The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit

Complexity of patients with or without infectious disease consultation in tertiary-care hospitals in Germany

PURPOSE

Patients seen by infectious disease (ID) specialists are more complex compared to patients treated by other subspecialities according to Tonelli et al. (2018). However, larger studies on the complexity of patients related to the involvement of ID consultation services are missing.

METHODS

Data of patients being treated in 2015 and 2019 in four different German university hospitals was retrospectively collected. Data were collected from the hospitals' software system and included whether the patients received an ID consultation as well as patient clinical complexity level (PCCL), case mix index (CMI) and length of stay (LOS) as a measurement for the patients' complexity. Furthermore, a comparison of patients with distinct infectious diseases treated with or without an ID consultation was initiated.

RESULTS

In total, 215.915 patients were included in the study, 3% (n = 6311) of those were seen by an ID consultant. Patients receiving ID consultations had a significantly (p < 0.05) higher PCCL (median 4 vs. 0), CMI (median 3,8 vs. 1,1) and deviation of the expected mean LOS (median 7 days vs. 0 days) than patients in the control group. No differences among hospitals or between years were observed. Comparing patients with distinct infectious diseases treated with or without an ID consultation, the differences were confirmed throughout the groups.

CONCLUSION

Patients receiving ID consultations are highly complex, frequently need further treatment after discharge and have a high economic impact. Thus, ID specialists should be clinically trained in a broad spectrum of diseases and treating these complex patients should be sufficiently remunerated.

Non-infectious diseases in infectious disease consultation: A descriptive study in a tertiary care teaching hospital

In this retrospective study, we aimed to investigate the frequency, trend, and nature of non-infectious diseases (non-IDs) as the final diagnosis for patients during an infectious disease (ID) consultation in an acute care hospital in Japan. This study included adult inpatients who underwent ID consultations between October 2016 and March 2018. The demographic data, clinical manifestations, and final non-ID diagnoses of cases were explored. Among the 502 patients who underwent ID consultations, 45 (9.0%) were diagnosed with non-IDs. The most common diagnoses were tumors (22.2%, n = 10), connective tissue and collagen vascular diseases (13.3%, n = 6), other inflammatory diseases (8.9%, n = 4), and drug-induced fever (8.9%, n = 4). Multiple logistic regression analysis showed that the presence of consultations for diagnosis (odds ratio [OR], 22.0; 95% confidence interval [CI], 10.1-48.2; p<0.01), consultations from the internal medicine department (OR, 2.5; 95% CI, 1.2-5.2; p = 0.02), and non-bacteremia cases (OR, 5.2; 95% CI, 1.4-19.3; p = 0.01) were independently associated with diagnosed non-IDs. Non-IDs after ID consultations were mainly tumor-related, inflammatory diseases, and drug fever. The presence of consultations for diagnosis, consultations from the internal medicine department and non-bacteremia cases were related to non-IDs among ID consultations. Further research is needed to explore the frequency and pattern of non-IDs to improve the quality of ID consultations in daily practice.

Infectious diseases consultations from general internal medicine physicians in Japan: A descriptive single-center study

In Japan, general internal medicine (GIM) physicians must be aware of frequently encountered infections because of the shortage of infectious disease (ID) specialists. However, there are currently no epidemiological data on this subject. This study aimed to describe the frequency and pattern of ID consultations requested by GIM physicians in Japan. This is a 3-year retrospective review of the ID consultations requested by GIM physicians in Japan at a community-based acute tertiary care teaching hospital in Tokyo from April 2018 to March 2021. Demographic data, such as reasons for consultation, causative organism, and final diagnoses, were collected. During the study period, ID consultations were requested by GIM physicians 128 times. The incidence rates of bacteremia and 30-day mortality were 65.6% (n = 84) and 3.1% (n = 4), respectively. The most common diagnostic classifications after ID consultation were bone/joint (24.2%, n = 31), respiratory (17.7%, n = 22), and cardiovascular infections (12.5%, n = 16). The most common final diagnoses were bacteremia (11.7%, n = 15), infective endocarditis (9.4%, n = 12), and vertebral osteomyelitis (7.8%, n = 10). This is the first study to describe the ID consultation cases requested by GIM physicians in Japan in a community-based acute tertiary care teaching hospital. Despite the shortage of ID specialists, GIM physicians covered a wide range of IDs, including bone/joint infections and infectious endocarditis, which require long-term care. ID and GIM physicians, including hospitalists, should cooperate to promote the quality of care and clinical management. Future multi-center studies with large numbers of clinical cases are needed to determine the ID clinical knowledge required by GIM physicians in Japan.

