Copyright 2001 by WUMS/Inf.Dis.Divison.
For Contact Information, please click here
Last modified: Mon Jan 29 11:47:12 2001

Disclaimer.

 

The following manual will answer many questions you may have concerning your I.D. fellowship. It summarizes administrative policies, contains conference schedules and phone lists, and provides some useful hints for particular aspects of the fellowship. This manual is intended to make your fellowship easier, and we would appreciate any feedback on how to make it more useful. However, the policies summarized in this manual shouldn't be altered until discussed with the clinical faculty.

1. Rotations
2. Consultations
3. Admissions
4. Night/weekend schedulle
5. Database
6. Antibiotic control policy
7. Employee health
8. Conferences
9. Miscellaneous
  1. ROTATIONS. A copy of the attending/fellow coverage schedule for the year is contained in Appendix A.
    1. Team members
      1. General I.D. (Blue) Service comprises one attending and one fellow.
      2. Immunocompromised Host (Red) Service consists of one attending and one fellow.
      3. VA Service includes one faculty attending (alternating between Wash. Univ. and St. Louis Univ.) and one fellow.
      4. Residents are under the supervision of the fellows. One or two Barnes Hospital residents may be rotating on the services at any time. Service assignments will be made at the beginning of each resident block.
      5. Medical students (1-3 per rotation) will be assigned to Red service.
    2. Daily work rounds are made each morning, on all services. Consultations and admissions are seen immediately after work rounds, unless an emergency requires an earlier evaluation. New patients are presented to the service attending as early as possible after rounds.
      1. Blue and Red Services. Fellows and residents should "pre-round" at 7:00 - 7:30 a.m. Attending rounds usually begin at 9:00 a.m. unless another starting time or place has been arranged - 8:30 on Mondays.
      2. VA Hospital. Morning work rounds are made daily at the fellow's discretion. Attending rounds are conducted at a time set by the attending and fellow. The attending should see all patients daily. VA fellow will also go to STD Clinic (Brad Stoner) every week.
    3. Weekend coverage
      1. Saturday. The attending and fellow round each Saturday.
      2. Sunday. One attending will round each Sunday - alternating with fellow. If fellow is on call they will round on Sunday.
      3. VA Service. The VA fellow rounds alone on all patients on Saturday and on acutely ill patients on Sunday. Attendings should be notified of new consults.
    4. Holidays. The service attendings determine the schedule for rounding on medical center holidays. In general, the schedule for holidays is the same as for Saturday.
    5. Laboratory work rounds. There are microbiology lab rounds each week (8:30 am on Fridays at Barnes Hospital; rounds will be held at Children's Hospital Micro Lab (2N40) on the first Friday of each month). At these sessions, interesting microbiologic cases are presented. You can also ask specific questions about your patients; prior discussions with the lab are often useful for preparing for such questions. Lab rounds last about 30 minutes. Both the Red and Blue Service teams must attend these conferences.
    6. Transition schedule. Fellows completing their first year of training continue to run the clinical services for the first month of the new academic year. Incoming fellows make rounds with their service during this period but do not take new consults.

