UCSF atology Inpatient Consultation Service Guidelines for Res B Wards (Res Bw) PEDIATRIC DERMATOLOGY Ilona Frieden, MD Kelly Cordoro, MD, MD Fellows Pristine Lee, MD Barrett Zlotoff, MD Resident and Conference Schedule while on atology (Res Bw) M T W Th F Inpatient / Inpatient Rounds Ward Consults or Academic Time 8:00-10:00 Staff Conference 10:00-12:00 Renee Howard/ Pedi Fellows (Please check in after resident teaching) Ward Consults or Academic Time 8:00-12:00 Vascular Anomalies Ilona Frieden Kelly Cordoro Ilona Frieden Kelly Cordoro Ilona Frieden Renee Howard Kelly Cordoro, Fellow Continuity Kelly Cordoro
I. Goals of the Service The goal of the pediatric dermatology inpatient consultation service is to provide timely, outstanding pediatric inpatient patient care. The primary educational goals are to educate dermatology residents and fellows, as well as consulting teams, about the care of dermatologic conditions in inpatient pediatric patients aged 0-12 years. II: Structure of the Service The Res B Ward resident (Res Bw) will be the primary point of contact for all pediatric inpatient consultations for children aged 12 and under. Res Bw will work very closely with the on-call pediatric dermatology fellow on each consultation. Res Bw will be excused from outpatient clinics to see new consults and follow-ups if insufficient time to see these during designated times (Monday AM, Tuesday, Thursday AM). At other times, if there are no active inpatients or new consults to be seen, the Res Bw will participate in the outpatient PD clinics at MZ. Because the fellows are based at MZ on the outpatient pediatric service with clinics every day but Tuesday including Monday afternoon, Wednesday all day, Thursday PM and Friday all day, Res Bw communication with the fellow by text page or phone call is essential. It is expected that each new pediatric consultation is communicated within 2 hours of receipt to the PD fellow on call, allowing the fellow to triage and plan regarding each consultation. If the consultation is urgent, the fellow should be paged immediately. The fellow will discuss each case with the PD attending and determine the timing of staffing the patient, whether later that day, the next, or at the regularly scheduled times for rounding (see below). Guidelines for seeing pediatric inpatient consults: o Pediatric consults that are requested by 3:00 PM will be seen by Res Bw on the same day. o After 3:00 PM, unless urgent (as determined by requesting service and discussion with fellow/attending) the patient can be seen the next day. o On the weekends, the service is covered by the weekend coverage resident. All urgent consults are seen the same day. Non-urgent consults can be seen the following day. o Calls from Pediatric urgent care and the ER should be discussed with the fellow to determine appropriate triage.
III. Procedures All procedures other than KOH, scabies and DFA preps and bacterial and viral cultures should be discussed with the fellow prior to performing. Part of the educational value of the pediatric service is to acquire the skills to, and learn the art of, performing procedures such as biopsies in neonates, infants and children who may in some cases involve coordination of care with the pediatric team to administer conscious sedation for such a procedure. Based on Res Bw level and experience and the age of the child, biopsies may be authorized to be performed without the direct on-site supervision of a fellow or attending. Consent for diagnostic biopsies and other invasive procedures (I&D, etc.) should be obtained from the caregiver by Res Bw in advance of the specified rounding times such that the procedure can be performed with the fellow or attending present when feasible. The pediatric consult service is often asked to perform biopsies on children while they are under general anesthesia for other procedures. Any such requests should be discussed with a PD fellow or attending. Ability to do this will depend on whether staffing coverage is sufficient to allow for accommodation of the specific request. For requests to provide technical services i.e. a patient has no skin disease and the primary team wants a biopsy to send for outside testing, Res Bw should arrange to perform the biopsy at a convenient time, but is NOT responsible for finding the correct medium, doing paperwork, sending it off, etc. The biopsy should be performed with the primary team intern or resident at the bedside and the specimen given to them for immediate processing. The primary team should arrange all other aspects of care including consent and suture removal. You do not need to write a consult note, only a brief procedure note. IV. Use of Digital Images and Photo Documentation The use of photographic images is important for timely patient care and learning opportunities. or fellows may request photographs of a case when clinical responsibilities do not allow their immediate presence on the wards. The images may be used for diagnosis and management when appropriate or for triage of personnel to the hospital when necessary with follow-up at regular times for rounding. Images may also be utilized by the attendings to identify appropriate locations for biopsies if the timing is urgent and the attendings/fellows are in clinic. A separate digital camera will be given to Res Bw for the purpose of photographing consult cases. It is their responsibility to keep this camera in a safe place and return it to Chris Walker at the end of the rotation. Digital images should be obtained of any consult cases where skin lesions are sufficiently visible to allow photography, for the purposes of documentation, serial evaluation if necessary, and for immediate use in some circumstances as outlined above. All digital images should also be filed in UCare in the T drive: Dermatology/atology by month. A photo book is part of the atology Call Bag. Either a sticker or the following information should be entered in the book including last name, first name, Med record number, DOB, diagnosis.