An evaluation of 1 year of advice calls to a tropical and infectious disease referral Centre

OBJECTIVES

Many secondary care departments receive external advice calls. However, systematic advice-call documentation is uncommon and evidence on call nature and burden infrequent. The Liverpool tropical and infectious disease unit (TIDU) provides specialist advice locally, regionally and nationally. We created and evaluated a recording system to document advice calls received by TIDU.

METHODS

An electronic advice-call recording system was created for TIDU specialist trainees to document complex, predominantly external calls. Fourteen months of advice calls were summarised, analysed and recommendations for other departments wishing to replicate this system made.

RESULTS

Five-hundred and ninety calls regarding 362 patients were documented. Median patient age was 44 years (interquartile range 29-56 years) and 56% were male. Sixty-nine per cent of patients discussed were referred from secondary healthcare, half from emergency or acute medicine departments; 43% of patients were returning travellers; 59% of returning travellers had undifferentiated fever, one-third of whom returned from sub-Saharan Africa; 32% of patients discussed were further reviewed at TIDU. Interim 6-month review showed good user acceptability of the system.

CONCLUSIONS

Implementing an advice-call recording system was feasible within TIDU. Call and follow-up burden was high with advice regarding fever in returned travellers predominating. Similar systems could improve clinical governance, patient care and service delivery in other secondary care departments.

Curbside Consults in Clinical Medicine: Empirical and Liability Challenges

In most U.S. jurisdictions, clinicians providing informal "curbside" consults are protected from medical malpractice liability due to the absence of a doctor-patient relationship. A recent Minnesota Supreme Court case, Warren v. Dinter, offers the opportunity to reassess whether the majority rule is truly serving the best interests of patients.

Pre-Coronavirus Disease 2019 Telehealth Practices Among Pediatric Infectious Diseases Specialists in the United States

BACKGROUND

Telehealth (TH) practices among pediatric infectious disease (PID) specialists prior to the coronavirus disease 2019 (COVID-19) pandemic are largely unknown.

METHODS

In 2019, the Pediatric Infectious Diseases Society (PIDS) Telehealth Working Group surveyed PIDS members to collect data on the use of TH modalities, adoption barriers, interest, extent of curbside consultations (CCs), and reimbursement.

RESULTS

Of 1213 PIDS members, 161 (13.3%) completed the survey, and the responses of 154 (12.7%) from the United States were included in our report. Medical school (63.6%) and hospital (44.8%) were the commonest work settings with 16.9% practicing in both of them. The most common TH modalities used were synchronous provider-patient virtual visits (20.8%) and synchronous provider-provider consultations (13.6%). TH services included outpatient consultations (48.1%), vaccine recommendations (43.5%), inpatient consultations (39.6%), and travel advice (39.6%). Barriers perceived by respondents included reimbursement (55.8%), lack of experience with TH (55.2%), lack of institutional support (52.6%), lack of administrative support (50%), and cost of implementation (48.7%). Most of the respondents (144, 93.5%) were interested in implementing a wide range of TH modalities. CCs accounted for 1-20 hours/week among 148 respondents.

CONCLUSIONS

Most of the PIDS survey respondents reported low utilization of TH and several perceived barriers to TH adoption before the COVID-19 pandemic. Nonetheless, they expressed a strong interest in adopting different TH modalities. They also reported spending considerable time on non-reimbursed CCs from within and outside their institutions. The results of this survey provide baseline information that will allow comparisons with post-COVID-19 changes in the adoption of TH in PID.