  2. CONSULTATIONS
    1. Timing of consults
      1. Consults should be seen as soon as possible on the day requested.
      2. Fellows are responsible for consults on their own services between the hours of 8:00 a.m. and 5:00 p.m., Monday-Friday, and 8:00 a.m. to 12:00 noon on Saturday (to a maximum of three). Consults at other times are the responsibility of the "on-call" fellow. The appropriate service fellow assumes coverage for these new patients the following morning. If a fellow on the Red or Blue Service sees a patient while on call, the patient should usually remain on that fellow's service to facilitate follow-up care (with the exception of solid organ and bone marrow transplant patients). The VA fellow is responsible for all VA consults during his or her one month rotation.
    2. Areas of coverage
      1. Red (Immunocompromised Host) Service covers
        1. all solid organ (kidney, liver, pancreas, heart, and lung) and bone marrow transplant recipients
        2. HIV-infected patients
        3. neutropenic patients
        4. all patients on North Campus
        5. all patients admitted from the ID Clinic
        6. patients referred to ID from outside physicians
      2. Blue (General I.D.) Service is responsible for all other consultations at Barnes-Jewish Hospital. Immunocompromised patients may be taken on the Blue Service as needed to keep an appropriate balance between the Blue and Red Services.
      3. VA Service covers all VA Hospital patients at both the John Cochran and Jefferson Barracks Hospitals, although fellows are not expected to see patients at Jefferson Barracks. If a patient at that facility requires consultation, arrangements can be made for the patient to come to John Cochran for evaluation, generally during ID Clinic.
    3. Patient list. A daily patient list should be maintained by the fellows on each service. This list should include the patient's name, location, birth date, hospital number, attending physician, and primary fellow. This list is generated from the consult database (see "Database"). Please make sure that the office receives a copy of the list daily. The attending who sees the patient must be listed.
    4. Documentation
      1. Initial consult note. The consult note should be brief with an emphasis on data synthesis, differential diagnosis, and recommendations. An appropriate note contains the following elements:
        1. The name of the requesting physician, the reason for the consultation, and how long the consult required (a typical case requires about two hours of combined fellow and attending time).
        2. A summary of pertinent data should appear on the first page of the consult note. Documentation that a complete history and physical was performed is important. Written comments should focus on pertinent positive and negative findings. A family/social history plus a review of systems is required. ROS should be: pertinent positives plus "review of all other systems negative".
        3. A critical assessment of the case with a complete differential diagnosis and clearly outlined recommendations should appear on the second page of the consult. The assessment should never be squeezed on to the bottom of the first page. This section should not be written until the case has been presented to the attending.
        4. Fellows should review student's (and where appropriate) resident's notes for accuracy, detail and clarity.
      2. Daily notes. Notes should be written every day a patient is seen. These notes should focus on our contributions to the case and in general should not be used to give advice outside our area of expertise. All medical student notes must be carefully read by the fellow and attending and countersigned by the attending on the day they are written. Inappropriate or inaccurate notes should be discussed with the attending. Resident notes do not require a fellow's countersignature but should also be reviewed by a fellow or attending on the day they are written. Daily progress notes should list current antibiotics for each patient, the number of days of therapy as of that day, and when possible the anticipated total course (e.g. ampicillin d# 3/14). By convention, amphotericin should always be listed with that day's dose and the total dose as of that date (e.g. ampho 30/å 240).
    5. Notification of referring physicians. Attending physicians should contact referring physicians within 24 hours of evaluation of the patient. Fellows should facilitate notification by identifying referring MD's and providing phone numbers when available.
    6. Consultation summaries and letters. On the day we sign off a case, a consultation summary (see appendix D) should be completed and a brief letter dictated to the attending and/or referring physician(s) responsible for the patient. If we are the primary caregivers, these documents should still be sent to the responsible attending or clinic physician. An e-mail should be sent to the clinic nurses the day of discharge summarizing plan and discharge needs. It is imperative that these items be sent to the clinic in a timely fashion as medical records frequently are not available at the time of clinic follow-up. Tape recorders and tapes are available from the office and may be taken on rounds. Tapes should be turned in the day they are dictated, regardless of how many dictations they contain. The fellow is responsible for the hospital discharge summary for cases who are not on a housestaff covered service.
    7. Out-patient follow-up. Each patient needs a definitive follow-up plan, which may or may not require us to see him or her again. If additional decision-making on our part will be required (e.g., when to switch from parenteral to oral antibiotic therapy), we usually should see the patient in the Infectious Diseases Clinic. If we are managing home I.V. therapy for a patient, we should see that patient in follow-up as well if this is feasible. Patients who are immobile or live a long distance (i.e., more than 3 hours away) from St. Louis require other follow-up arrangements for home I.V. therapy. To schedule I.D. clinic follow-up for a patient notify the ID nurse (phone #454-8341). Please make certain that the action required at follow-up is clearly outlined in the dictated consultation summary (see "Documentation").
    8. "Curbside" consultations. Fellows are often requested to render an opinion concerning a patient's care without formally seeing the patient. Frequently, this occurs during conversations concerning antibiotic approval requests. This is a tricky issue for which several rules should be observed.
      1. Always remember that information you are given in making such judgments may be inaccurate or incomplete. Be wary of cases that seem confusing or in which data appear to be conflicting.
      2. If a case is very complicated, it is best to tell the physician that advice cannot be given without seeing the patient. The physician will usually be happy to have a formal consultation.
      3. If you do elect to give advice that involves more than dosing recommendations or a straight-forward antibiotic substitution, it is best to do so in general terms. Patient-specific recommendations should be avoided whenever possible. Remember that what you tell the physician on the phone often gets recorded in the chart as an official I.D. Service recommendation. This can be very embarrassing if the advice was based on erroneous information.

