Infectious diseases consultations at an Australian Tertiary Hospital: a review of 11 511 inpatient consultations

Infectious diseases consultations at an Australian TertiaryHospital: a review of 11 511 inpatient consultationsE. C. Bursle,1,2 E. G. Playford1,2 and D. F. M. Looke1,2

1Infection Management Services, Princess Alexandra Hospital and 2School of Medicine, University of Queensland, Brisbane, Queensland, Australia

Key wordsinfectious diseases consultation, consult,

Australia.

CorrespondenceEvan C. Bursle, Pathology Queensland

Microbiology Department, Building 7, Royal

Brisbane and Women’s Hospital, Butterfield

Street, Herston, Brisbane, Qld 4006, Australia.

Email: [email protected];

[email protected]

Received 30 May 2014; accepted 15 July 2014.

doi:10.1111/imj.12536

Abstract

Background: Infectious diseases (ID) clinicians provide an important service within

tertiary hospitals. However, as a largely consultation-based service, their value can be

difficult to evaluate.

Aims: A review of 13.5 years of consultations was undertaken to define the scope of

the service and any changes over time.

Methods: ID consultations at the Princess Alexandra Hospital are tracked on a data-

base, recording information including the requesting team, indication for and outcome

of the consult. Incident formal inpatient consultations between July 1999 and December

2012 were reviewed retrospectively. Phone consultations, repeat consultations and ID

admissions were excluded.

Results: Eleven thousand five hundred and eleven consultations were identified, with

annual consultations increasing significantly during this period. Overall, formal consul-

tations were performed on 1.3% of admissions. Consultations were most commonly

requested by orthopaedics (14.3%) and general medicine (11.4%). The two most

common syndromes triggering a consult were bloodstream infection (13.9%) and com-

plicated soft tissue infection (7.8%). The final diagnosis was most frequently osteomy-

elitis (7.9%). Staphylococcus aureus (19.4%) and Pseudomonas aeruginosa (8.3%) were the

most commonly identified pathogens.

Conclusion: The demand for ID consultations has increased over time and there are

likely to be many drivers of this increase. Information derived from this audit can

enhance the ID service by guiding service delivery, trainee education and informing

funding or accreditation applications.

Introduction

The role of a hospital infectious diseases (ID) service ismultifaceted, typically involving managing inpatients,inpatient and outpatient consultations, infection controlmanagement and critical interactions with the micro-biology laboratory and public health departments. Inrecent decades, the role has undergone significantchange. The drivers of this change include a more vul-nerable population (because of ageing, immunosuppres-sion and invasive procedures), the recognition of theimportance of the preventability and consequences ofhealthcare-acquired infection,1 the increasing complexityof ID and microbiology and the reduction in under-graduate teaching of microbiology. More recently, theemergence of multidrug-resistant organisms has driven

increased ID physician involvement in antimicrobialstewardship programmes. In Australia, the importance ofhospital antimicrobial stewardship was formalised in the2012 National Safety and Quality Healthcare Standardswhere active and effective stewardship programmes arelisted as a requirement for hospital accreditation.2

The value of an ID consultation has been demonstratedin a variety of areas. These include decreased mortalityand length of stay for particular conditions such asStaphylococcus aureus bloodstream infection,3–5 reducedantimicrobial resistance and hospital-acquired infectionrates,6 more appropriate antibiotic prescribing7 and sig-nificant cost savings.8,9 A more recent retrospectivereview pointed to additional broad benefits, particularlyearly in a patient’s hospital stay, with improved outcomesincluding reduced mortality, hospital and intensive careunit length of stay and healthcare costs.10 However, cir-cumstances require practitioners to continue to demon-strate their value, both clinically and economically.As a predominantly consultation-based specialty with

Funding: None.Conflict of interest: None.

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© 2014 The AuthorsInternal Medicine Journal © 2014 Royal Australasian College of Physicians998

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relatively few inpatients, it can be difficult to define therole and value of an ID service, as information on clinicalactivity is not captured through traditional means such asInternational Classification of Diseases (ICD-10) coding.A recent 2-week survey of ID physicians in Australia,New Zealand and Singapore11 has provided insight intothe scope, diversity and volume of current practice.However, this study was unable to examine changes to IDpractice over time, nor proportional use of the serviceagainst occupied bed days (OBD) or separations. Weaimed to define the scope of the ID consultation servicewithin our hospital, the evolution of consultationdemands over time and areas for improvement throughthe retrospective review of an inpatient consultationsdatabase.