What Are We Really Talking About? An Organizing Framework for Types of Consultation and Their Implications for Physician Communication

Consultation amongst providers is a foundation of modern health care and one of the most frequent means of interdisciplinary communication. Accordingly, clear and efficient communication between providers and across medical specialties during consultation is essential to patient care and a collegial work environment. Traditionally, consultation requests are felt to require a clear question that falls within the purview of the consultant's expertise. However, this narrow constraint is often lacking in the real-world clinical environment and may in fact be detrimental to physician communication and patient care. In this Perspective, the authors propose an organizing framework of seven specific consultation types, which apply broadly across disciplines: ideal, obligatory, procedural, S.O.S., confirmatory, inappropriate, and curbside. The authors describe what factors define each type and the benefits and pitfalls of each. The proposed framework may help providers have more productive, efficient, and collegial conversations about patient care, which may facilitate improved work satisfaction and an enhanced learning environment.

Practices, organisation, and regulatory aspects in advising on antibiotic prescription: the international ESCMID AntibioLegalMap survey

PURPOSE

Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising.

METHODS

We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks.

RESULTS

Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices.

CONCLUSION

Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.

Infectious disease consultations in a Japanese tertiary care teaching hospital: a retrospective review of 508 cases

Objective

Limited epidemiological data are available at tertiary care teaching hospitals in Japan. We reviewed infectious disease (ID) consultations in a tertiary acute care teaching hospital in Japan.

Methods

This is a retrospective review of the ID consultations from October 2016 to December 2017. The demographic data, such as requesting department, consultation wards, and final diagnosis, were analyzed.

Results

There were 508 ID consultations during the 15-month study period. Among the 508 consultations, 201 cases (39.6%) were requested from the internal medicine department and 307 cases (60.4%) were requested from departments other than internal medicine. The most frequent requesting departments were Surgery (n = 102, 20.1%), Pulmonary Medicine (n = 41, 8.1%), and Plastic Surgery (n = 35, 6.7%). The most common diagnoses were intra-abdominal (n = 81, 16.0%), respiratory (n = 62, 12.2%), and skin and soft tissue infections (n = 59, 11.6%). ID consultations for disease diagnosis and management were more frequent in the internal medicine group than in the non-internal medicine group (37 cases, 20.8% vs. 40 cases, 13.7%, p = 0.046), and the number of requests for consultations for noninfectious diseases at the time of final diagnosis was higher in the internal medicine group than in the non-internal medicine group (21 cases, 11.8% vs. 16 cases, 5.5%, p = 0.0153).

Conclusion

Some physicians prefer ID specialists to identify and solve various medical problems. Internists had a greater tendency to request consultations for diagnostic problems, and noninfectious disease specialists have more requests for consultation at the point of final diagnosis. The role of ID specialists is expanding, from individual patient management to antibiotic stewardship, antibiotic prophylaxis, and development of and adherence to antibiotic protocol implementation based on the hospital’s microbial susceptibility and infection control. Although the number of specialists is limited in Japan, ID services now play an important role for achieving a good outcome in patient management.

Developing a decision support system for patients with severe infection conditions in pre-hospital care

OBJECTIVE

To develop and validate a pre-hospital decision support system (DSS) for the emergency medical services (EMS), enabling the identification and steering of patients with critical infectious conditions (i.e., severe respiratory tract infections, severe central nervous system (CNS) infections, and sepsis) to a specialized emergency department (ED) for infectious diseases.

METHODS

The development process involved four consecutive steps. The first step was gathering data from the electronic patient care record system (ePCR) on patients transported by the EMS, in order to identify retrospectively appropriate patient categories for steering. The second step was to let a group of medical experts give advice and suggestions for further development of the DSS. The third and fourth steps were the evaluation and validation, respectively, of the whole pre-hospital DSS in a pilot study.

RESULTS

A pre-hospital decision support tool (DST) was developed for three medical conditions: severe respiratory infection, severe CNS infection, and sepsis. The pilot study included 72 patients, of whom 60% were triaged to a highly specialized emergency department (ED-Spec) with an attending infectious disease physician (ID physician). The results demonstrated that the pre-hospital emergency nurses (PENs) adhered to the DST in 66 of 72 patient cases (91.6%). For those patients steered to the ED-Spec, the assessment made by PENs and the ID physician at the ED was concordant in 94% of cases.

