General Consult Service
The General Neurology Consult service is responsible for consultations throughout the hospital and STC for patients with a neurological question or diagnosis that is not vascular in nature (e.g., seizure, headache, multiple sclerosis, neuromuscular weakness, etc). Consultations for management of status epilepticus (confirmed NCSE or Convulsive SE with AED drips involved), cerebral edema management, post-arrest cooling or prognosis are typically handled by the NeuroCritical Care Consult Service (8-4083) during the day, and by the Neurology Call resident on nights and weekends.
If the patient is appropriate for admission to neurology, the consult team will admit the patient and present to the General Inpatient team.
Day 1 (for the PGY-2)
Touch base with the consults senior about specific consults they want you to take over. Chart review these patients before you come in on your first day.
Arrive by 7:00AM to the resident library. Chart review any updates (major clinical changes, whether our recommendations were enacted) on your patients and pre-round on them.
Be ready by 8:15AM to present updates on follow-ups to the attending in a SOAP format.
After attending rounds, you will write brief update notes on the old consults, communicate with teams, and see any new consults that come in. Usually the team will round again in the afternoon.
Team Structure
Consult Attending
Ultimately responsible for the care of all patients on the service
Present for rounds (at 08:15AM) and available all day for any patient care issues
Usually on service in 7-day periods, starting on Fridays. Check EZcall to see who is on.
PGY-4 Consult Neurology Senior
Responsible for oversight of the service including triaging, assessing, and following-up consults.
Determines the division of labor among the team.
Responsible for staffing consults with the PGY-2 and rotators for review prior to presenting to the attending.
There may be times when the consult volume will require the consult senior to see consults as well. If there are still remaining consults to see with all active members on the team seeing consults, the senior may reach out to other teams for assistance.
PGY-2 Consult Neurology Junior
Responsible for evaluation and management (seeing patients, chart reviewing, presenting to attendings, communicating with consulting teams) for majority of consults (i.e. will see more consults than non-neurology resident rotators).
Will see most higher acuity consults and follow-ups.
Share pager duty with the PGY-4 resident for consult intake and questions. In the beginning of the year, this will be done with supervision.
All consults will be reviewed with the PGY-4 before presenting to the attending.
Non-Neurology Rotators (Psych, EM, Midtown IM)
Responsible for evaluation and management for consults and follow-ups, generally at a lower quantity compared to the PGY-2 consult junior.
Coverage is variable ***
2-3 Medical Students
Carry at least 2 patients and as many as they feel comfortable with.
Present their patients on rounds:
They should evaluate new patients when available and present a full H&P.
For follow-up patients they will present in the SOAP format.
Utilize the Medical Student Note functionality in EPIC to write notes on their patients. They can send these to the senior resident and/or attending for review and feedback.
If patients are amenable to having an LP performed by a medical student under the Senior Resident's direct supervision, this should be encouraged.
They should be involved with the care of their patients, obtaining accurate medication lists, and assist with other tasks. They may pend orders for the Senior Resident to review and sign.
They should review as many of the medical student cases as possible with neurology resident.
Other info
First Seizure Clinic Workflow
Notes
The General Neurology EPIC templates are under the following dot phrases:
General History and Physical or Consultation Template: .UMHNEUROGENHP or .UMHNEUROCONSULT
General Progress Note Template: .UMHNEUROGENPROGNOTE
Ideally, patient progress notes should be completed before Morning Report starts. However, when the service is busier it is reasonable to complete them by the end of the morning.
Please keep in mind that the daily progress notes should reflect what is happening to the patient that day.
Brief Consult Note: UMMC consult policy response times (to note on file stating discussion with senior resident)
- 90 minutes for emergent consults
- 120 minutes for urgent consults
- 24 hours for routine consults
If full consult note will not be completed on this timeframe, use .BCN (Brief Consult Note) to state patient seen, discussed with senior, and recommendations.
Admission
Any patient with a primary neurological complaint that requires observation or further inpatient work up that is not a stroke patient with candidacy for acute intervention is eligible to be admitted to the Clinical Neurology Service. The consult team will in most cases see and admit the patient.
CONTINUOUS EEG CONSULTS
We are responsible for seeing consults for continuous EEG requests throughout the hospital EXCEPT from neurology services including the NCCU, Neurotrauma (T4S), Peds Neuro. cEEG requests are to be treated as AMS consults with a low threshold for EEG monitoring.
For new CEEG requests and related communications, residents will directly contact the EEG techs. The techs can be reached via their TigerConnect group, “UMMC EEG Team.” As a backup, their portable phone number is 8-4095. The techs understand that requests coming from Neurology teams are de facto "approved." Residents should identify themselves as being from Neurology, to make the process as smooth as possible. EEG results will be communicated from epilepsy to the Consult team.
Guidelines for neurology residents' role in Neuro-ICU consults
Neurocritical Care phone (8-4083) (covered by NCCU fellow during the day)
Diagnoses covered by NCCU consult service:
refractory status epilepticus
coma
increased ICP, including from hepatic encephalopathy
prognosis after cardiac arrest
If you see a consult that you think needs the NCCU, this should be staffed with the NCCU attending. Once accepted, the consult resident who saw the patient should place the admission order. Until the patient reaches the NCCU, the consult resident is the point of contact for nursing or ED providers regarding that patient (and patient should be signed out to covering resident at changes of shift). If called with changes / concerns patient should be evaluated as with any cross-cover patient and event note written (Event note template: .UMHNEUROEVENTNOTE). If questions arise that need an ICU attending’s input, the resident should call the NCCU attending and document any changes to the plan based on that discussion.
If the patient needing an NCCU bed is in the ED and there are no available beds, after speaking to the NCCU attending, next call the Access Center 8-1234, who will connect you to the central triage ICU provider (typically CCRU attending) to determine what ICU bed may be available for patient. You can then speak directly to the provider on that unit to give sign out. Stroke patients should go to NCCU preferentially, then CCRU, then MICU, then any ICU that is available.
Observation vs. Admission
The general rule of thumb is that if a patient will be staying in the hospital for 2 midnights (including their time in the ED), then they should be admitted. If you anticipate that he will not be staying that long, then you should place them under Observation. Keep in mind that a patient placed under Observation can later be converted to an Admission. The opposite can also be done (Admission --> Observation), but is slightly more complicated.
UMMC Clinical consultation policy
Please review the official hospital policy on consults.
GOALS & OBJECTIVES
Be able to evaluate undifferentiated neurological patients, formulate their cases, and propose appropriate diagnostic and therapeutic plans.
Develop appropriate differential and initiate further diagnostic testing and management for movement, neuromuscular, cognitive/behavioral, demyelinating, seizure, neuro-oncologic, and neuropsychiatric/somatofoam disorders, along with headache and neurologic manifestation of systemic disease.
Accurately perform neurologic exams on comatose or braindead patients.
List the indications, contraindications, and complications of Lumbar Puncture and perform the procedure.
Incorporate feedback and develop a learning plan.
Review literature to incorporate evidence-based medicine in patient care.
Appropriately order and interpret neuroimaging studies.
Clearly and completely document patient care in a timely fashion.
Communicate effectively with other members of the care team, both verbally and through documentation.
Recognize and manage neurologic emergencies.
Be able to describe basic and advanced neuroanatomy.