The consult service covers all nephrology inpatient consults within Barnes-Jewish Hospital (North and South Campus). The service is split up into three parts, including two traditional attending-fellow teams and one Renal Hospitalist attending who sees patients on his/her own. Patients from the CCU (8200) and CT-ICU (5600) are preferentially assigned to one of the attending-fellow teams (Consult I) while patients from the MICU (8400) and SICU (4400) are preferentially assigned to the other attending-fellow team (Consult II). Patients from the Neuro ICU and BMT do not have specific assignments.
Walk rounds with the attending typically begin at 8 a.m. with teaching/sign-out rounds at 1p.m. in the 14300 (acute dialysis) conference room. After-hours coverage begins at 4 p.m. with home-call (on Q6 rotating basis). The average census is 18-24 patients per team. Renal Fellows are capped at 20 patients per day, with the balance seen by the resident or alternatively the attending.
The primary responsibility on this service is to cover chronic dialysis patients within our system. This service cares for patients receiving outpatient dialysis at the Chromalloy American Kidney Center with weekly attending rounds as well as inpatient consultative care when these patients are admitted to Barnes-Jewish Hospital. Patients from the Barnes-Jewish Dialysis Unit also are covered by this service when admitted to the hospital. The fellow rotates on the Q6 call schedule, although other consults seen after-hours are passed onto the consult teams in the morning. The average in-patient census is 8-10 patients.
The fellow on this service provides after-hours coverage in the call-cycle (Q6), with the Renal Hospitalist providing attending coverage. Consults seen overnight are handed off to the Renal Hospitalist the following morning. During the day, the fellow is free to work on any other academic pursuits.
The procedure fellow serves as the “backup” for fellows on service. There are four responsibilities while on this rotation:
- Triage: The fellow holds the consult pager from 8 a.m. until noon, Mon.-Fri., and distributes the new consults to the inpatient consult teams (fellows/hospitalists). This allows the consult teams to round on old patients in the morning without being constantly interrupted by the call pager.
- Procedures: If assistance is required for line placements, the procedure fellow steps in to do it. The fellow also performs native kidney biopsies.
- Coverage: This fellow steps in to cover clinic for colleagues who are on vacation. The fellow also comes in on two Saturday mornings each month to cover the consult fellow who has the day off.
- Conferences: The procedure fellow is responsible for presenting two cases and a Journal Club each month for the Thursday noon conference.
There are two fellows on the transplant service each block. Typically, one is a general nephrology fellow and the other is a transplant nephrology fellow. Patients are seen with the transplant team (attending, nurse practitioner, surgical team), managing new transplants, impending transplants and old transplants with new renal complications. This service also provides in-patient consultative service for acute kidney issues in patients with solid organ transplants other than kidneys. The average census is 16-24 patients. Overnight, most coverage is handled by the internal medicine hospitalist service, although questions specifically relating to the kidney or about a new or recent transplant are directed to the fellow on-call and may require the fellow to come in to evaluate the patient. This most commonly occurs when a deceased-donor kidney becomes available after-hours and the fellow is required to prepare a recipient prior to the operation. Call alternates between the two fellows on service.
Each fellow is assigned to an outpatient general nephrology clinic that meets one half-day per week. Patients are staffed with the clinic attending and the goal is to maintain longitudinal follow-up over the course of two years. Subjects covered include chronic kidney disease, acute kidney injury, glomerular diseases, inherited diseases of the kidney, hypertension, nephrolithiasis and electrolyte disturbances. For one half-day in the month, each fellow also participates in an outpatient peritoneal dialysis clinic, with a dedicated roster of patients to maintain continuity.
The in-patient rotation schedule reflects those fellows who have an in-patient role. When off-service, first-year fellows should use the time to read, study and identify research mentors and projects. Second-year fellows are expected to use this time to complete research projects and for elective rotations (HTN clinic, GN clinic, VIR exposure, pathology, home modalities, etc).