CONCLUSIONS

The development of a specific DSS aiming to identify patients with three different severe infectious diseases appears to give accurate decision support to PENs when steering patients to the optimal level of care.

A Handshake From Antimicrobial Stewardship Opens Doors for Infectious Disease Consultations

Implementation of a unique in-person pediatric antimicrobial stewardship program was associated with a significant increase in infectious disease consultations at a quaternary care children's hospital. This study demonstrates that antimicrobial stewardship programs support, and do not compete with, infectious disease programs.

Pilot of integrated, colocated neurology in a primary care medical home

RATIONALE, AIMS, AND OBJECTIVES

Novel health care delivery models are needed to reduce health care use while delivering effective and safe care. We developed a model of a neurologist integrated and colocated in primary care leveraging "curbside," electronic, and traditional consultations. Our objective was to examine the impact on health care resource use of diagnostic testing and referrals for face-to-face neurological consultation and adverse outcomes associated with electronic and curbside consultations.

METHODS

Consecutive patients from December 1, 2014, to March 13, 2015, were included in the analysis about whom contact was made between a primary care clinician and a colocated neurologist.

RESULTS

Over 3.5 months of the pilot, 359 unique patients generated 429 consultations (179 curbsides, 68 electronic consultations, and 182 face-to-face visits). The integrated model resulted in avoidance of 78 face-to-face tertiary neurology consultations, 39 brain magnetic resonance imaging, 50 electromyograms, and 53 other advanced imaging studies. Earlier curbside consultation may have prevented unnecessary testing or face-to-face tertiary neurology consultations in 40 (22%) patients. Earlier face-to-face consultation may have avoided expensive testing in 31 (17%) patients. No cases met criteria for an adverse outcome. The number of referrals to tertiary neurology declined by 64%, and the total number of face-to-face visits per month declined by 25%.

CONCLUSION

Colocated neurology in a primary care medical home offers a promising intervention to deliver high-value care.

Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System

The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site providers. E-consults increased the breadth and volume of total consults.

The Association Between Geographic Density of Infectious Disease Physicians and Limb Preservation in Patients With Diabetic Foot Ulcers

Background

Avoiding major (above-ankle) amputation in patients with diabetic foot ulcers is best accomplished by multidisciplinary care teams with access to infectious disease specialists. However, access to infectious disease physicians is partially influenced by geography. We assessed the effect of living in a hospital referral region with a high geographic density of infectious disease physicians on major amputation for patients with diabetic foot ulcers. We studied geographic density, rather than infectious disease consultation, to capture both the direct and indirect (eg, informal consultation) effects of access to these providers on major amputation.

Methods

We used a national retrospective cohort of 56440 Medicare enrollees with incident diabetic foot ulcers. Cox proportional hazard models were used to assess the relationship between infectious disease physician density and major amputation, while controlling for patient demographics, comorbidities, and ulcer severity.

Results

Living in hospital referral regions with high geographic density of infectious disease physicians was associated with a reduced risk of major amputation after controlling for demographics, comorbidities, and ulcer severity (hazard ratio, .83; 95% confidence interval, .75–.91; P < .001). The relationship between the geographic density of infectious disease physicians and major amputation was not different based on ulcer severity and was maintained when adjusting for socioeconomic factors and modeling amputation-free survival.

Conclusions

Infectious disease physicians may play an important role in limb salvage. Future studies should explore whether improved access to infectious disease physicians results in fewer major amputations.

Infectious diseases consultations at an Australian tertiary hospital: a review of 11,511 inpatient consultations

BACKGROUND

Infectious diseases (ID) clinicians provide an important service within tertiary hospitals. However, as a largely consultation-based service, their value can be difficult to evaluate.

AIMS

A review of 13.5 years of consultations was undertaken to define the scope of the service and any changes over time.

METHODS

ID consultations at the Princess Alexandra Hospital are tracked on a database, recording information including the requesting team, indication for and outcome of the consult. Incident formal inpatient consultations between July 1999 and December 2012 were reviewed retrospectively. Phone consultations, repeat consultations and ID admissions were excluded.

