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ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses 44 (2014) 107–111
Original article
Informal consultation at a teaching hospital infectious diseases department Consultations informelles en infectiologie dans un CHU C. Rameau , S. Mahy , A.-L. Simonet Lamm , A. Fillion , M. Buisson , A. Waldner , M. Duong , L. Piroth , P. Chavanet ∗ Infectious Diseases Department, Dijon Teaching Hospital, BP 97908, 21000 Dijon, France Received 29 August 2013; received in revised form 26 September 2013; accepted 28 January 2014 Available online 4 March 2014
Abstract 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. © 2014 Elsevier Masson SAS. All rights reserved. Keywords: Informal consultation; Recommendation; Appropriate antibiotherapy
Résumé Introduction. – Les consultations informelles en infectiologie (CII) constituent un travail non négligeable pour les praticiens. Cette étude vise à objectiver rétrospectivement cette activité en la quantifiant et en établissant ses caractéristiques. Méthodes. – Les données ont été recueillies à partir des demandes faxées, d’octobre 2009 à mai 2012. Mille neuf cent soixante-douze avis ont été inclus. Après analyse de la demande, un entretien téléphonique avec le demandeur permettait d’apporter des précisions puis, l’avis était transmis par fax. Résultats. – Les patients avaient en moyenne 64 ± 21 ans. Vingt-neuf pour cent des requêtes émanaient des services de chirurgie et 71 % de médecine. La cardiologie (10 %), l’hépato-gastro-entérologie (10 %) et la chirurgie cardiovasculaire (9,69 %) étaient les plus représentées. Les pathologies principales étaient urogénitales (19 %), ostéoarticulaires (14 %) et cardiovasculaires (11 %). Quarante-neuf pour cent étaient qualifiées de nosocomiales et 25,3 % étaient des bactériémies. Les demandes concernaient dans 95,6 % une question thérapeutique et diagnostique dans 16,2 % des cas. Les recommandations de l’infectiologue étaient thérapeutiques dans 96,5 % des cas et diagnostiques dans 43,7 %. Une modification du traitement était suggérée dans 38,5 % des cas. Vingt-deux pour cent des consultations avaient nécessité un avis supplémentaire.
∗
Corresponding author. E-mail address: [email protected] (P. Chavanet).
0399-077X/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.medmal.2014.01.009
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C. Rameau et al. / Médecine et maladies infectieuses 44 (2014) 107–111
Conclusion. – Ce travail démontre, par les importantes modifications de traitements antibiotiques, le nombre de demandes qui augmente et la complexité des cas, la nécessité d’avis en infectiologie dans notre établissement. Le système « en deux étapes » par fax mis en place semble acceptable pour tenter de limiter les biais liés au mode informel par rapport à celui du téléphone, modalité la plus usitée dans d’autres établissements. © 2014 Elsevier Masson SAS. Tous droits réservés. Mots clés : Consultation informelle ; Recommandations ; Antibiothérapie appropriée
1. Introduction Informal consultations in the infectious diseases department (IDD) have been implemented for several years at the Dijon Teaching Hospital (TH) but it became structured only in October 2009 with the introduction of forms to be filled out and faxed by TH physicians. This activity has become increasingly timeconsuming for the IDD. These consultations are crucial for the institution, but have not been highlighted for various reasons including a lack of evaluation. The fax system, when initiated, was not really well accepted by all physicians because of an increased workload compared to informal telephone calls used before. The informal consultations are meant to obtain advice from a specialist who does not examine the patient but considers the managing physician’s analysis on the form. They have numerous advantages but also important drawbacks compared to formal consultation. The medical data exchange as a written request transmitted by fax appeared as an intermediary and more reliable step than a simple telephone conversation. We had for aim to analyze this service after several years of practice in the IDD. 2. Method The fax system to obtain advice from an IDD specialist was available in October 2009 for all the TH physicians. Their requests for advice had to be written out on a standardized file available in all departments and on the intranet. The standardized files included a first part documenting the patient and the managing physician’s name. Then the file included a second part for the patient’s history, followed by a “clinical summary” including details of the anamnesis and clinical examination. A “bacteriological synthesis” listed all the samplings performed. Finally, the managing physician had to ask specific questions defining the infectious issue. The IDD specialist replied in the part dedicated to “synthesis of IDD specialized advice”. A senior physician faxed the advice, after a telephone conversation with the requesting physician. This telephone conversation was completed by reviewing the biological data available with the software common to the whole institution. This piece of advice was sent back on the same day as the request. The data was extracted from 2,410 files filled out from October 2009 to May 2012. One thousand nine hundred and seventy-two files were used, and we did not analyze the extraadvices. The elements taken into account were the requiring department, the infections concerned, the type of questions and answers provided by the IDD specialist (therapy, diagnosis, concerning hygiene in the department or prevention).
The 2 test and Kruskal-Wallis’s test were used to compare the variables. A threshold with P < 0.05 was considered as significant. 3. Results The 1,972 files concerned 39% of female and 61% of male patients (P < 0.001), with a mean age of 64 ± 21 year. The average number of files filled out every month was 84; there was a significant fluctuation during the year, with a decrease during the summer. The yearly number of files tended to increase with time. The IDD specialist dedicated 1 hour per day to this activity. Twenty-nine percent of requests came from surgical departments and 71% from medical departments (P < 0.01). The detailed distribution among surgical departments showed that the cardiovascular surgery department was the one that had consulted the IDD most often (9.69%), before neurosurgery (3.65%), urology (3.60%), and orthopedics (3.45%). The detailed distribution among medical departments showed that the cardiology (10.14%), hepato-gastro-enterology (10.14%), rheumatology (6.85%), and internal medicine (6.80%) departments were the most frequent users. The most frequent questions concerned therapy in 95.6% of cases. Among the questions, 16.2% concerned the diagnosis or a diagnostic method. Finally, 3% of requests concerned hygiene and 1.4% prevention. The therapeutic issues were classified in 3 categories: difficulty in understanding the antibiogram, management of antibiotherapy (choice, mode of administration, dose, duration), or dealing with a switch per os, in respectively 12.6, 7 8.6, and 8.8% of files. Urinary tract infections (UTI) were the most frequent infections (19.10%), followed by bone and joint (14.06%), cardiovascular (11.23%), and airway infections (10.22%). Sixtynine percent of infections were documented in our study, and only 54% of nosocomial infections were documented. The IDD specialist’s answers did not exhibit the same distribution as the requests. Indeed, the distribution was similar concerning therapeutic issues (96.5%), as well as for problems of hygiene (3%) or prevention (1.9%); but 43.7% of answers concerned the diagnosis. Concerning therapeutic issues, initiating a treatment was suggested in 24% of cases, modifying the ongoing antibiotic treatment in 38.5% (changing the agent in 35.2% and the dose in 3.3% of cases), continuing the treatment in 17% of cases, and stopping antibiotherapy in 5.5% of cases. Finally, there was no indication for any antibiotherapy in 14.6% of cases.
C. Rameau et al. / Médecine et maladies infectieuses 44 (2014) 107–111
In 22% of cases, at least one additional consultation was necessary. This concerned a nosocomial infection in 53.6% of cases. 4. Discussion 4.1. Comparing our activity It was not easy to compare our activity with that of other institutions; the management of each department is specific, and institutions are different in size, budget, and priorities. We noted that at this stage not having included outside requests for advice led to underestimating the number of requests since they account from 37 to 64% according to authors [1,2]. The same conclusion could be drawn when considering the additional advice (22%) ranging between 10 and 38.5% in similar studies [3,4]. The Dijon system relies essentially on informal consultations; but several authors have reported an uneven distribution between formal and informal consultations, the latter concerned more frequently outside requests [1–6]. There was a significant difference in the sex ratio, in our results, without any clear explanation. The results concerning the distribution of requests, between medical and surgical departments, differ among studies, ranging from an almost balanced distribution [1,3–5], to a predominance of medical departments, as in our study [2,6,7]. The low number of requests in some departments may be explained. The emergency or the oncology departments are the only ones to benefit from a direct and immediate telephone access to an IDD specialist, as for accidental exposure to blood. Other departments never make any request, such as the hematology department. Conversely, some specialties such as orthopedics were attributed a referent IDD specialist for direct advice. The most concerned surgical department, according to published data, is orthopedic surgery [7,8]. Among medical departments, according to several authors, the emergency and the hematology departments often request IDD consultations [2,6,9,10]. But as previously mentioned, these departments almost never made any requests in our institution. The most frequent infections in our study were UTI. It was not always easy to discriminate between colonization and infection, using the faxed file. Thus, there was probably an overestimation of infection and underestimation of colonization. Cardiovascular infections were often mentioned. Any superinfection following cardiovascular surgery was included as an infection. The most frequent infections reported by other authors were UTIs but also respiratory tract infections. This distribution seems to be related to the quality of relationship among departments, specific to each institution. This can be noted in our study, by an important number of cardiovascular infections suggesting numerous interactions with the cardiovascular surgery department as we already mentioned. We noted, when considering the IDD specialist’s advice, that complementary examinations were suggested 43.7% of cases whereas the “requesting” physicians asked the question only in 16% of cases: this suggests that the IDD specialist, besides
