)HowtoUseROCA:

1. NavigatetotheAHSInsitepage(thisisthedefaultbrowserpageonallAHScomputersifyouopenaninternetexplorerwindow).

2. FindtheROCAlinkeitheroftwoways:a. TypeROCAintothesearchbar,thenclicktheROCAhyperlinkforCalgary&Areab. Ontheright-handsideoftheAHSInsitehomepage,under“ContactCentre”,click

the“On-Call/ROCA”hyperlinkforCalgary&Area3. Youwillseethefollowingscreen:

4. Entertherelevantfields(time-frame,siteofinterest,service)andclickthecircled“view”buttontoseewhoisoncallforthatservicetodayvs.“viewcalendar”toseewhoisoncalloverthecalendarmonth

5. Eachindividualoncallwillhaveapagernumberlistedundertheirname.6. Usethepagernumberlistedtopagetheindividualandarrangeaphoneconsult.


CALGARYPAGINGSYSTEM:SUPPLEMENTARYINFORMATION

HowtousetheAHSpagingsystem:1. NavigatetotheAHSInsitepage(thisisthedefaultbrowserpageonallAHScomputersif

youopenaninternetexplorerwindow).2. FindthePaginglinkonthehomepageandclickit:

3. Clickthelinkfor“CalgaryAreaPagingSystem”4. Youwillseethefollowingscreenpopupandcansendpagesbypagernumberorname

5. Besuretoincludeinyourpage:yourname/initials/pgrnumber,briefreasonforpage(eg.“newconsult”),patientinitialsorlastname,phonenumberforconsultanttocall.


SPECIALISTLINK

www.specialistlink.ca


TIPS ON HOW TO MAKE CONSULTS MORE EFFECTIVE (Compiled in 2015 by Anthony Seto)

GIM – Calgary PGY-3, Calgary PGY-3, Kingston PGY-3

o Accurate vitals o Ensure to complete workup and avoid anchoring bias o Responses to treatment so far o Synthesis of what we think is happening and provisional diagnosis o Goals of care

Surgery – Calgary PGY-2

o Try to have a diagnosis in mind and avoid consulting when the patient is still undifferentiated

o Remember to have labs back and imaging completed Psych – Calgary PGY-3

o Avoid consulting automatically if, in a previous chart, the patient was seen by psych in past

o Remember to go through psych screening Q’s: psych illness symptoms, substances, suicidal ideation, and social/housing

o Consult ED SW first if primarily social/housing/financial/drug detox issue Ortho – Calgary PGY-3

o State the issue/problem right away o Keep mechanism fairly brief, unless it involves some relevant

information such as syncope o Neurovascular examination

Radiology – Calgary PGY-3

o Please provide history. Avoid simply putting the question (e.g. r/o PE) as the “history”, but provide some context and story.

o Include hx cancer or hx surgery, because it frames way incidental findings are interpreted

Obsgyne – Vancouver PGY-3

o Remember to do pelvic exam o Obs history, Rh status


Cardiology – Calgary Staff, Calgary Fellows, Edmonton Fellow o Ask Goals of Care so cardiology knows how aggressive to be o Look up relevant data, i.e. past history on Netcare o Think about whether CCU vs ICU vs IM vs FM is best; fellows find it

challenging with pan-consults o Have the appropriate blood work before consultation

Neuro – Calgary Staff, Calgary PGY-3

o Is the patient already known to neuro? Gives a point of contact and background information.

o Legible handwriting would be useful for paper forms o Be aware of General Neuro clinic versus Urgent Neuro clinic. Urgent

Neuro clinic is if patient needs to be seen <72h. Resp – Calgary Staff

o Say upfront if you want consult, admission, or both Peds – Edmonton PGY-4, Newfoundland PGY-3

o Tend to miss: if they have a pediatrician or not o Vitals, sick or not sick, do they need immediate attention o Premature? o Growth charts

Plastics – Calgary PGY-3, Manitoba PGY-3

o Do thorough exam


Neurosurg – Calgary PGY-5 o Spine

§ Duration of signs/symptoms important § Localizing neuro exam § Comorbidities § PMhx of prior spine surgery, surgeon, and location § Red flags: IVDU, fever, wt loss, hx of cancer, etc.

o Please tell surgeon/resident if neurosurgeon should be at bedside urgently to assist with management or expediting appropriate care in deteriorating patient. Sometimes it’s difficult to assess neuro status and urgency over phone.

o Cranial § GCS, focal motor and cranial nerve deficits, pupillary exam, vital

signs § Anticoagulation and antiplatelet agents § Meds confounding exam: etoh, benzos, narcotics, paralytics § Seizure: post-ictal or suspect ongoing seizures/status § Include plan for managing/stabilizing patient § Do not start patients with suspected VP shunt infection, post-op

infected craniotomy, or suspected brain abscess on antibiotics until reviewed with neurosurgery

Ophthalmology – Calgary PGY-3

o Visual acuity o IOP, both eyes for comparison o Acuity of the presenting complaint o Prior history of same o Recent eye surgery o Current ophthalmologist


Derm – Calgary PGY-3 o Many consultants request a photo. Derm residents have been told to

use AHS emails as they are encrypted. Hopefully we can develop some sort of system to send photos.

o Most common consults: § Allergic contact dermatitis (e.g. polysporin) § Poorly controlled eczema § Arthropod reactions (e.g. scabies) § Drug eruptions § Vasculitis

o Missed information: § Does the patient have a dermatologist or previous biopsy result? § Drug history (changes or new meds in last 6 months) § Distribution of the lesions § Morphology: site, primary lesion (macule/patch, papule/plaque,

vesicle/bullae), and secondary changes (crust, erosion, ulceration) § All topicals used (OTC and Rx)

ENT – Calgary PGY-3

§ Patient ID, hx, DX, DDX § What have you done so far? (often missed) § What would you like ENT to do? Come and see? Admit? Arrange

f/u? (sometimes missed) § Identify if there is concern for airway


Uro – Edmonton PGY-2 o Most common consults: gross hematuria, stones, catheters o Gross hematuria

§ How bad is it? § Is it clearing up with a trial of CBI for several hours? Remember to

manually irrigate to clear clots prior to trialing CBI. § ?hx bladder cancer § CT urogram, urinalysis, urine C&S, urine cytology

o Stones § ?signs of infxn (fever, WBC) – would need to stent § size/location of stone on imaging § pain status, pain management § N/V § # of visits to ER for this stone

o Catheters § Why inserted in first place? § Hx of strictures or dilations? § Has ER doc attempted cath? If it’s stuck in shaft, probably a

stricture. If stuck in perineum, probably prostatic issue; if so, give coude tip foley a try.

Vascular – Ottawa PGY-3

o Proper pulse exam § Doppler signals alone don’t mean adequate flow § One needs palpable pulses

o Distinguish between acute and chronic limb ischemia o ?Ruptured aneurysm may appear stable and be triaged lower. Need to

improve communication so these patients seen earlier. Dentistry – Calgary Hospital Dentist

o Some patients led to believe that dental treatment would be free when only some parts may be covered by Alberta Health & Wellness

o Whatever is delineated by Alberta Health and Wellness billing codes would be covered:

§ E.g. cost of consult § E.g. biopsy § E.g. cost of general anesthesia for dental treatment, but only

patients meeting a certain criteria o Consult SW to navigate potential sources for dental coverage

presentations and consultations workshop · npo, iv ppi, bloodwork (e.g. type & screen, cbc,...

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