RESULTS

Eleven thousand five hundred and eleven consultations were identified, with annual consultations increasing significantly during this period. Overall, formal consultations were performed on 1.3% of admissions. Consultations were most commonly requested by orthopaedics (14.3%) and general medicine (11.4%). The two most common syndromes triggering a consult were bloodstream infection (13.9%) and complicated soft tissue infection (7.8%). The final diagnosis was most frequently osteomyelitis (7.9%). Staphylococcus aureus (19.4%) and Pseudomonas aeruginosa (8.3%) were the most commonly identified pathogens.

CONCLUSION

The demand for ID consultations has increased over time and there are likely to be many drivers of this increase. Information derived from this audit can enhance the ID service by guiding service delivery, trainee education and informing funding or accreditation applications.

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.

The impact of infectious disease specialists on antibiotic prescribing in hospitals

Given the current bacterial resistance crisis, antimicrobial stewardship programmes are of the utmost importance. We present a narrative review of the impact of infectious disease specialists (IDSs) on the quality and quantity of antibiotic use in acute-care hospitals, and discuss the main factors that could limit the efficacy of IDS recommendations. A total of 31 studies were included in this review, with a wide range of infections, hospital settings, and types of antibiotic prescription. Seven of 31 studies were randomized controlled trials, before/after controlled studies, or before/after uncontrolled studies with interrupted time-series analysis. In almost all studies, IDS intervention was associated with a significant improvement in the appropriateness of antibiotic prescribing as compared with prescriptions without any IDS input, and with decreased antibiotic consumption. Variability in the antibiotic prescribing practices of IDSs, informal (curbside) consultations and the involvement of junior IDSs are among the factors that could have an impact on the efficacy of IDS recommendations and on compliance rates, and deserve further investigation. We also discuss possible drawbacks of IDSs in acute-care hospitals that are rarely reported in the published literature. Overall, IDSs are valuable to antimicrobial stewardship programmes in hospitals, but their impact depends on many human and organizational factors.

Value and process of curbside consultations in clinical practice: a grounded theory study

OBJECTIVES

To clarify the value and process of the curbside consultation and identify ways to optimize this activity.

PARTICIPANTS AND METHODS

We conducted 13 focus groups at an academic medical center and outlying community sites (September 2011 to January 2013), involving a purposive sample of 54 primary care and subspecialist internal medicine and family medicine physicians. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify benefits, liabilities, mechanisms, and potential improvements related to curbside consultations.

RESULTS

We developed a model describing the role and process of the curbside consultation. Focus group participants perceived that curbside consultations add particular value in offering immediate, individualized answers with bidirectional information exchange, and this in turn expedites patient care and elevates patient confidence. Despite the uncompensated interruption and potential risks, experts provide curbside consultations because they appreciate the honor of being asked and the opportunity to help colleagues, expedite patient care, and teach. Key decisions for the initiator (each reflecting a potential barrier) include whom to contact, how to contact that expert, and how to determine availability. Experts decide to accept a request on the basis of personal expertise, physical location, and capacity to commit time and attention. Participants suggested systems-level improvements to facilitate expert selection, clarify expert availability, enhance access to clinical information, and acknowledge the expert's effort.

CONCLUSIONS

Curbside consultations play an important role in enhancing communication and care coordination in clinical medicine, but the process can be further improved. Information technology solutions may play a key role.

Informal consultation at a teaching hospital infectious diseases department

INTRODUCTION

Informal consultations for advice in the infectious diseases department (IDD) induce a significant workload for physicians. Our aim was to retrospectively quantify and describe this activity in our institution.

METHOD

The data was obtained from files documented and faxed by physicians from October 2009 to May 2012. One thousand nine hundred and seventy-two files were included. The file was faxed to the IDD specialist, analyzed, then a telephone conversation allowed making precisions, and the documented form was faxed back.

RESULTS

The requests for advice concerned 39% of female and 61% of male patients with a mean age of 64±21 years. Twenty-nine percent of requests came from surgical departments and 71% from medical departments (P<0.01). The departments most frequently concerned were cardiology (10%), gastro-enterology (10%) and cardiovascular surgery (9.7%). The most frequent infections were urogenital (19%), osteoarticular (14%), and cardiovascular (11%). Forty-nine percent were considered as nosocomial and 25.3% were bacteremic. The requests concerned diagnostic aid in 16.2% of cases and therapeutic issues in 95.6%. The IDD specialist made therapeutic recommendation in 96.5% of cases and gave diagnostic advice in 43.7%. Treatment modification was suggested in 38.5% of cases. Twenty-two percent of consultations required a second one.

