UW Consults
What to expect:
Daily schedule: 8am-5pm Mon-Fri. Rounds typically occur early afternoon.
Team: 1 attending, 1 fellow, 0-2 medical students
Attending is usually a general cardiologist on staff but may also be an interventional, EP, or ACHD faculty member. Attendings rotate every 2 weeks.
Occasionally, medicine residents may also be on service
Home base: Cardiology Consult Room BB-504, code 77-513
Objective: Perform inpatient general cardiology consults and routine DC cardioversions. See responsibilities as outlined below.
Census: Usually 5-10 patients. Average 1-5 new consults daily.
Responsibilities:
1. Cardiology consults from inpatient services or the ED (or rarely, urgent outpatient or PACU consults)
Your job is to take all the consult calls and evaluate them in a timely manner and provide recommendations to the primary service. If the call starts with "we would like a consult " then the default is to do a consult. This is real world practice.
“Curbsiding” consults results in pushing work to your co-fellows and can cause a delay in patient care.
You may answer simple interpretative questions (what is this rhythm on this ECG, how do I convert IV to PO diltiazem) without performing a full consult.
If a question involves clinical management, or the patient is hemodynamic unstable and subsequent questions are likely to follow, you should see the patient and do a formal consult.
The ED will frequently call for a “consult” that is actually an admission. Contact the appropriate service (Card A/B/C/D/CCU). Sometimes, this may not be clear and work it out with the Card A/B/CCU/MCS fellow on who should come see and triage the patient.
There is a medicine consult service that can perform routine pre-op cardiac risk assessment and some post-op management, except in complex cases, and may consult you on behalf of a surgical service if they need help.
Answer some basic questions from outpatient providers (EKG interpretation, what kind of stress test to order, etc.).
Perform consults for simple rhythm disturbances (eg. afib/flutter), which are unlikely to require EP procedures. For instance, non-cardiology services will often ask a consult for a pacemaker that is usually not warranted. However, if it’s a complex question that likely requires an EP attending’s opinion (eg. heart block post-TAVR), it should be handled by the EP service.
ACHD has its own separate consult service for adult congenital heart disease patients, including those with peri-partum cardiomyopathy. In some cases (eg. remote hx of ASD closure), it may be appropriate for general consults. Ask the ACHD consult attending if you are not sure.
If a post-transplant patient is admitted to a non-cardiology service, the transplant/MCS consult service can help manage immunosuppressant therapy, etc.
Help primary teams arrange for any cardiac procedures you are recommending (cath, TEE, etc.) by ideally speaking directly to the cath or echo fellow performing the procedure.
Make sure patients have appropriate cardiology follow-up.
2. Help facilitate transfers to and from cardiology services when appropriate.
Discuss with your attending and the primary team if you feel the patient’s issues are primarily cardiac, and they are best served on a cardiology service (usually CCU or Card A). If so, discuss the case with the accepting team’s attending.
Cardiology services may also sign out to you patients being transferred to a non-cardiology service.
3. Perform routine DC cardioversions on patients without an ICD or pacemaker.
Check the daily cardioversion schedule on ORCA (under HOV-E/PROC, choose the resource “U Card Cardioversion”) and figure out which ones you will be responsible for (those without devices; the EP fellow does cardioversions for patients with devices).
Verify that the scheduled cardioversion is appropriate and that there are no contraindications (NPO status, INR therapeutic, whether or not a TEE is needed).
Make sure your attending is aware of any cardioversions for the day. If they are unavailable, it is their responsibility to find another attending to staff the procedure.
Contact Betsy Davidson (EP scheduler, 8-2441) with any changes or new cardioversions you would like to add on for the day. Ask the primary team to place the cardioversion order using the ORCA or EPIC cardioversion order set.
Write cardioversion orders in ORCA (use the "peri-procedural" powerplan) for outpatients when they arrive in ICRU.
Consent patients for the procedure, ideally prior to their arrival in the PACU.
Write the procedural note in ORCA. Don’t forget to leave recommendations on anticoagulation, especially for patients on non-cardiology services.
If you are unavailable for a cardioversion, your back-up is the EP Fellow, then the Echo fellow, then the ACHD fellow
4. Teach any medical students or residents on the service.
It may be worth spending some time with the medical students at the beginning of their rotation reviewing how to perform a good cardiology consult, including how to gather pertinent data, what information is important, keys to a thorough cardiac review of systems.
Do not have medical students triage consults for you. In addition to learning cardiology from you, their role is to practice taking H&P’s, formulate an assessment and plan with your help, and present to the attending on rounds.
You could have medical students also spend some time in cardiology clinic shadowing your attending (if they are okay with this) or in the echo lab watching stress tests, etc., especially on patients that they are following.
5. Ensure proper handoffs.
Communicate your recommendations clearly to the consulting service with a phone call or in person.
Sign out your consult list to the Card A fellow for the weekend, also noting which patients to see and what to follow-up on.
Although painful, it is extremely helpful to leave detailed notes on Fridays and over weekends. This is how you build trust with your co-fellows, faculty, and other medical/surgical services.
Card A fellow on call for the weekend is responsible for all new consults during the daytime (8-5pm) on Saturday and Sunday, not just “urgent” consults, and staffed by the Card A attending. Do not push consults to the next business day, which just delays patient care.
Pick up sign-out from the Card A fellow on Monday morning.
During the week, the procedure call fellow or the Card A fellow should sign out to you any new overnight consults.
Card A fellow on call is responsible for new consults from 5pm to 8pm on weekdays
Procedure fellow on call is responsible for new consults from 8pm to 8am on weekdays
If your consult patient has an outpatient cardiologist at UWMC/HMC, they would appreciate an update on their patient (via email or copy your consult note to them) and a follow-up plan.
CARDIOVERSION CHECKLIST:
Housekeeping: (For details, refer to paper order set)
[ ] Make patient NPO (including tube feeds) 6hours prior to procedure
[ ] Make sure anticoagulation plan in place
Cardioversion without TEE
If on warfarin, therapeutic INR weekly x 4 weeks
If on NOAC, uninterrupted 4 weeks of therapy
Scheduling:
[ ] Place order for cardioversion
Include indication, presence of device, anticoagulation, ICU vs Floor status
[ ] Call scheduling PCC at 82441
PCC coordinates with Echo, PACU, & Anesthesia
If unreachable, discuss with appropriate fellow (ie Weekends)
[ ] If needed, call appropriate Fellow
Pacemaker or defibrillator: EP fellow
If not: Consult fellow
If TEE is needed: Echo fellow
For questions, issue or suggestions please e-mail:
Jill Steiner: jills8@uw.edu
James Lee: jamchlee@uw.edu
Tips:
Your clinic days can be busy. Work it out with the EP consult fellow whether you’d like to cover each other’s pagers during continuity clinic.
If you are inundated with consults and cardioversions, the EP or ACHD consult fellows may be available for backup.
Touch base early in the day with your consult attending to figure out their availability for rounds.
Keep your consult notes focused on the consult question and the cardiology problems. It can be easy to get lost in jargon and a thick patient chart.
Write your consult notes to your audience. Depending on the consulting service, you may have to be more explicit on your recommendations.
Remember that a consult is a cry for help and that we are providing a service, however basic it may seem, for patient care.
It can be very helpful to access outside records on Care Everywhere on Epic, or ask the primary team to obtain any outside studies you need to do a thoughtful consult.
Sign off on patients you no longer need to actively follow. However, be sure to let the primary team know that you are signing off so they know to call you if questions arise.
Always include the elements of a full H&P and name of the consulting provider on your initial consult note. Forward all notes to your attending for co-signature.
Resources: