Perioperative Medicine Services
Quinn Cheng, MD
Medical Director of Perioperative Medicine Services
Manisha Israni-Jiang, MD
Assistant Medical Director of Perioperative Medicine Services
In addition to our work on the general medicine service, our hospitalists work closely with other specialties on our various perioperative medicine services, including our Neurosurgery Co-Management service, as well as our two consult services, the Medicine Consult Service at Moffit-Long, and the Mission Bay Consult Service. We also co-manage orthopedic patients at our Mt. Zion site.
A new, more intensive model of perioperative medical care known as "comanagement" has grown in popularity. Driven largely by hospitalists, comanagement is a collaborative effort that lets the internist share the responsibility, authority, and accountability for care of the surgical patient. At UCSF, the Co-Management with Neurosurgery Service (CNS) manages acute and chronic medical problems in patients hospitalized on the adult Neurological Surgery Service. Going beyond the role of a traditional consultant, the CNS hospitalists form an integral and vital component of their care team.
CNS hospitalists screen all neurosurgery patients at the time of admission for conditions that increase the risk of medical complications. The hospitalists proactively round on these high-risk patients, and orders tests, treatments, and subspecialty consultation as needed to prevent complications, or address them at the earliest possible time. The CNS service also performs urgent preoperative medical evaluations and trouble-shoots medical problems. To ensure that these patients receive the highest quality and safest care, the CNS hospitalists communicate and coordinate their efforts with a multidisciplinary team of physicians, pharmacists, nurses, rehabilitation therapists, and case managers.
In addition to performing this clinical mission, CNS hospitalists collaborate with the neurosurgeons in research endeavors (Arch Intern Med, 2010) and education of Neurosurgery housestaff. A UCSF hospitalist, Sujatha Sankaran, also serves as the Department of Neurological Surgery's Director of Quality & Patient Safety.
Medicine Consultation Service
At UCSF, major operations are routinely performed on patients deemed too sick for surgery at other institutions. These patients are prone to medical complications and require attentive perioperative medical care. The Medicine Consultation Service (MCS) assists in this mission by evaluating and treating medical problems in patients hospitalized on UCSF's non-Medicine services.
The MCS is available 24 hours every day at Moffitt-Long Hospital, the Ambulatory Surgery Center, and Langley Porter Psychiatric Institute. Common reasons to obtain a medical consultation include:
- Acute medical problems, e.g., respiratory distress, delirium, electrolyte disorders, venous thromboembolism;
- Chronic medical problems, e.g. cardiopulmonary disease, diabetes, polypharmacy;
- Preoperative medical evaluation and postoperative medical management for hospitalized patients;
- Request to transfer a UCSF inpatient to the Moffitt-Long Medical Service.
All consultations are performed by a hospitalist attending physician, generally with the assistance of a UCSF internal medicine resident. The service also provides a didactic curriculum on preoperative evaluation and perioperative medicine appropriate for both residents and practicing physicians.
Mission Bay Service
Mission Bay is the new UCSF hospital. It is primarily a women's and children's hospital, housing all of pediatrics and OB/Gyn. In addition, several adult surgical services (mostly oncology related) moved to Mission Bay from Mount Zion and Moffitt-Long.
Our Prime Directive of the hospitalist's role is to Always Try to Help. There are no medicine patients at Mission Bay, and the hospitalist will never be the attending of record at MB. Instead, the hospitalist's job is help ensure adult patients receive excellent medical care while they are undergoing surgical, gynecologic, or obstetric care. More specifically, our primary roles include:
Perform medicine consultation
Facilitate consultation by medical specialists
Assist the (pediatric) Emergency Department with adult patients
Respond to Code Blue & assist Rapid Response Team as needed
The hospitalist will consult on medical problems in adult patients. This includes performing preoperative medical evaluations and assessing and managing chronic and acute medical problems in the perioperative period.
Facilitate subspecialty consultation:
As with Mount Zion, few medical specialists are stationed on-site at MB. The hospitalist will be the point of contact for requests for consultation from medical subspecialties, as well as Neurology and Psychiatry. In some cases, the hospitalist may be able to perform the consultation in lieu of the subspecialist. In other cases, the hospitalist will triage and facilitate the specialist's involvement, acting as the liaison between the consultant and primary team. In addition to coming to MB to see the patient in person, specialists also have the option of doing an eConsult (a documented, structured "curbside") or using Tele-health technology to interview and examine patients remotely using a video link.
Emergency Department evaluation and management:
The MB ED is staffed by pediatric emergency medicine providers who may have limited experience with adult patients. The ED will try to minimize the number of adult visits, but recent Mission Bay surgical patients may be referred there. For these patients, the ED will ask the hospitalist to perform the initial evaluation and management with the input from the patient's surgical service. However, patients who cannot be quickly admitted upstairs or discharged should be transported to Parnassus.
The hospitalist will be part of the Code Team (led by the ICU attending or on-call anesthesiologist). The hospitalist is not expected to intubate patients, but needs to be certified in ACLS. The Rapid Response Team may occasionally ask the hospitalist for assistance as well.