CONCLUSION

This study documented the importance of antibiotic changes among medical and surgical units, the increasing need of these units to be helped, and also the complexity of the medical cases, all requiring the advice of an ID specialist. Our fax-phone-fax procedure seems to prevent the bias associated with informal consultations by phone, which is the most commonly used in other institutions.

The impact of infectious diseases consultation on oncology practice

PURPOSE OF REVIEW

Traditional utilization of infectious diseases consultants by oncologists ranges from inpatient management of a variety of acute infectious syndromes to management of ambulatory patients with acute or chronic infections; however, there is a paucity of data to evaluate in which circumstances the impact of infectious diseases input may be most valuable.

RECENT FINDINGS

Data derived from the general population of patients emphasize the value of infectious diseases consultation in specific infections, such as Staphylococcus aureus bacteremia, candidemia, and hepatitis C virus infection. In addition, infectious diseases involvement has been associated with greater adherence to guidelines (up to 34% increase), more appropriate antibiotic utilization (up to 52% increase in appropriate duration), decreased cost and complications of care, and lower mortality (up to 17% decrease). Recent studies suggest that bedside, formal infectious diseases consultation is more optimal than informal interactions (e.g., e-mail, telephone, other). Furthermore, infectious diseases consultants play central roles in antibiotic stewardship, infection control, and quality improvement, particularly in oncology centers.

SUMMARY

Infectious diseases consultants contribute value in various inpatient and outpatient infections, decreasing mortality, cost, and complications.

[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.

Antimicrobial Stewardship Through Telemedicine in a Community Hospital in Southern Brazil

We developed an antimicrobial stewardship programme, based on telemedicine, for a remote community hospital in southern Brazil. Expertise in infectious diseases was provided from a 250-bed tertiary hospital for cardiology patients located 575 km away. At the community hospital, antimicrobial prescriptions were completed via a secure web site. A written reply was sent back to the prescriber by email and SMS text message. During a 4-month study period there were 81 prescriptions for 76 patients. Most antimicrobial prescriptions (67%) were for respiratory infections. Ampicillin was prescribed in 44% of cases ( n = 56), gentamicin in 18% of cases ( n = 23) and azithromycin in 18% of cases ( n = 23). Two infectious diseases specialists independently reviewed each antimicrobial prescription. A total of 41 prescriptions (55%) were considered inappropriate. The median time to obtain a second opinion via the web site was 22 min (interquartile range 12–55). Overall compliance with the recommendations of the infectious diseases specialist was 100% (81 out of 81 requests). Telemedicine appears to have a useful potential role in antimicrobial stewardship programmes.

Prospective comparison of curbside versus formal consultations

BACKGROUND

Curbside consultations are commonly requested during the care of hospitalized patients, but physicians perceive that the recommendations provided may be based on inaccurate or incomplete information.

OBJECTIVE

To compare the accuracy and completeness of the information received from providers requesting a curbside consultation of hospitalists with that obtained in a formal consultation on the same patients, and to examine whether the recommendations offered in the 2 consultations differed.

DESIGN

Prospective cohort.

SETTING

University-affiliated, urban safety net hospital.

MAIN OUTCOME MEASURES

Proportion of curbside consultations with inaccurate or incomplete information; frequency with which recommendations in the formal consultation differed from those in the curbside consultation.

RESULTS

Curbside consultations were requested for 50 patients, 47 of which were also evaluated in a formal consultation performed on the same day by a hospitalist other than the one performing the curbside consultation. Based on information collected in the formal consultation, information was either inaccurate or incomplete in 24/47 (51%) of the curbside consultations. Management advice after formal consultation differed from that given in the curbside consultation for 28/47 patients (60%). When inaccurate or incomplete information was received, the advice provided in the formal versus the curbside consultation differed in 22/24 patients (92%, P < 0.0001).