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answering the request question, provided supplementary information. Other authors noted the same trend. Nevertheless, this dynamics in Dijon seemed limited compared to the results of other studies in which it ranged between 53 and 71.8% [3,7]. The rate of modified antibiotherapy in other studies ranged between 22 and 45.6% [4,9]. The rates in our study are similar to those of other studies, whatever the local guidelines were. The number of nosocomial infections was high in Dijon. The reported rates elsewhere ranged between 34 and 48% [3,5] and they more frequently led to formal consultations. 4.2. The contribution of an informal consultation It was interesting to compare the differences between formal and informal consultations. This was done and presented as Table 1. Informal consultations have been increasingly requested. It is a simple, rapid, immediate way to benefit from specialized advice. Indeed, they meet the expectations of physicians, in the hospital or elsewhere, as proved by the reported satisfaction rate in various studies, at 95% on average [11]. They allow obtaining answers to precise questions, adapted to the physician’s issue, often to confirm a diagnosis. They help train and maintain a professional network, they help colleagues get on better together, and they allow continuous medical training. Sometimes, they are also the only means to share emotional stress, especially for physicians working alone. The advantages are also essentially organizational. They induce a significant time gain for the requesting physician who will solve his problem through a simple conversation, but also for the patient, avoiding any administrative operation, and moving around. It avoids formal and longer consultations for the specialist, without having to go to the patient’s bed, or making useless transfers [12–14]. With this system, the requesting physician obtains specialized advice with an expected benefit for the patient equivalent to that of a formal consultation [15], except in case of severe sepsis such as Staphylococcus aureus bacteremia [16], with a lesser cost for the institution. According to Wegner et al. [17], 1 dollar injected in the informal consultation system in IDD would allow saving 39 dollars. Nevertheless there are significant drawbacks. Theses informal consultations may lack reliability, with many imprecisions identified at the end of the discussion [18]. Indeed, they are not at all adapted to complex presentations, and the greater the number of questions during a telephone conversation, the higher the chances for erroneous information [19,20]. All the problems of communication can also be mentioned: the speech characteristics for example, speaking too fast, a strong accent, etc. may alter the telephone conversation [21]; likewise for the physician’s capacity to synthesize his file and to present it [22]. Lack of precision in the questions results in less specific answers. Tensions between speakers, often related to a differences of opinion or to level of emergency perceived differently, may also degrade the quality of the discussion [21]. Responsibility is also a problem. Stricto sensu, the IDD specialist should not be responsible for the patient, since he has never examined him, but as soon
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Table 1 Comparison of formal and informal consultation, advantages and drawbacks. Comparaison d’une consultation formelle et informelle, avantages et inconvénients. Items
Type of consultation Formal
Informal Requesting physician
Infections or clinical presentation Questions Answers Delay before consultation Administrative steps Delay before answer Access to information Medical management Capacity Complex cases Reliability Responsibility
Nosocomial bacteremia Treatment Treatment and diagnosis Variable according to the institution Mandatory Long Postponed Postponed Limited Adapted Relatively good Shared
Financial
Medical record
Includes consultant fee, transportation costs, and extended hospital stay costs Documented and traceable
Compliance
Good
as he takes the file into account, he assumes a partial responsibility [23–25]. Finally, this activity is not paid, despite the fact that the workload assumed by the IDD specialist, as well as his responsibility, induce a financial gain for the institution [26,27]. 4.3. The expected advantages of an informal consultation by fax The specificity of our fax system brings some improvement to informal consultations. The consultation is a 2-step process. First the requesting physician must make a synthesis of his problem, alone, without the pressure of an answerer potentially in a hurry, according to a standardized file. The various elements required to answer the infectious issue are collected. From a judicial point of view, this allows determining the mandatory elements for the IDD specialist’s decision, limiting the risk of a medical mistake by omission or negligence. This first step can prevent the numerous imprecisions reported by various authors. This can also limit interfering elements such as communication problems, speech issues, or tensions. In the second step, the IDD specialist calls the requesting physician to specify some information and gives him his advice directly. The fax is then sent back, with the IDD specialist’s written answer, preventing most misinterpretations. The medical file is thus completed; the IDD specialist’s activity is not completely “invisible”. This way also, in case supplementary advice is requested, the initial fax is available both in the IDD, which keeps a copy, and in the patient’s medical record, allowing for an adequate follow-up. The name of the IDD specialist is systematically mentioned on the file so as to avoid changing answerer for each new exchange. This procedure was also used by other teams, as in Nottingham in neurosurgery [28].
