Infectious disease telephone consultations: Numerous, varied and an important educational resource

Fast track consultation in the infectious diseases department of a French university hospital: evaluation of the service delivered to the general practitioner

PURPOSE

Since 2010, the Infectious Diseases (ID) department of the Nice university hospital (France) has implemented a fast track consultation (FTC): it allows General Practitioners (GP) to directly reach an ID specialist through a dedicated phone number for initial advice. Depending on the first observation, a formal consultation can be planned within 48 h. Our aim was to evaluate in a pilot study, the contribution of the FTC regarding the management of patients 28 days after the first phone contact.

METHODS

This prospective current care study was conducted between November 2014 and January 2015 in our ID department. The GP indicates the most likely diagnosis, the therapeutic strategy and the patient's management he would have applied. After the formal consultation, ID specialist provides his diagnosis, therapeutic strategy and patient's management. An adjudicative committee has evaluated the benefit of the FTC after 28 days of follow-up.

RESULTS

Fifty-one patients referred by 49 GP were included. ID specialists modified the diagnosis in 22 (43%) patients, antibiotic treatment in 35 (68%) and treatment plan in 30 patients (59%). FTC provided at least one service for 41/51 patients (94%): antibiotic treatment was reassessed for 11 (22%) patients, averted for 9 (18%) patients, unnecessary hospitalization was avoided for 8 (16%) of them and emergency room visit averted for 5 (10%) patients.

CONCLUSIONS

FTC can provide significant improvement in the management of the patients in terms of decrease in unnecessary hospitalization, emergency room visit averted and appropriate use of antibiotics.

Spectrum of advice and curbside consultations of infectious diseases specialists

OBJECTIVES

Curbside consultation (CC) of infectious diseases specialists for advice is very frequent but the corresponding workload has rarely been assessed. This activity is mostly oral (phone or direct contact) and poorly quantifiable because it is not charged. We had for aim to evaluate this activity in a French teaching hospital.

METHODS

We recorded all CCs given during a 2.5-year period, from mid-2011 to the end of 2013.

RESULTS

During the study period, 6789 CCs were recorded (2715 per year), or slightly more than 10 per day. These CCs were divided in 676 travel recommendations and 6113 for other reasons. They were mostly given by phone (77.4%). Most demands came from our hospital (61.4%), followed by community family physicians and specialist (27.1%), other local hospitals (6.5%) and clinics (4.3%). All the departments in our hospital consulted us for advice at least once and answers were mainly given by phone (70.1%) and at bedside (30.5%). The answers were principally advice (50.8%), modification of antibiotic prescription (22.9%), initiation of antibiotic course (14.8%), maintaining the same treatment (6.2%), and stopping antibiotics (4.3%). CCs accounted for 20% of clinical work for 1 physician. If the CCs in our hospital had been paid, our department would have received an additional 77,000€ in revenue.

CONCLUSION

This curbside activity is very important and time-consuming for infectious diseases specialists, but it is currently not acknowledged or rewarded.

A national network of infectious diseases experts

OBJECTIVES

The aim of this study was to consider the implementation of a network of infectious diseases (ID) experts to optimize the antibiotic prescriptions of community and hospital practitioners.

METHODS

An observational prospective study was conducted among ID experts in the Pays-de-la-Loire Region to evaluate the number of calls and to determine the practitioner's reasons for soliciting ID expertise. For each phone consultation, four criteria were recorded during 5 days: origin of the call (internal/external), kind of question (diagnostic/therapeutic) time spent for the advice provided, type of advice.

RESULTS

A total of 386 phone consultations for 20 infectious disease specialists were recorded during the study period (5 days); 81% were internal to the hospital, 7.7% from another hospital, and 11.3% from private practice, 56.3% of the questions concerned a therapeutic strategy, 21% a diagnostic advice, and 22.6% concerned both diagnosis and therapy. Two third of the questions were answered within 10minutes. In 68.7% of cases, the ID specialist answered immediately, 19.8% of calls required following-up the patient, 6% led to refer the patient to an ID consultation, and 5.5% to hospitalization.

CONCLUSION

The survey results stress the important need for such ID expertise, both in hospitals and in ambulatory medicine. Collaboration of ID specialists in a regional network would allow an easy and permanent access to antibiotic therapy advice for prescribers. This network would improve the quality and safety of care.

[The referral of infectious diseases is a key activity for infectious diseases departments and units, as well as for the hospital]

Infectious diseases referrals (IDR) is a core activity of infectious diseases departments, and is certainly the one with the greatest potential impact on the hospital due to their cross-sectional nature, and with the emergence of a bacterial resistance and antimicrobial crisis. However, there is no standard model for IDR, no official training, and evaluation is merely descriptive. Paradoxically IDR are at risk in a health system that demands more quality and efficiency. The aim of this review is to assess what is known about IDR, its definition, key features, objectives, method, and the evaluation of results, and to suggest improvements to this key activity for the infectious diseases departments and the hospital.

Distinguishing malaria and influenza: early clinical features in controlled human experimental infection studies

During the H1N1 influenza pandemic (pH1N1/09) diagnostic algorithms were developed to guide antiviral provision. However febrile illnesses are notoriously difficult to distinguish clinically. Recent evidence highlights the importance of incorporating travel history into diagnostic algorithms to prevent the catastrophic misdiagnosis of life-threatening infections such as malaria.