CONCLUSIONS

Information presented during inpatient curbside consultations of hospitalists is often inaccurate or incomplete, and this often results in inaccurate management advice.

Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus Bacteremia

BACKGROUND

Infectious disease specialist (IDS) consultation improves the outcome of Staphylococcus aureus bacteremia (SAB). Although telephone consultations constitute a substantial part of IDS consultations, their impact on treatment outcome lacks evaluation.

METHODS

We retrospectively followed 342 SAB episodes with 90-day follow-up, excluding 5 methicillin-resistant S. aureus SAB cases. Patients were grouped according to bedside, telephone, or no IDS consultation within the first week. Patients with fatal outcome within 3 days after onset of SAB were excluded to allow for the possibility of death occurring before IDS consultation.

RESULTS

Seventy-two percent of patients received bedside, 18% telephone, and 10% no IDS consultation. Patients with bedside consultation were less often treated in an intensive care unit during the first 3 days compared to those with telephone consultation (odds ratio [OR], 0.53; 95% confidence interval [CI], .29-.97; P = .037; 21% vs 34%), with no other initial differences between these groups. Patients with bedside consultation more often had deep infection foci localized as compared to patients with telephone consultation (OR, 3.11; 95% CI, 1.74-5.57; P < .0001; 78% vs 53%). Patients with bedside consultation had lower mortality than patients with telephone consultation at 7 days (OR, 0.09; 95% CI, .02-.49; P = .001; 1% vs 8%), at 28 days (OR, 0.27; 95% CI, .11-.65; P = .002; 5% vs 16%) and at 90 days (OR, 0.25; 95% CI, .13-.51; P < .0001; 9% vs 29%). Considering all prognostic markers, 90-day mortality for telephone-consultation patients was higher (OR, 2.31; CI, 95% 1.22-4.38; P = .01) as compared to bedside consultation.

CONCLUSIONS

Telephone IDS consultation is inferior to bedside IDS consultation.

Infectious Disease Consultation for Staphylococcus aureus Bacteremia Improves Patient Management and Outcomes

BACKGROUND: Staphylococcus aureus bacteremia (SAB) is a common, severe infectious disease with accepted standards of care. METHODS: A retrospective cohort study of all 233 SAB cases at the Minneapolis Veterans Affairs Medical Center (MVAMC) between October 2004 and February 2008 was performed to measure the impact of Infectious Disease (ID) consultation on conformance to standards and patient outcomes. Outcomes were classified as survived without relapse, relapsed, or died without relapse. ID involvement was classified as consultation, curbside, or no involvement. RESULTS: ID involvement occurred in 179/233 cases (77%). Management conformed to accepted standards in 162/197 cases (82%) evaluable for conformance. ID involvement was associated with increased conformance in univariable analysis and multivariable analysis adjusted for propensity for ID consultation (OR 5.9, 95% CI 2.5 - 13.8). Relapse occurred in 14/156 cases (9%) in which therapy conformed to standards compared with 8/35 cases (23%) in which therapy did not conform to standards (p=0.045). Relapse was more common in older patients (OR 1.05, CI 1.01-1.09) and in cases without ID involvement (OR 3.02, CI 1.003-9.1). Death was associated with greater Charlson Index scores (OR 1.89, CI 1.4-2.5). Of 111 cases with definitely or possibly infected devices, relapse occurred in 9/92 cases (9.8%) in which the device was wholly or partially removed compared with 6/19 cases (32%) in which the device was left in place (p=0.02). CONCLUSIONS: ID involvement in SAB cases was associated with increased adherence to accepted standards and fewer relapses. ID consultation should be performed for all SAB cases.

Curbside Consultations in Pediatric Infectious Diseases

The Pediatric ID Consultant section provides brief reviews of topics relevant to the day-to-day practice of pediatric infectious diseases. The reviews are placed in context by a short vignette, followed by one or more questions which are addressed. Pediatric infectious diseases physicians are often asked by medical colleagues to provide recommendations for management of a patient without the benefit of a formal consultation. This article relates a story exemplifying such a request and discusses the possible quality of care, medical liability, and financial implications of informal consultations.