Methods

The Princess Alexandra Hospital (PAH) is a 780-bed ter-tiary level, university-affiliated, teaching hospital in Bris-bane, Australia, providing care in all major adultspecialties (including liver and renal transplantation)with the exception of obstetrics and gynaecology. SinceJuly 1999, all inpatient ID consultations have been pro-spectively recorded by the advanced trainee in ID on aMicrosoft Access database known as ‘ID consultationmanager’ or ‘ID ConMan’.12 The following informationwas prospectively recorded: requesting team, patientdemographics, syndrome prompting the consultation,final diagnosis and relevant microbiology. Syndromesand diagnoses were based upon the chapters in ‘Princi-ples and Practice of Infectious Diseases’, by Mandellet al.13 Only one syndrome and diagnosis could beentered for each separate consultation, while multipleorganism entries per consultation were allowed. The IDregistrar providing the consultation prospectively enteredthese data.

Incident formal (bedside) inpatient consultationsoccurring from 1 July 1999 to 31 December 2012 werereviewed retrospectively. Phone consultations and IDadmissions were excluded, as were consultations as partof ID rounds in high antibiotic use areas (e.g. haematol-ogy, intensive care) unless a formal bedside review sub-sequently occurred. Repeat visits to the same patient forongoing advice regarding an issue were not recorded.Consultations recorded on the system were used to gen-erate daily work lists for the registrar and as such it isunlikely any consultations avoided entry into the system.The system was functional for the entire period exam-ined. Consultation data were compared with totalhospital OBD and separations over the time periodexamined. Data were analysed using Microsoft Excel(v2003; Microsoft, Redmond, WA, USA) and Stata v11

(StataCorp, College Station, TX, USA). P values of <0.05were considered significant. The study was approved bythe Metro South Human Research Ethics Committee.

Results

Eleven thousand, five hundred and eleven consultationswere identified. The mean age of the patients was 53years, with a median of 55 years. Formal bedside consul-tations were performed on 1.28% of admissions duringthe period 2000 to 2012 (incomplete 1999 dataexcluded). Annual consultations increased almost three-fold during this period. This rise was not explained byincreases in hospital bed occupancy or separations(Fig. 1). The observed rise was statistically significant forboth consultations per 1000 OBD (slope 0.23/year, 95%confidence interval (CI) 0.14–0.31, P < 0.001) and con-sultations per 1000 separations (slope 0.84/year, 95% CI0.5–1.18, P < 0.001).

Consultations were most commonly requested byorthopaedic surgery and general medicine (see Table 1).However, when OBD were factored in, the renal unit,diabetes and endocrinology and intensive care were thelargest users of the service (Table 2). When the data wereanalysed by separations, units with lengthy hospitaladmissions (spinal injuries and geriatrics and rehabilita-tion) proved the most frequent referrers (Table 3).

The most common organism types encountered werebacteria (64%), followed by no organism isolated or non-infectious causes (26%), fungi (5%), viruses (4%) andparasites (1%). Consultations were most frequently forS. aureus (24.8%), Streptococcus sp. (8.8%), P. aeruginosa(8.3%), Escherichia coli (6%), coagulase negative Staphy-lococci (5.81%) and Enterococcus sp. (5%).

The most common syndrome prompting an ID reviewwas bloodstream infection (13.9%), followed by compli-cated soft tissue infection (7.8%), osteomyelitis (7.2%),cellulitis (5.2%) and surgical site infection (5.2%). Themost frequent final diagnosis was classified as ‘other diag-nosis’ (10%). Of these, a large proportion was malignantor non-infective in nature (46%). Other common finaldiagnoses were osteomyelitis, complicated soft tissueinfection and surgical wound infections. The number ofinpatient consultations per advanced trainee ranged from28.2 to 54.8 per month, with a mean of 42.5 and amedian of 45.1.

Discussion

This audit outlines the inpatient work of an Australiantertiary hospital ID unit over more than a decade. Previ-ously reported rates of ID consultations have ranged from0.9% to 4.1% of admissions.1,14–17 The overall rate in our

Infectious diseases inpatient consultations

© 2014 The AuthorsInternal Medicine Journal © 2014 Royal Australasian College of Physicians 999

study was 1.3%, which sits at the lower end of this range.However, not all the reported studies excluded repeatconsultations (as our study did) and these may accountfor up to 45% of all bedside consultations.1 In fact, in ourhospital, we estimate that each new formal consultationgenerates an average of four follow-up visits.

