Managing Inpatient Consultations

1. What is the specific clinical question you need answered? (Default: Must be a question, not "please evaluate")
2. What is the urgency — Emergent (< 1 hour), Urgent (< 4 hours), Routine (within 24 hours)? (Default: Routine)
3. What workup has already been done relevant to this question? (Default: List labs, imaging, prior consults)
4. What is the working diagnosis and relevant history? (Default: Per admitting H&P and progress notes)
5. Has the requesting physician spoken directly with the consultant (required for Emergent/Urgent)? (Default: Phone call for Emergent/Urgent; EMR order for Routine)
6. What does the requesting physician think is going on and what are they hoping the consultant will help with? (Default: Document pre-consult differential)
7. Is the patient's code status relevant to the consultation question? (Default: Include if goals-of-care may affect recommendation)

Documents to Request

• Recent H&P and daily progress notes
• Relevant lab results (trending, not just most recent)
• Imaging reports and actual images available for consultant review
• Medication list with recent changes
• Prior consultation notes (from current and recent admissions)
• Allergy list
• Advance directives if goals-of-care impact is possible

Step 1: Structure the Consultation Request (5 Cs Framework)

Use the 5 Cs to write effective consultation requests:

Contact

• Requesting physician name, pager/phone, service
• Patient name, MRN, room number, admitting diagnosis

Clinical Question

Write the question in one of these formats:

• Diagnostic: "Does this patient have [condition]? Supporting data includes [X, Y, Z]."
• Management: "Patient has confirmed [diagnosis]. What is the recommended treatment approach given [complicating factors]?"
• Procedural: "Patient requires [procedure]. Is the patient a candidate given [risk factors]?"
• Risk assessment: "What is this patient's risk for [outcome] given [clinical scenario]?"

Bad examples (vague, non-actionable):

• "Please evaluate" ← No question
• "Consult for management" ← No specificity
• "Abnormal labs" ← Which labs? What is the clinical concern?

Good examples (specific, actionable):

• "72F with new AFib with RVR on telemetry. CHA2DS2-VASc 4. Is rate control vs. rhythm control preferred, and what anticoagulation do you recommend given CrCl 35 mL/min?"
• "55M with cirrhosis, platelet count 45K, needs therapeutic paracentesis. Is platelet transfusion required pre-procedure?"

Context

• Relevant PMH, medications, allergies
• Workup already completed with results
• Current treatment and response

Constraints

• Time-sensitive factors (planned discharge, scheduled surgery)
• Patient preferences or goals-of-care considerations
• Insurance or formulary restrictions

Communication Preference

• How should the consultant communicate recommendations — note only, call back, see urgently?
• Who should be contacted if the requesting physician is off service?

Step 2: Process Consultant Recommendations

When a consultation note is received, the hospitalist must document:

Acknowledgment Template:

Consultant: [Name, Specialty]
Date of consultation: [Date]
Clinical question: [Restate]
Key recommendations:
1. [Recommendation 1] — AGREE / DISAGREE / MODIFY
2. [Recommendation 2] — AGREE / DISAGREE / MODIFY
3. [Recommendation 3] — AGREE / DISAGREE / MODIFY

Rationale for any disagreement or modification: [Explain]
Orders placed based on recommendations: [List]
Follow-up plan with consultant: [One-time vs. ongoing, next contact]

Step 3: Manage Multiple Consultants

For patients with 3+ active consultants, prevent fragmentation:

1. Maintain a consultation tracker in the progress note:

2. Identify the primary decision-maker for each clinical issue — the hospitalist owns the overall care plan
3. Resolve conflicting recommendations — When two consultants disagree, document the conflict and the hospitalist's resolution with rationale
4. Set expectations for follow-up frequency — "Consultant will follow daily" vs. "One-time consult, recs only"

Step 4: Consultation Etiquette and Efficiency

Follow these evidence-based practices to optimize consultation:

• Call before clicking: For urgent/emergent consults, always call the consultant before placing the EMR order
• One question per consult: Avoid "kitchen sink" consult requests — multiple unrelated questions reduce response quality
• Provide the data: Ensure labs and imaging are resulted before requesting the consult
• Respect scope: Do not request consultants to manage problems outside their specialty
• Follow up promptly: Acknowledge consultation recommendations within 24 hours
• Close the loop: When a one-time consult is complete, document that the consultant has signed off

Checkpoint B: Post-Draft Alignment (Mandatory)

After processing each consultation:

1. Is the clinical question specific and answerable?
2. Have all consultant recommendations been acknowledged with agree/disagree/modify?
3. Are orders reflecting accepted recommendations actually placed?
4. Is the follow-up plan documented (ongoing vs. one-time, next contact)?
5. Have conflicting recommendations from multiple consultants been resolved and documented?

Quality Audit

• Consultation request contains a specific, answerable clinical question
• Urgency level is documented and communicated appropriately
• Relevant workup results are available to the consultant at time of request
• Direct physician communication occurred for Emergent/Urgent consults
• Consultant note is reviewed within 24 hours of completion
• Each recommendation has documented agree/disagree/modify response
• Orders reflecting accepted recommendations are placed promptly
• Conflicting consultant recommendations are resolved with documentation
• Consultation tracker is maintained for patients with 3+ consults
• Follow-up frequency is documented (daily, PRN, one-time, signed off)
• Curbside consultations that result in management changes are documented as formal consults
• Code status is communicated to consultants when relevant

Guidelines

• The consultation question drives the quality of the response — invest time in writing a precise question
• Never place a consultation request without first reviewing what workup has already been done
• Emergent and Urgent consults require direct verbal communication — an EMR order alone is insufficient
• The hospitalist remains the primary coordinator of care — consultant recommendations are advisory, not directive
• When a consultant recommends a test or treatment, the hospitalist is responsible for evaluating it in the context of the full clinical picture
• Document disagreements respectfully and with clinical rationale — "Declining cardiology recommendation for cardiac catheterization given patient's comfort-measures-only code status and documented goals-of-care discussion"
• Curbside consultations (informal phone advice) should not be used for complex clinical decisions — if the recommendation changes management, convert to a formal consult
• Close out consultations explicitly — "Endocrinology signing off per Dr. X, insulin regimen optimized, follow up as outpatient"