Infectious diseases specialist
Blood exposure, unexplained fever Prophylaxis, diagnosis Prophylaxis, diagnosis Immediate None Short Immediate Immediate Unlimited Increased workload Not adapted Not very or moderately reliable because of imprecisions Case by case Almost null if phone-based Possible if phone-fax based Not paid, no cost for the institution No cost
NA
Not traceable if phone-based Traceable if phone-fax based
Moderate
5. Conclusion The informal consultation activity in our department is important, and compares to other IDD. It should be given value to ensure its sustainability, given the benefits provided, in time and responsibility. The specificity of our system is the informal fax method that, according to published data, meets expectation in terms of quality of care. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Gennai S, Franc¸ois P, Sellier E, Vittoz JP, Hincky-Vitrat V, Pavese P. Prospective study of telephone calls to a hotline for infectious disease consultation: analysis of 7,863 solicited consultations over a 1-year period. Eur J Clin Microbiol Infect Dis 2011;30(4):509–14. [2] Yinnon AM, Schlesinger Y. Analysis and impact of infectious disease consultations in a general hospital. J Infect 1998;3:39–46. [3] Gennai S, Franc¸ois P, Bal G, Epaulard O, Stahl JP, Vittoz JP, et al. Evaluation of a remote infectious disease consultation. Med Mal Infect 2009;39(10):798–805. [4] Sellier E, Pavese P, Gennai S, Stahl JP, Labarère J, Franc¸ois P. Factors and outcomes associated with physicians’ adherence to recommendations of infectious disease consultations for inpatients. J Antimicrob Chemother 2010;65(1):156–62. [5] De La Blanchardière A, Boutemy J, Thibon P, Michon J, Verdon R, Cattoir V. Clinical benefit of infectious diseases consultation: a monocentric prospective cohort study. Infection 2012;40(5):501–7. [6] Yinnon AM. Whither infectious diseases consultations? Analysis of 14,005 consultations from a 5-year period. Clin Infect Dis 2001;33(10):1661–7.
C. Rameau et al. / Médecine et maladies infectieuses 44 (2014) 107–111 [7] Lo E, Rezai K, Evans AT, Madariaga MG, Phillips M, Brobbey W, et al. Why don’t they listen? Adherence to recommendations of infectious disease consultations. Clin Infect Dis 2004;38(9):1212–8. [8] Yapar N, Erdenizmenli M, O˘guz VA, Kuruüzüm Z, Senger SS, Cakir N, et al. Infectious disease consultations and antibiotic usage in a Turkish university hospital. Int J Infect Dis 2006;10(1):61–5. [9] Méan M, Pavese P, Tudela É, Dinh-Van KA, Mallaret MR, Stahl JP. Conseil téléphonique en infectiologie : bon suivi des recommandations proposées par un référent infectiologue. Presse Med 2006;35(10):1461–6. [10] Sipahi OR, Tasbakan M, Pullukcu H, Arda B, Yamazhan T, Mizrakci S, et al. Accuracy of consultations performed by infectious diseases trainees and factors associated with adherence to them. Int J Infect Dis 2007;11(6):518–23. [11] Bal G, Sellier E, Gennai S, Caillis M, Ois P, Pavese P. Infectious disease specialist telephone consultations requested by general practitioners. Scand J Infect Dis 2011;43(11–12):912–7. [12] Perley BCM. Physician use of the curbside consultation to address information needs: report on a collective case study. J Med Libr Assoc 2006;94(2):137–44. [13] Keating NL, Zaslavsky AM, Ayanian JZ. Physicians’ experiences and beliefs regarding informal consultation. JAMA 1998;280(10):900–4. [14] Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA 1998;280(10):905–9. [15] Sellier E, Labarère J, Gennai S, Bal G. Compliance with recommendations and clinical outcomes for formal and informal infectious disease specialist consultations. Eur J Clin Microbiol Infect Dis 2011;30(7):887–94. [16] Forsblom E, Ruotsalainen E, Ollgren J., Järvinen A. Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus bacteremia. Clin Infect Dis 2013;56(4):527–35. [17] Wegner SE, Humble CG, Feaganes J, Stiles AD. Estimated savings from paid telephone consultations between subspecialists and primary care physicians. Pediatrics 2008;122(6):e1136–40.