The stratification of consultations by requesting teamprovided some interesting results, especially in compari-son to recently published Australian data by Ingramet al.11 In addition to examining the volume of consulta-tions, our study was also able to estimate the proportionaluse of the service per specialty by evaluating consulta-tions against OBD and separations. General medicine andorthopaedics generated most consultations, which wasconsistent with the Ingram et al. study. Areas with tradi-tionally high rates of complicated infections and IDinvolvement, such as intensive care and haematology,were surprisingly infrequent users of the service. Whilethe overall volume of consultations from these serviceswas similar to the Ingram et al. study, when stratified by

Figure 1 Consult numbers by year. Note 1999 data are for 6 months only (excluded from statistical analysis). Consultations/1000 occupied bed day (OBD)

slope = 0.23/year, P < 0.001. Consultations/1000 separations slope = 0.84/year, P < 0.001. ( ), Consultations; ( ), consultations/1000 separations;

( ), consultations/1000 OBD; ( ), trendline.

Table 1 Total consultations by requesting team (top 20 only)

Team requesting consultation Total consultation number (%)

1 Orthopaedic 1644 (14.28)

2 General medicine 1311 (11.39)

3 Renal 790 (6.86)

4 Haematology 612 (5.32)

5 Cardiology 573 (4.98)

6 Neurosurgery 569 (4.94)

7 Renal transplant 507 (4.40)

8 Intensive care 500 (4.34)

9 Plastic surgery 447 (3.88)

10 Hepatobiliary 370 (3.21)

11 Cardiothoracic surgery 355 (3.08)

12 Gastroenterology 348 (3.02)

13 Oncology 309 (2.68)

14 Urology 234 (2.03)

15 Vascular surgery 228 (1.98)

16 Respiratory 219 (1.90)

17 Geriatrics and rehabilitation 198 (1.72)

18 Upper GI surgery 192 (1.67)

19 Diabetes and endocrinology 189 (1.64)

20 Spinal injuries unit 187 (1.62)

GI, gastrointestinal.

Bursle et al.


separations they fell to 11th and 17th respectively. At ourhospital, ID case discussion rounds (where all patients arediscussed) occur twice per week in the intensive care unitand once per week in the haematology unit. This regularcollaboration may explain the lower than expected con-sultation rates.

In contrast to the Ingram et al. survey, we had notablyhigher referral rates from renal medicine and very few

consultations from the emergency department. The highconsultation rates from renal medicine (including bothtransplant and non-transplant renal medicine) differedmarkedly from the Ingram et al. study (11% vs 4%). The

Table 2 Consultations by occupied bed days (top 19)

Admitting team Consultations/1000 OBD

Renal transplant 10.19

Renal (not transplant) 9.14

Diabetes and endocrinology 8.83

Intensive care 6.67

Orthopaedic 6.23

Plastic surgery 5.36

General medicine 5.25

Oncology and haematology 4.57

Geriatrics and rehabilitation 4.14

Neurosurgery 4.00

Cardiology 3.99

Gastroenterology 3.98

Cardiothoracic surgery 3.96

Hepatobiliary surgery 3.94

Upper GI surgery 3.19

Respiratory 2.69

Spinal injuries unit 2.67

Urology 2.40

Vascular surgery 2.36


Table 3 Consultations by separations (top 19)

Admitting team Consultations/1000 separations

Spinal injuries unit 79

Geriatrics and rehabilitation 70

Renal (not transplant) 59

Diabetes and endocrinology 59

Renal transplant 40

Orthopaedics 35

Neurosurgery 35

Cardiothoracic surgery 29

General medicine 27

Hepatobiliary surgery 25

Intensive care 19

Respiratory 19

Plastic surgery 17

Vascular surgery 16

Cardiology 13

Upper GI surgery 13

Oncology and haematology 9

Gastroenterology 8

Urology 6


Table 4 Consultations by microbiology† (top 20)

Organism % of total consultations

Staphylococcus aureus (methicillin sensitive) 19.38

Pseudomonas aeruginosa 8.30

Escherichia coli 5.94

Staphylococcus spp. (coagulase negative) 5.81

Staphylococcus aureus (MRSA) 3.93

Enterococcus faecalis 3.84

Enterobacter spp. 3.67

Klebsiella spp. 3.58

Streptococcus spp. 2.22

Candida albicans 2.04

Mixed enteric bacteria 2.02

Streptococcus milleri (intermedius/anginosus) 1.75

Serratia spp. 1.73

Cytomegalovirus 1.49

Candida spp. (non-albicans) 1.45

Staphylococcus aureus (nmMRSA) 1.36

Streptococcus pyogenes 1.31

Streptococcus pneumoniae 1.00

Proteus spp. 0.90

Streptococcus agalactiae 0.88

†Multiple organisms per consultation were allowed.

