Orthopedic – Medicine CoManagement
The Division of Hospital Medicine offers a special “Co-Management”
Medical Consult option to the Orthopedic service. In this model, the
hospitalist medical consultant actually functions as another attending of
record for the patient. Our goal is to provide the same quality of medical
care these patients would receive on a medical service.
Comanagement originally evolved in part to decrease the number of patients
with routine hip fractures admitted to the Medical Ward Service. Medical
Consult housestaff and faculty caring for these patients should thus
understand: we “own” these patients’ medical issues, as if they were in fact
on our own service. Practically speaking, the major difference between this
and the usual consult model is that we write orders, we are available to
nursing for any acute medical issues that arise, and we dictate a brief
addendum to the discharge summary. In addition we do not sign off on
patients unless their stay is held up for non-medical reasons.
Responsibilities of Medical Team
- Daily progress notes
- Writing orders on any recommendations made in note
Note that Ortho is responsible for pain control, NPO orders pre-op, DVT
prophylaxis, physical therapy orders.
- Following up on results of any tests we order
- Availability to nursing for any acute medical issues that arise
By day the Medical Consult resident is available. At night it is the hospital
medicine NP.
-
Put all co-managed patients on a signout sheet (code MEDCS) .
It is expected that at night the Orthopedics resident can take first call for
routine medical problems, HM NP thereafter.
- Review of discharge paperwork including medication list
- Writing addendum to discharge summary or putting this info into PDI
Since this is not the true transfer summary it can be as short as 3 lines, eg
“Postop blood sugars were high so we increased pt’s Metformin, this needs to
be followed at rehab.”
- Run list with Ortho resident #2663 or NP daily at 8:15AM on 4th floor
back nursing station. They know to page #8888.
On wkends either Consult attd or MC res/Triage should touch base with Ortho
oncall resident #2663.
- On Friday afternoon, meet with Ortho NP to go over all PDIs on any
anticipated wkend discharges.
Transition of Care
- As a general principle we follow all patients until discharge.
If the patient is truly medically stable and their discharge is held up for nonmedical reasons – eg no rehab bed available – then as a courtesy we discuss the
case with the Ortho team before we sign off.
- We accept transfers of patients to the medical service if active medical
issues are the only reason for ongoing hospitalization.
We do ask that Ortho wait a reasonable period of time (24 – 48 hours) as some
medical issues can be resolved in this time frame. We also ask that when
Orthopedics signs off, a transfer summary will be dictated up to that date.
- Occasionally a medically complex patient warrants initial admission to
Medicine with Orthopedics consulting. A general guideline is that if the
patient’s medical issue is active enough to consider Medical admission
irrespective of their Ortho issue, these pts are best served under a Medicine
attending with a housestaff ward team involved.
An example of a patient better served admitting directly to a Medical team
would be someone with end-stage liver disease & encephalopathy or tense
ascites on presentation. An example of a patient not appropriate to admit to a
Medical team would be a patient who needs rehab for an Ortho reason such as
neck fracture with new Halo placed.
If disagreements do arise regarding need for admission or transfer to the
Medical service rather than Co-Management, these will best be solved by
attendings contacting one another directly.
Important Access numbers
# 8888 Medical Consult resident, Mon – Fri 7:30 – 5:00
# 8884 Medical Consult Attending, daily 7:30AM – 7:30PM
# 1122 Medical Triage/Admitting resident, available evenings and weekends
# 1574 Night Hospital Medicine NP
# 2663 (#BONE) Orthopedics on-call resident
# 0479 Claudine Arsenis Ortho NP. To text use long-range (508)713-1161
Any questions regarding Orthopedics Co-Management should be directed to
either Dr Majid Yazdani or Dr. Christine Donahue.