  3. ADMISSIONS. Patients may be admitted to Barnes or Jewish Hospitals. Except under unusual circumstances, each such patient will be the responsibility of one of the I.D. fellows and attendings.
    1. Admitting procedure
      1. Patients may be admitted to the I.D. inpatient service from the I.D. Clinic or the ACTU without prior approval of the service attending. Physicians wishing to send patients from outside offices or hospitals should present the case to an attending or to a fellow who then relays the information to the appropriate service attending. A "Physician Access Line" has been developed whereby there would always be an I.D. physician on call. I.D. Clinic patients should be admitted to the red service irrespective of their diagnosis unless previously followed by general I.D. service. All I.D. Clinic patients requiring admission from the E.R. should be admitted to the immunocompromised service. As of 7/97, HIV positive patients at Regional Medical Center may be directly admitted to Infectious Diseases by either Dr. Leon Robisen or Dr. Matt German. They should be subsequently discharged back to the care of Drs. Robisen and German.
      2. Insurance status. Patients without third-party insurance require special approval before they can be admitted. For referrals to Barnes Hospital from areas outside St. Louis, referral budget funds are available. Please notify one of the service attendings concerning such cases. Interesting teaching cases that cannot be admitted to the referral budget can often be admitted on the Department of Medicine's charity budget. These cases must be approved by one of the Internal Medicine Chief Residents (362-8065) and become patients of the Department of Medicine. Patients with third-party insurance, including Medicare and Medicaid patients, can usually be admitted without special arrangements, although prior approval may be required by some organizations. Barnes Admitting can help assess each patient's insurance status.
      3. Reserving a bed. As soon as you decide to admit a patient, the admitting department of the appropriate hospital (BJS - 362-7777; BJN 454-7050) should be contacted. For acutely ill patients or good teaching cases, a "covered" medical service should be requested. If a covered bed is not available, the "Gold" Service at Barnes and "Intermed" at Jewish, which are staffed by physicians who have completed internal medicine training, are acceptable alternatives. For less severely ill patients or routine admissions, Attending Service Medicine (ASM) at Barnes is adequate, but the fellow will be responsible for all care of the patient, including routine orders and dictating discharge summaries.
    2. Responsibility for service admissions includes careful review of all aspects of care. The distinction between our role as consultants and our role as primary care givers should be recognized. Complex patients require "pre-rounding" before morning work rounds to allow adequate time for complete review of the case.
    3. Notification of the referring physician. Clinic, ACTU, and other referring physicians should be kept abreast of their patient's progress while the patient is on one of our services. These physicians should be afforded the opportunity to participate in their patient's care if they so desire, particularly if they will be assuming primary care of the patient at the time of discharge.