Table 5 Consultations by syndrome† (top 20)

Syndrome % of consultations

1 Bloodstream infection 13.90

2 Complicated soft tissue infection 7.83

3 Osteomyelitis 7.18

4 Cellulitis 5.17

5 Surgical wound infection 5.15

6 Other 4.76

7 Intraabdominal sepsis 3.68

8 Pneumonia – community acquired 3.55

9 Urinary tract infection 3.21

10 Arthritis 2.74

11 Fever – nosocomial/post-operative 2.54

12 Epidural abscess/Discitis 2.22

13 Diabetic foot infection 2.15

14 Fever – febrile neutropenia 2.10

15 Fever – unclassified 1.89

16 Endocarditis – native valve 1.85

17 Osteomyelitis – prosthesis associated 1.81

18 Pneumonia – hospital acquired 1.54

19 Fever – immune-deficient (not neutropenia or HIV) 1.49

20 Diarrhoea 1.17

†Only one syndrome per consultation was permitted. HIV, human immu-

nodeficiency virus.



size of the PAH renal unit (one of the largest dialysisfacilities in Australia which also performs the highestnumber of renal transplants per year in the SouthernHemisphere) is likely to drive this observation. The addi-tional complexity of this patient population may result inthe high rate of consultation work per OBD and separa-tions. These high rates may also be evidence of effectivecollaboration between the two departments. In contrast,our study revealed a paucity of emergency departmentreferrals. This is partially explained by the exclusion of IDinpatient admissions from our database. However, theselow numbers may also represent further opportunity forearly, formal ID involvement in patient care. Furtherimprovements to the consultation service may beachieved by matching consultation request data withother performance measures (such as antibiotic usageaudits and hospital-acquired or surgical site infectionrates) to identify admitting teams that may beunderutilising the service.

The data pertaining to the microbiology and clinicaldiagnoses most frequently encountered during ID hospitalconsultations are of value in informing research prioritiesand designing programme requirements for ID trainees. Asignificant proportion of syndromes and diagnoses pertainto surgical problems, highlighting the need for solidknowledge of surgical principles by ID physicians, particu-larly in relation to orthopaedics. In contrast, the propor-tion of final diagnoses that were non-infective ormalignant in nature (4.6%, 7th most common) mirrored

recent findings by Ingram et al.11 and underlines the needfor ID physicians to have a broad base of general medicalknowledge. Furthermore, the frequency of ‘other diagno-sis’, while showing the limitations of the database options,also highlights the breadth of ID practice.

The role of the ID advanced trainee includes not onlynew formal inpatient consultations, but also their repeatfollow-up consultations, ID inpatient management, out-patient clinics and informal and phone consultations.This review has given a snapshot of new inpatient con-sultation work only and shows an advanced trainee per-forms approximately 10 new consultations per week.Despite our study excluding ID inpatients, these numbersare very similar to other Australian data.11 Defining thevolume and breadth of new consultations provides aninformed snapshot of this component of ID training andcould help inform college training requirements in thefuture by defining acceptable clinical exposure acrosscore training years.

There was an observed increase in inpatient consulta-tions from 2000 to 2012 that was not accounted for bychanges in hospital separation rates or occupancy. Thereare several potential explanations for this rise. Onesimple explanation is that this reflects ongoing medicalspecialisation in response to an ever-expanding medicalknowledge base and the demands of the community.Alternatively, the increase may reflect a rise in compli-cated infections, driven by changes in patient character-istics, such as ageing and increased immunodeficiency(related to chemotherapy, transplantation and otherforms of immunosuppression) or by changes to microbi-ology, such as rising antimicrobial resistance.