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[18] Linkin DR, Fishman NO, Landis JR, Barton TD, Gluckman S, Kostman J, et al. Effect of communication errors during calls to an antimicrobial stewardship program. Infect Control Hosp Epidemiol 2007;28(12): 1374–81. [19] Burden M, Sarcone E, Keniston A, Statland B, Taub JA, Allyn RL, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med 2013;8(1):31–5. [20] Manian FA, McKinsey DS. A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest. Clin Infect Dis 1996;22(2):303–7. [21] Wadhwa A, Lingard L. A qualitative study examining tensions in interdoctor telephone consultations. Med Educ 2006;40(8):759–67. [22] Bergus GR, Randall CS, Sinift SD, Rosenthal DM. Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues? Arch Fam Med 2000;9(6):541–7. [23] Fox BC, Siegel ML, Weinstein RA, Ronald AR. “Curbside” consultation and informal communication in medical practice: a medicolegal perspective. Clin Infect Dis 1996;23(3):616–22. [24] Cotton VR. Legal risks of “curbside” consults. Am J Cardiol 2010;106(1):135–8. [25] Dusserre L. La télé expertise : un acte médical à reconnaître et à rémunérer. Rapport au Conseil national de l’Ordre des médecins; 1999 http://www. conseil-national.medecin.fr/sites/default/files/teleexpertise.pdf [26] Grace C, Alston WK, Ramundo M, Polish L, Kirkpatrick B, Huston C. The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit. Clin Infect Dis 2010;51(6):651–5 [Internet]. [27] Stemer A. The complexity, relative value, and financial worth of curbside consultations in an academic infectious disease unit. Clin Infect Dis 2011;52(4):556. [28] Choudhari KA. “In-lay” duraplasty: a useful method of effective dural closure. Br J Neurosurg 2001;15(6):533–5.
ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses 44 (2014) 107–111
Original article
Informal consultation at a teaching hospital infectious diseases department Consultations informelles en infectiologie dans un CHU C. Rameau , S. Mahy , A.-L. Simonet Lamm , A. Fillion , M. Buisson , A. Waldner , M. Duong , L. Piroth , P. Chavanet ∗ Infectious Diseases Department, Dijon Teaching Hospital, BP 97908, 21000 Dijon, France Received 29 August 2013; received in revised form 26 September 2013; accepted 28 January 2014 Available online 4 March 2014
Abstract 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. © 2014 Elsevier Masson SAS. All rights reserved. Keywords: Informal consultation; Recommendation; Appropriate antibiotherapy
Résumé Introduction. – Les consultations informelles en infectiologie (CII) constituent un travail non négligeable pour les praticiens. Cette étude vise à objectiver rétrospectivement cette activité en la quantifiant et en établissant ses caractéristiques. Méthodes. – Les données ont été recueillies à partir des demandes faxées, d’octobre 2009 à mai 2012. Mille neuf cent soixante-douze avis ont été inclus. Après analyse de la demande, un entretien téléphonique avec le demandeur permettait d’apporter des précisions puis, l’avis était transmis par fax. Résultats. – Les patients avaient en moyenne 64 ± 21 ans. Vingt-neuf pour cent des requêtes émanaient des services de chirurgie et 71 % de médecine. La cardiologie (10 %), l’hépato-gastro-entérologie (10 %) et la chirurgie cardiovasculaire (9,69 %) étaient les plus représentées. Les pathologies principales étaient urogénitales (19 %), ostéoarticulaires (14 %) et cardiovasculaires (11 %). Quarante-neuf pour cent étaient qualifiées de nosocomiales et 25,3 % étaient des bactériémies. Les demandes concernaient dans 95,6 % une question thérapeutique et diagnostique dans 16,2 % des cas. Les recommandations de l’infectiologue étaient thérapeutiques dans 96,5 % des cas et diagnostiques dans 43,7 %. Une modification du traitement était suggérée dans 38,5 % des cas. Vingt-deux pour cent des consultations avaient nécessité un avis supplémentaire.
∗
Corresponding author. E-mail address: [email protected] (P. Chavanet).