  4. NIGHT/WEEKEND CALL. A copy of the call schedule for the summer is found in appendix B.
    1. Coverage times for the on-call fellow are 5:00 p.m. to 8:00 a.m. each weeknight, 12:00 noon Saturday to 8:00 a.m. Monday, and holidays.
    2. Responsibilities
      1. All antibiotic approval requests are handled by the on-call fellow during coverage hours.
      2. Problems with service patients can be handled by the on-call fellow if the question is straight-forward. Otherwise, the appropriate attending should be contacted.
    3. Clinic patients. Fellows on call often receive calls concerning I.D. Clinic patients. When you receive such a call, the following guidelines apply:
      1. Fill out a phone encounter "slip" for each call, particularly if you start a new medication or make a change in therapy. These simply list who called, when and why they called, and what you did. You may page clinic physician whenever you have questions concerning a clinic patient.
      2. Notify the ID nurse of the contact the next morning.
      3. Do not give telephone prescriptions for narcotics.
    4. Portable phone. A cellular phone is provided by the division for your convenience while on call at Barnes-Jewish and the VA Hospital. Please take special care of this phone. Notify the office as soon as possible if the phone malfunctions.

  5. DATABASE. The I.D. database is on a Microsoft Access file. As this is the main method by which the division bills for its inpatient activities, it is very important that the information within it be accurate (especially name, date of birth and hospital number). Note that the attendings no longer keep cards for billing purposes.
    1. Accessing the database
      1. To access the database, double-click on the "Access Consult Database" icon from the Windows 95 program manager.
      2. The initial screen encountered is an overall listing of all patients in the database. To view the appropriate service, click once on "Red" or "Blue".
    2. To enter a new record
      1. Using the mouse, place the cursor on the line of the record to be added (or modified).
      2. Add name, medical record number, room, service and hospital on the first screen. You can either tab between fields or just hit the "Enter" key between fields. The service and hospital fields also contain pull-down menus, if you prefer to use them.
      3. After finishing the first screen, click off of a record and then double-click back on to access the second screen of information, which includes date of birth, ID attending, consulting attending, consulting service, fellow, resident, and billing information (billing can also be accessed by a pull-down menu on the first screen). The ID attending, consulting service and billing information are accessed via pull-down menus. This screen is closed by clicking on the innermost box which contains an "X" in the upper right corner of the database screen.
      4. Alternatively, you can enter all of the information pertaining to a consult from the second screen if you find this easier. You will notice that this screen will be blank if you have not "clicked off" of the information from the first screen before entering the second screen (the process by which data is entered in the database). All of this will make more sense if you do this in front of the terminal.
      5. The "important numbers" section at the bottom of the printout can be modified to suit your needs by deleting and adding information as you see fit. This is in the lower right-hand section of the database screen. Note that there are more lines available than are visible (accessed by toggling down with the sliding rule at extreme right) and that the lines are also longer than are visible.
    3. Printing
      1. To print, just click once on "Print Red" or "Print Blue"
      2. You can print either service's list without having to enter its customized database.
    4. Notes
      1. The date of initial billing (usually level five on consult patients) is the first day that the attending physically sees the patient.
      2. We have added a level zero consultation to be used to keep the patient on the billing list generated by the division office, while not charging them for a visit (such as when you are seeing a patient every other day).
      3. When you sign off of a patient, make them inactive by changing the status field from "A" to "I".
      4. If you have to re-activate a patient, such as when you are called back to a case you have previously signed off on, you need only "Find" them from the "All consults" list, specifying "Any part of field" from the name choice (one of the second year fellows can show you how at the beginning of the year).
      5. If you have a new problem arise on a patient seen earlier that admission (thus requiring a new consult), you can re-enter them in the database with a one, two, three, etc. appended to their hospital number. Otherwise, the database will think you are trying to re-enter a previous record and will give you an error message. Similarly, North Campus (Jewish Hospital) patients will need to undergo this process if they have ever been seen by the ID service at any time, as the first six digits of their record number never change. There are also four digits at the end of the record number that can be used for this purpose.