We applied retrospectively the UK pH1N1/09 case definition to a unique cohort of healthy adult volunteers exposed to Plasmodium falciparum malaria or influenza to assess the predictive value of this case definition, and to explore the distinguishing clinical features of early phase infection with these pathogens under experimental conditions.

For influenza exposure the positive predictive value of the pH1N1/09 case definition was only 0.38 (95% CI: 0.06–0.60), with a negative predictive value of 0.27 (95% CI: 0.02–0.51). Interestingly, 8/11 symptomatic malaria-infected adults would have been inappropriately classified with influenza by the pH1N1/09 case definition, while 5/8 symptomatic influenza-exposed volunteers would have been classified without influenza (P = 0.18 Fisher's exact). Cough (P = 0.005) and nasal symptoms (P = 0.001) were the only clinical features that distinguished influenza-exposed from malaria-exposed volunteers.

An open mind regarding the clinical cause of undifferentiated febrile illness, particularly in the absence of upper respiratory tract symptoms, remains important even during influenza pandemic settings. These data support incorporating travel history into pandemic algorithms.

Requesting physicians' experiences regarding infectious disease consultations

BACKGROUND

Solicited consultations constitute a substantial workload for infectious disease (ID) specialists in the hospital setting. The objectives of this survey were to describe requesting physicians' experiences regarding ID consultations.

METHODS

A cross-sectional survey was conducted in a university-affiliated hospital in France in 2009. All physicians were eligible (n = 530) and received a self-administered questionnaire. The main outcomes were reasons for request and opinion. Secondary outcomes were frequency of request and declared adherence to recommendations.

RESULTS

The participation rate was 44.7% (237/530). Among the responders, 187 (79%) had solicited the ID consultation service within the previous year. Ninety-three percent of the responders (173/187) were satisfied with the ID consultation. The main reasons for requesting consultations were the need for therapeutic advice (93%), quality of care improvement (73%) and the rapidity of access (61%). ID consultations were requested several times a month by 52% (72/138) of senior physicians and by 73% (36/49) of residents (p = 0.01). Self-reported adherence to diagnostic and therapeutic recommendations was 83% and 79%, respectively.

CONCLUSION

The respondent requesting physicians expressed great satisfaction regarding ID consultations that they requested principally to improve patient care and to assist in medical decision making.

Compliance with recommendations and clinical outcomes for formal and informal infectious disease specialist consultations

The purpose of this study was to compare compliance with recommendations and clinical outcomes between formal and informal infectious disease specialist consultations. Six hundred twenty-seven consecutive adult inpatients who received an infectious disease consultation in a university-affiliated hospital were included. After adjusting for quintile of propensity score, we compared compliance with the consultant's recommendations and clinical outcomes for 443 (70.7%) and 184 (29.3%) formal and informal consultations. Informal and formal consultations were associated with comparable levels of compliance with recommendations for antimicrobial treatment (86.5% vs 88.9%; adjusted odds ratio [aOR], 0.63; 95% confidence interval, 0.34-1.14; P = 0.13) and diagnostic or monitoring tests (72.6% vs 72.0%; aOR, 0.91 [0.53-1.57]; P = 0.73). The rates of early clinical improvement (58.2% vs 58.6%; aOR, 1.11 [0.70-1.74]; P = 0.66), subsequent consultation (34.2% vs 36.3%; aOR, 0.80 [0.53-1.21]; P = 0.29), in-hospital mortality (4.9% vs 8.4%; aOR, 0.55 [0.24-1.24]; P = 0.15), and the median length of stay (23 vs 20 days; aOR of discharge, 0.90 [0.74-1.10]; P = 0.30) did not differ depending on the type of consultation. This study provides observational evidence that informal consultations result in levels of compliance with recommendations comparable to formal consultations, without compromising patient safety. Further study is needed to refine the criteria for requesting or providing informal rather than formal consultations.

[Curbside consultation: another healthcare activity of the infectious disease specialist]

INTRODUCTION

"Curbside consultation" is the term used to describe an informal process in which a physician requests information from another physician about the management of a patient who has not been assessed by the person consulted.

MATERIAL AND METHODS

Prospective, observational study designed to determine the frequency, services requested, and final result of curbside consultations made over the period of 3 March to 12 May 2008. The variables recorded included the means by which contact was made, the type of question, person requesting information, complexity of the subject, related subject, recommendations, and degree of follow-up and evolution of the consultation. The degree of difficulty was evaluated using the system of the American Collage of Physicians. Parametric and nonparametric statistical tests were used in the analysis.

RESULTS

A total of 208 consultations (1.13/day) were reported, lasting a median of 2 minutes. The most common reasons for consulting were selection of an antimicrobial agent (54.4%), evaluation of a diagnosis (10.5%), interpretation of microbiological data (9.6%), and a combination of reasons (27.4%). In 5.8% of cases, hospitalization was required to study and treat the infectious disease. A formal consultation was required in 27% of cases. Significant differences were found between staff physicians and medical residents and between medical and surgical departments.

CONCLUSIONS

Curbside consultations comprise an important part of healthcare activity in the Infectious Disease Department, although most requests are easily resolved and do not imply an excessive work burden. Nonetheless, when the consultation involves a difficult clinical case, the request is by a staff physician, and the surgery department is implicated, a significant amount of formal activity is generated.