0399-077X/$ – see front matter © 2014 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.medmal.2014.01.009
108
C. Rameau et al. / Médecine et maladies infectieuses 44 (2014) 107–111
Conclusion. – Ce travail démontre, par les importantes modifications de traitements antibiotiques, le nombre de demandes qui augmente et la complexité des cas, la nécessité d’avis en infectiologie dans notre établissement. Le système « en deux étapes » par fax mis en place semble acceptable pour tenter de limiter les biais liés au mode informel par rapport à celui du téléphone, modalité la plus usitée dans d’autres établissements. © 2014 Elsevier Masson SAS. Tous droits réservés. Mots clés : Consultation informelle ; Recommandations ; Antibiothérapie appropriée
1. Introduction Informal consultations in the infectious diseases department (IDD) have been implemented for several years at the Dijon Teaching Hospital (TH) but it became structured only in October 2009 with the introduction of forms to be filled out and faxed by TH physicians. This activity has become increasingly timeconsuming for the IDD. These consultations are crucial for the institution, but have not been highlighted for various reasons including a lack of evaluation. The fax system, when initiated, was not really well accepted by all physicians because of an increased workload compared to informal telephone calls used before. The informal consultations are meant to obtain advice from a specialist who does not examine the patient but considers the managing physician’s analysis on the form. They have numerous advantages but also important drawbacks compared to formal consultation. The medical data exchange as a written request transmitted by fax appeared as an intermediary and more reliable step than a simple telephone conversation. We had for aim to analyze this service after several years of practice in the IDD. 2. Method The fax system to obtain advice from an IDD specialist was available in October 2009 for all the TH physicians. Their requests for advice had to be written out on a standardized file available in all departments and on the intranet. The standardized files included a first part documenting the patient and the managing physician’s name. Then the file included a second part for the patient’s history, followed by a “clinical summary” including details of the anamnesis and clinical examination. A “bacteriological synthesis” listed all the samplings performed. Finally, the managing physician had to ask specific questions defining the infectious issue. The IDD specialist replied in the part dedicated to “synthesis of IDD specialized advice”. A senior physician faxed the advice, after a telephone conversation with the requesting physician. This telephone conversation was completed by reviewing the biological data available with the software common to the whole institution. This piece of advice was sent back on the same day as the request. The data was extracted from 2,410 files filled out from October 2009 to May 2012. One thousand nine hundred and seventy-two files were used, and we did not analyze the extraadvices. The elements taken into account were the requiring department, the infections concerned, the type of questions and answers provided by the IDD specialist (therapy, diagnosis, concerning hygiene in the department or prevention).
The 2 test and Kruskal-Wallis’s test were used to compare the variables. A threshold with P < 0.05 was considered as significant. 3. Results The 1,972 files concerned 39% of female and 61% of male patients (P < 0.001), with a mean age of 64 ± 21 year. The average number of files filled out every month was 84; there was a significant fluctuation during the year, with a decrease during the summer. The yearly number of files tended to increase with time. The IDD specialist dedicated 1 hour per day to this activity. Twenty-nine percent of requests came from surgical departments and 71% from medical departments (P < 0.01). The detailed distribution among surgical departments showed that the cardiovascular surgery department was the one that had consulted the IDD most often (9.69%), before neurosurgery (3.65%), urology (3.60%), and orthopedics (3.45%). The detailed distribution among medical departments showed that the cardiology (10.14%), hepato-gastro-enterology (10.14%), rheumatology (6.85%), and internal medicine (6.80%) departments were the most frequent users. The most frequent questions concerned therapy in 95.6% of cases. Among the questions, 16.2% concerned the diagnosis or a diagnostic method. Finally, 3% of requests concerned hygiene and 1.4% prevention. The therapeutic issues were classified in 3 categories: difficulty in understanding the antibiogram, management of antibiotherapy (choice, mode of administration, dose, duration), or dealing with a switch per os, in respectively 12.6, 7 8.6, and 8.8% of files. Urinary tract infections (UTI) were the most frequent infections (19.10%), followed by bone and joint (14.06%), cardiovascular (11.23%), and airway infections (10.22%). Sixtynine percent of infections were documented in our study, and only 54% of nosocomial infections were documented. The IDD specialist’s answers did not exhibit the same distribution as the requests. Indeed, the distribution was similar concerning therapeutic issues (96.5%), as well as for problems of hygiene (3%) or prevention (1.9%); but 43.7% of answers concerned the diagnosis. Concerning therapeutic issues, initiating a treatment was suggested in 24% of cases, modifying the ongoing antibiotic treatment in 38.5% (changing the agent in 35.2% and the dose in 3.3% of cases), continuing the treatment in 17% of cases, and stopping antibiotherapy in 5.5% of cases. Finally, there was no indication for any antibiotherapy in 14.6% of cases.