  6. ANTIBIOTIC CONTROL POLICY
    1. Barnes-Jewish Hospital. Please refer to the Barnes-Jewish Hospital Antibiotic Control Program notebook for complete details concerning the antibiotic policy.
    2. VA Hospital. The antibiotic policy is in general similar to that at Barnes, although restrictions may differ for specific agents. A list of restricted antibiotics is posted in the VA fellow's room and is also available from the inpatient pharmacy.

  7. EMPLOYEE HEALTH AND INFECTION CONTROL ISSUES. The following are applicable to Barnes-Jewish employees only. Washington University employees are serviced through Washington University Employee Health. Barnes-Jewish hospitals Infection Control policy/ Employee Health policy is summarized in appendix E.
    1. Body substance exposures. The following summarized actions you should take when confronted with an employee body substance exposure question. The current Barnes/Jewish body substance exposure protocols can be found in appendix G, as can a comprehensive review of pertinent literature.
      1. Ensure adequate cleansing and decontamination of wound.
      2. Take a detailed history of the accident - blood or no blood, size and type of needle, depth of wound, etc..
      3. Assess risk, then counsel and reassure employee.
      4. If needed, AZT and 3TC emergency dose packs are available from the pharmacy. You must call the pharmacy to approve their use ONLY for employees with HIGH-RISK exposures from HIV+ patients; employees sustaining HIGH-RISK exposures from high-risk but HIV- status unknown patients can get AZT and 3TC for 24 hours until the HIV result is available. If there is a high-risk exposure from an HIV+ patient who is likely to have AZT resistance or high viral loads then Indinavir can be added in the morning the next day (500 mg PO TID). Call Vicky Fraser (home: 991-3649; beeper: 424-0270).
      5. Notify employee health the following morning if you put anyone on AZT/3TC.
      6. Remind all employees they must go to employee health with an injury report (as soon as it's open).
      7. The employee health nurse should handle all daytime issues.
    2. Other employee health issues. Employees may call for many different infectious disease-related employee health issues (i.e. scabies, conjunctivitis, rashes). Please use your judgment, but don't be manipulated. Employees with pink eye, chickenpox, fevers, weeping dermatitis, etc. should be sent home. The vast majority of these should be handled when employee health is open. There are very few employee health emergencies. You should not write prescriptions or call in medications for employees. If there is a true emergency, please call or beep Vicky Fraser to facilitate getting employee health and infection control nurses in to handle the crisis. If you hear of a communicable disease issue involving employees, please notify employee health the following morning (362-9194).
    3. Frequent questions
      1. Prophylaxis for meningitis. When patients have invasive meningococcal infections (bacteremia or meningitis), household contacts should receive prophylaxis with rifampin (600 mg PO BID x 3 days). Employees usually become excited and often demand prophylaxis for themselves, but prophylaxis for health care workers is only indicated for those who have had extensive, intimate exposure to a patient with meningococcal disease (i.e., mouth to mouth resuscitation). Do not start the vicious cycle of giving prophylaxis to health care workers without notifying infection control or employee health. It takes a huge amount of time and effort (e.g., counseling, chart review to find all eligible persons, etc.). This should be handled by employee health and infection control.
      2. Scabies. Employees who care for patients with scabies DO NOT ROUTINELY get prophylaxis with lindane. Refer them to employee health to be screened. One exception may be exposure to a non-treated non-isolated patient with Norwegian Scabies. This is highly infectious.
      3. Communicable diseases. Chickenpox, measles, rubella, or TB in an employee are significant issues that need to be handled by employee health and infection control. Please get the employee OUT of the hospital and notify employee health and infection control with the person's name and department ASAP. Employee health has policies and procedures to provide the follow up.
    4. Reporting nosocomial infections. It is really helpful if you communicate frequently with infection control. Please notify infection control ASAP if you identify surgical wound infections or communicable diseases (meningococcus, group A strep, TB, VZV, etc.).