Another explanation for the rise may lie in theincreased recognition of the need for improved antimi-crobial prescribing. In Australian hospitals, inappropriateantibiotic usage rates range from 30% to 80%.18 Such usehas widespread implications, including increasedhealthcare expenditure, the potential for adverse events,increased infection rates with Clostridium difficile andselection for multidrug-resistant pathogens. Further-more, infection with these organisms is associated withincreased length of hospital stay, morbidity, mortality andtheir associated economic costs.19–21 The publicising ofsuch issues, the rising clinical impact of resistance onnon-ID specialist practice and public campaigns such asthe Australian National Prescribing Service’s ‘ResistanceFighter’ programme have heightened understanding ofthe importance of rational antibiotic use. This increasedawareness has potentially played a role in increasing IDconsultations. Furthermore, changes in antimicrobialrestrictions related to the implementation of antimicro-bial stewardship may have served to alert the ID serviceto patients with complicated infections or suboptimal

Table 6 Consultations by final diagnosis† (top 20)

Final diagnoses % of consultations

1 Other final diagnosis 9.96

2 Osteomyelitis 7.89

3 Complicated soft tissue infection 7.86

4 Surgical wound infection 5.06

5 Cellulitis 5.01

6 IV line infection 4.89

7 Intraabdominal sepsis 4.56

8 Urinary tract infection 4.53

9 Bloodstream infection 3.92

10 Pneumonia – community acquired 3.87

11 Fever – cause unknown 3.42

12 Unspecified 3.32

13 Endocarditis – native valve 2.45

14 Epidural abscess/discitis 2.22

15 Septic arthritis 2.21

16 Diabetic foot infection 2.02

17 Osteomyelitis – prosthesis associated 2.02

18 Pneumonia – hospital acquired 1.96

19 Empyema – thoracic 1.09

20 Meningitis – post-neurosurgical/drain associated 1.02

†Only one final diagnosis per consultation was permitted. IV, intravenous.

Bursle et al.


therapy who would not have otherwise had ID specialistinvolvement.

Alternatively, the rise in formal consultations may rep-resent a move away from informal ‘curbside’ or phoneconsultations. Informal consultations represent a largeproportion of ID physician consult work,1,22–26 with ratesup to 73% of all consultations in one study.27 However,the effect of such consultations has been poorly evaluatedand outcomes may be inferior for some conditions suchas S. aureus bloodstream infection.28 There has also beenconcern regarding the quality of the information trans-ferred24,29 and the medicolegal implications of informalconsultations.29,30 The rise we observed might representrecognition of the added value of converting some infor-mal consultations into a bedside review, from both aclinical and legal standpoint. However, as informal con-sultations were not recorded in our database, we wereunable to ascertain whether the rise in bedside consulta-tions had been offset by a drop in informal advice.

As a result of this review, our consult database has beencomprehensively rewritten. This included standardisinglists of diagnoses, syndromes and organisms, the additionof free-text fields for ward round notes and admissionsummaries, along with antibiotic usage information. Thedatabase now allows automatic generation of ID-specificdischarge summaries for consultation patients whorequire follow up and for referral to the outpatient anti-biotic service. This is important for patient care, as IDfollow-up plans are often poorly detailed in the admittingteam’s discharge documentation. The system could befurther enhanced by developing a convenient and reli-able mechanism for capturing repeat, informal andphone consultations.

There are several limitations of this review. Firstly, thisaudit represents the experience of a single centre andmay not be generalisable to other settings. Secondly,during the long study period, data entry variability mayhave occurred due to differences in registrar evaluationsand data collection. Furthermore, poor standardisation of

the final diagnosis list resulted in a higher than expectedfinal diagnosis of ‘other’ and limited the usefulness ofthese data. In addition, our database did not collect infor-mation on repeat, informal or phone consultations,which may form a significant portion of the workload.Identifying the pattern of these consultations mayprovide useful insight into the complexity of the consul-tations provided and further inform workforce and train-ing requirements. Finally, this audit is unable to providean accurate estimation of the cost-effectiveness or clinicalbenefit of an ID consult. Collecting detailed data regard-ing changes made to a patient’s diagnosis or managementas a result of an ID consultation may assist in this regard.However, this type of analysis is likely to remain subjec-tive and a formal assessment of the benefit of ID consul-tations would be limited by many confounders.

Conclusion

This review provides a reflection on the consult practiceof an Australian ID tertiary hospital and its changes overrecent years. The increasing demand for ID consultationsmay reflect recognition of the value of hospital ID phy-sicians. However, as a largely consult-based service, thevalue of an ID unit can be difficult to quantify; thus,ongoing auditing is essential to the quality assurancepractice of the service. These data can enhance planningin several areas, including directing services to potentiallyneglected areas, informing the direction of research andthe training of ID physicians. Furthermore, it can be usedto assess changing service demands and cost-effectiveness, thus informing future funding applications,workforce planning and service provision.

Acknowledgement

The authors gratefully thank Mr David McDougall (Prin-cess Alexandra Hospital Infection Management Services)for statistical analysis.

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Infectious diseases consultations at an Australian Tertiary Hospital: a review of 11 511 inpatient consultations