C. Rameau et al. / Médecine et maladies infectieuses 44 (2014) 107–111
In 22% of cases, at least one additional consultation was necessary. This concerned a nosocomial infection in 53.6% of cases. 4. Discussion 4.1. Comparing our activity It was not easy to compare our activity with that of other institutions; the management of each department is specific, and institutions are different in size, budget, and priorities. We noted that at this stage not having included outside requests for advice led to underestimating the number of requests since they account from 37 to 64% according to authors [1,2]. The same conclusion could be drawn when considering the additional advice (22%) ranging between 10 and 38.5% in similar studies [3,4]. The Dijon system relies essentially on informal consultations; but several authors have reported an uneven distribution between formal and informal consultations, the latter concerned more frequently outside requests [1–6]. There was a significant difference in the sex ratio, in our results, without any clear explanation. The results concerning the distribution of requests, between medical and surgical departments, differ among studies, ranging from an almost balanced distribution [1,3–5], to a predominance of medical departments, as in our study [2,6,7]. The low number of requests in some departments may be explained. The emergency or the oncology departments are the only ones to benefit from a direct and immediate telephone access to an IDD specialist, as for accidental exposure to blood. Other departments never make any request, such as the hematology department. Conversely, some specialties such as orthopedics were attributed a referent IDD specialist for direct advice. The most concerned surgical department, according to published data, is orthopedic surgery [7,8]. Among medical departments, according to several authors, the emergency and the hematology departments often request IDD consultations [2,6,9,10]. But as previously mentioned, these departments almost never made any requests in our institution. The most frequent infections in our study were UTI. It was not always easy to discriminate between colonization and infection, using the faxed file. Thus, there was probably an overestimation of infection and underestimation of colonization. Cardiovascular infections were often mentioned. Any superinfection following cardiovascular surgery was included as an infection. The most frequent infections reported by other authors were UTIs but also respiratory tract infections. This distribution seems to be related to the quality of relationship among departments, specific to each institution. This can be noted in our study, by an important number of cardiovascular infections suggesting numerous interactions with the cardiovascular surgery department as we already mentioned. We noted, when considering the IDD specialist’s advice, that complementary examinations were suggested 43.7% of cases whereas the “requesting” physicians asked the question only in 16% of cases: this suggests that the IDD specialist, besides
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answering the request question, provided supplementary information. Other authors noted the same trend. Nevertheless, this dynamics in Dijon seemed limited compared to the results of other studies in which it ranged between 53 and 71.8% [3,7]. The rate of modified antibiotherapy in other studies ranged between 22 and 45.6% [4,9]. The rates in our study are similar to those of other studies, whatever the local guidelines were. The number of nosocomial infections was high in Dijon. The reported rates elsewhere ranged between 34 and 48% [3,5] and they more frequently led to formal consultations. 4.2. The contribution of an informal consultation It was interesting to compare the differences between formal and informal consultations. This was done and presented as Table 1. Informal consultations have been increasingly requested. It is a simple, rapid, immediate way to benefit from specialized advice. Indeed, they meet the expectations of physicians, in the hospital or elsewhere, as proved by the reported satisfaction rate in various studies, at 95% on average [11]. They allow obtaining answers to precise questions, adapted to the physician’s issue, often to confirm a diagnosis. They help train and maintain a professional network, they help colleagues get on better together, and they allow continuous medical training. Sometimes, they are also the only means to share emotional stress, especially for physicians working alone. The advantages are also essentially organizational. They induce a significant time gain for the requesting physician who will solve his problem through a simple conversation, but also for the patient, avoiding any administrative operation, and moving around. It avoids formal and longer consultations for the specialist, without having to go to the patient’s bed, or making useless transfers [12–14]. With this system, the requesting physician obtains specialized advice with an expected benefit for the patient equivalent to that of a formal consultation [15], except in case of severe sepsis such as Staphylococcus aureus bacteremia [16], with a lesser cost for the institution. According to Wegner et al. [17], 1 dollar injected in the informal consultation system in IDD would allow saving 39 dollars. Nevertheless there are significant drawbacks. Theses informal consultations may lack reliability, with many imprecisions identified at the end of the