On a weekly basis Wednesday is best - the SD photo card should be given to Chris Walker for downloading onto the pediatric dermatology G drive. She can recharge battery at that time. V. Chart Documentation and Service Expectations The service will provide thorough and detailed initial consultations, close follow-up until active cutaneous issues are stabilized or resolved, and timely sign off. Initial consultations should be fully investigated with a review of the birth history, hospital course, PMH, FH, SH, full ROS, allergies, medications, and relevant laboratory and radiographic results. Whenever feasible, a complete physical exam is performed on every patient, including scalp, trunk, extremities, palms, soles, hair, teeth nails, lips, conjunctivae, oral mucosa, genitalia, anus and peri-anal skin, etc. Lesions (if individual, i.e. not a rash) should be precisely measured and documented. Each consultation should be documented with a full initial H&P in the chart on the day the patient is evaluated. However, Res Bw or other covering resident should not document the assessment and recommendations in the permanent medical record until the patient is reviewed with a PD fellow and/or attending via photos or in person. Follow up notes may be concise and include only significant changes in status, physical exam, new data such as biopsy and culture results and other information/discussions that will impact patient care, and new treatment recommendations. When you see patients with an attending please post the notes in UCare by selecting the following options: Add a note, Pediatrics Note, Note type: C-DERM (Consult Dermatology). Enter your name as the Provider and the attending s name (Frieden, Cordoro, or Mathes) as the Signing Provider. Your note will appear in the attending s inbox for them to edit and sign. When you see patients without the attending (by yourself or with the fellow), post the note by selecting the following options: Add a note, Consults A-M, Dermatology Consult. Your name will automatically be entered as the provider and signing provider. The fellows and attendings will determine the frequency with which semi-active patients need to be seen and when we will sign off as a service. (Example: we follow many kids through BMT, PBSCT, but those patients may only need periodic examinations, typically 3x/week if there are no or only minor cutaneous issues). Even if not actively following with exams and notes daily, Res Bw is expected to keep up to date on all active and semi-active patients via UC Care including data such as daily progress, input from other consultants, results of labs and procedures, etc. for daily discussion with (or on rounds per schedule below) the fellow and/or attending. The pediatric dermatology inpatient service mission control white board is mounted in the PD derm fellow office at MZ. It is the responsibility of the Res Bw to update the board regularly and review with the on-call fellow. Pediatric dermatology patients often have complex developmental or genetic anomalies that require our expertise in diagnosing. Searches of PUBMED and
OMIM are expected when relevant, and knowledge and experience with this type of literature searching is expected as an educational aspect of the service. Going to the literature: Res Bw will have 3 half days without outpatient clinic responsibilities for their inpatient work. The resident is expected to read relevant medical literature re: patients being seen as inpatients in order to support the differential diagnosis, recommended evaluation, and management of these patients. When appropriate, patients should leave the hospital with a follow-up appointment scheduled prior to hospital discharge. When possible, follow-up in fellow continuity clinic should be arranged with the help of the fellow. For scheduling of inpatients for outpatient follow-up, please check with fellow for disposition or call Carol Uharriet: 353-7803 In accordance with the Department of Dermatology s commitment to adhering to an 80 hour work week and 10 hours off between work shifts, the Res Bw work should be completed by 9:30 PM on Monday night and 10 PM on Tuesday through Thursday nights. The resident may not stay in the hospital after these hours; the only exceptions are emergency consults. UCare notes may be written at home; the hours spent at home writing notes do not count as work hours. VI. Structured Rounding Times Res Bw will round at the minimum with the PD dermatology attending once weekly and the PD fellow once weekly. Additional fellow and/or attending rounding times will be added on an as-needed basis. When Dr. Frieden is on call, teaching rounds with Res Bw and the on-call fellow will typically be on Mondays or Thursdays at 9:30 AM. Res Bw will round with the PD fellow on Monday AM. When Dr. Cordoro is on call, teaching rounds with Res Bw and the on-call fellow will be on Mondays at 9:30AM. Res Bw will round with the PD fellow on Thursday AM. When Dr. Mathes is on call, teaching rounds with Res Bw and the on-call fellow will typically be on Mondays or Thursdays at 9:30 AM. Res Bw will round with the PD fellow on Monday AM. Rounding times may vary slightly based on travel schedules, holidays and ASC laser times VII. Documentation of Pediatric Consultations Res Bw is responsible for keeping an updated electronic sign-out (similar to the adult inpatient service) which they provide to the on-call fellow/attending on a regular basis. They should have 2 copies of the sign-out printed out for structured rounds. Each month, Res Bw should maintain a running list of each pediatric consultation separate from the adult service list. This will include the patient s name, MRN, age, reason for consult, biopsy and results if done, and final dermatologic diagnosis. This should be maintained digitally and provided to the pediatric derm on-call fellow at the end of the month for archive on the PedDerm Shared drive.
VIII. Curbside Consult Policies Phone requests for urgent outpatient appointments should be referred to Louise Crotwell or if she is not available to a pediatric dermatology fellow. Phone requests by a primary team for treatment options for a known disorder is ok without doing a formal consult as a professional courtesy, but residents should only answer within their own comfort level of knowledge. All other queries or if calls from one physician or site are unusually frequent should be referred to one of the fellows and attendings. If the primary team calls with a question and the diagnosis is not certain, a formal consultation should be requested or an outpatient visit arranged if not urgent. If the team is rounding and asked to take a look to confirm a suspected diagnosis and this requires more than a look (or it requires a history), a formal consultation is required and should be requested.