  8. CONFERENCES
    1. Each I.D. Division conference is intended to fulfill an important educational objective, and the fellows are an integral part of most. First year fellows are encouraged to attend as many of these conferences as they are able; attendance at the Course in I.D., and I.D. Rounds is mandatory.
      1. Course in I.D. meets each Wednesday at 8:00 a.m. from September to June. This is a review of significant, new, or controversial areas in microbiology and clinical infectious diseases.
      2. Clinical Journal Club meets regularly on Thursday at 11:45 a.m. from September to June. Papers are presented for review by fellows and attendings. The emphasis of this series is on critical evaluation of study design and data interpretation. Attendance by the first year fellows is expected. A schedule for this conference will be mailed in August.
      3. I.D. rounds are held each Tuesday morning at 8:00 a.m. throughout the year. Cases are selected for presentation by the fellows and attendings on each service (including Pediatric I.D.) who should also review the appropriate points for discussion at conference. Cases should be selected far enough in advance so that pertinent radiographs, slides or other supporting material can be obtained for demonstration. A radiologist (Dr. Bill Reinus, phone 4-7400) attends the conference. Try to let him review pertinent x-rys (especially complex scans) the day before the conference. At least one presentation each week should include a brief (no more than 5 minutes) review of the literature concerning some important or unique aspect of the case. See Appendix J for some helpful guidelines for this conference.
      4. Research seminars are held September through June and are a good way to get to know the type of work being done by faculty. Basic science research seminars are held each Thursday at 8:30 a.m. September to May. These conferences are devoted to discussion of individual basic science research efforts of faculty, microbiology graduate students and post-docs, and research fellows. The schedule for this conference will also be sent out in August.

  9. MISCELLANEOUS
    1. Phone numbers. A list of useful phone and beeper numbers is found in Appendix C. A list of attending and fellow home phone numbers is also attached.
    2. VA Hospital rotation. Some useful comments concerning the John Cochran VA Hospital rotation can be found in Appendix K.
    3. Photographing cases. First-year fellows should have photographs taken of all particularly interesting clinical material, including unusual physical exam (e.g., skin lesions), radiographic and pathologic findings. For patient photographs, Medical Illustration at Washington University School of Medicine (362-3238) should be contacted. The Department of Pathology will take photomicrographs of pathologic findings in striking cases but must be given adequate advance notice. Please consider how soon you would like to have these slides available. Facilities are also available for making our own photomicrographs.
    4. Vacations. Each fellow is allotted three weeks of vacation per year. During the first year, vacations are best taken at the beginning or end of the Blue Service rotation but may be taken at other times if necessary. Each fellow is responsible for arranging appropriate coverage. Two first-year fellows should not take vacation at the same time except under extraordinary circumstances. Vacation scheduling should be cleared with the service attending affected and Dr. Powderly. The clinical office should also be notified as soon as vacation plans are made.
    5. Pharmaceutical companies. We do not have a formal policy prohibiting contact between the fellows and pharmaceutical companies, but you should realize that their interactions with you are motivated by their desire to sell their product.
    6. Investigational agents. Please see Appendix L for a summary concerning the use of investigational drugs.
    7. Moonlighting. According to the Department of Medicine, moonlighting is allowed only at "approved" locations. A copy of this policy can be found in Appendix M.
    8. Photocopy cards. An account number to get Photocopy cards from the Library can be obtained from one of the secretaries in the I.D. office.
    9. Literature searches may be performed using the EUCLID system in the medical library. Fellows are strongly encouraged to use this resource for appropriate research. However, EUCLID is expensive and should be used judiciously. Do not "loan" the I.D. fellow password to non-I.D. division personnel. Instructions for using EUCLID can be found in Appendix N.