discussion [18]. Indeed, they are not at all adapted to complex presentations, and the greater the number of questions during a telephone conversation, the higher the chances for erroneous information [19,20]. All the problems of communication can also be mentioned: the speech characteristics for example, speaking too fast, a strong accent, etc. may alter the telephone conversation [21]; likewise for the physician’s capacity to synthesize his file and to present it [22]. Lack of precision in the questions results in less specific answers. Tensions between speakers, often related to a differences of opinion or to level of emergency perceived differently, may also degrade the quality of the discussion [21]. Responsibility is also a problem. Stricto sensu, the IDD specialist should not be responsible for the patient, since he has never examined him, but as soon
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Table 1 Comparison of formal and informal consultation, advantages and drawbacks. Comparaison d’une consultation formelle et informelle, avantages et inconvénients. Items
Type of consultation Formal
Informal Requesting physician
Infections or clinical presentation Questions Answers Delay before consultation Administrative steps Delay before answer Access to information Medical management Capacity Complex cases Reliability Responsibility
Nosocomial bacteremia Treatment Treatment and diagnosis Variable according to the institution Mandatory Long Postponed Postponed Limited Adapted Relatively good Shared
Financial
Medical record
Includes consultant fee, transportation costs, and extended hospital stay costs Documented and traceable
Compliance
Good
as he takes the file into account, he assumes a partial responsibility [23–25]. Finally, this activity is not paid, despite the fact that the workload assumed by the IDD specialist, as well as his responsibility, induce a financial gain for the institution [26,27]. 4.3. The expected advantages of an informal consultation by fax The specificity of our fax system brings some improvement to informal consultations. The consultation is a 2-step process. First the requesting physician must make a synthesis of his problem, alone, without the pressure of an answerer potentially in a hurry, according to a standardized file. The various elements required to answer the infectious issue are collected. From a judicial point of view, this allows determining the mandatory elements for the IDD specialist’s decision, limiting the risk of a medical mistake by omission or negligence. This first step can prevent the numerous imprecisions reported by various authors. This can also limit interfering elements such as communication problems, speech issues, or tensions. In the second step, the IDD specialist calls the requesting physician to specify some information and gives him his advice directly. The fax is then sent back, with the IDD specialist’s written answer, preventing most misinterpretations. The medical file is thus completed; the IDD specialist’s activity is not completely “invisible”. This way also, in case supplementary advice is requested, the initial fax is available both in the IDD, which keeps a copy, and in the patient’s medical record, allowing for an adequate follow-up. The name of the IDD specialist is systematically mentioned on the file so as to avoid changing answerer for each new exchange. This procedure was also used by other teams, as in Nottingham in neurosurgery [28].
Infectious diseases specialist
Blood exposure, unexplained fever Prophylaxis, diagnosis Prophylaxis, diagnosis Immediate None Short Immediate Immediate Unlimited Increased workload Not adapted Not very or moderately reliable because of imprecisions Case by case Almost null if phone-based Possible if phone-fax based Not paid, no cost for the institution No cost
NA
Not traceable if phone-based Traceable if phone-fax based
Moderate
5. Conclusion The informal consultation activity in our department is important, and compares to other IDD. It should be given value to ensure its sustainability, given the benefits provided, in time and responsibility. The specificity of our system is the informal fax method that, according to published data, meets expectation in terms of quality of care. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Gennai S, Franc¸ois P, Sellier E, Vittoz JP, Hincky-Vitrat V, Pavese P. Prospective study of telephone calls to a hotline for infectious disease consultation: analysis of 7,863 solicited consultations over a 1-year period. Eur J Clin Microbiol Infect Dis 2011;30(4):509–14. [2] Yinnon AM, Schlesinger Y. Analysis and impact of infectious disease consultations in a general hospital. J Infect 1998;3:39–46. [3] Gennai S, Franc¸ois P, Bal G, Epaulard O, Stahl JP, Vittoz JP, et al. Evaluation of a remote infectious disease consultation. Med Mal Infect 2009;39(10):798–805. [4] Sellier E, Pavese P, Gennai S, Stahl JP, Labarère J, Franc¸ois P. Factors and outcomes associated with physicians’ adherence to recommendations of infectious disease consultations for inpatients. J Antimicrob Chemother 2010;65(1):156–62. [5] De La Blanchardière A, Boutemy J, Thibon P, Michon J, Verdon R, Cattoir V. Clinical benefit of infectious diseases consultation: a monocentric prospective cohort study. Infection 2012;40(5):501–7. [6] Yinnon AM. Whither infectious diseases consultations? Analysis of 14,005 consultations from a 5-year period. Clin Infect Dis 2001;33(10):1661–7.
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