Inpatient Dermatology Consultation Research Articles

51209 Utilization of a Formalized Manual to Improve Residents’ Comfort Level with Inpatient Dermatology Consultations

51209 Utilization of a Formalized Manual to Improve Residents’ Comfort Level with Inpatient Dermatology Consultations

A Critical Assessment of Inpatient Dermatology Service Line in the Rural United States

Objective: We sought to classify dermatologic conditions presenting in rural inpatient hospitalization. Methods: Retrospective chart review. Conclusion: Limited rural dermatology care in the United States prompted the establishment of an inpatient dermatology consult line in rural Upstate New York. Over 3 years, 27.7% of consults were admitted for dermatologic concerns, 21.5% for both dermatologic and medical issues and, 50% for non-dermatologic reasons but later seen by dermatologists. Common conditions included eczematous rashes, infections, drug reactions, edematous skin conditions, and autoimmune diseases. Among patients admitted for dermatologic concerns, cellulitis (3) and rashes (3) were the most common. Interestingly, 74% of provisional dermatologic diagnoses matched final diagnoses before further workups. Approximately 58.5% of consults were deemed highly valuable. Followup showed 73.8% improvement, 23.1% deceased from different pathologies, and 3.1% stable. Understanding the rural dermatology landscape could enhance access, diagnostic accuracy, and the feasibility of inpatient consult services. Understanding the rural dermatology landscape may improve access to specialist care, increase diagnostic accuracy, reduce disease burden and associated costs, and communicate the feasibility of inpatient consult services either in-house or via teledermatology to rural hospital systems.

Acute Interstitial Inflammation on Skin Biopsies and Positive Tissue Cultures in Cellulitis Patients Are Associated a Worse Prognosis.

Cellulitis is a significant public health burden and lacks a gold standard for diagnosis. Up to 1/3 of patients are incorrectly diagnosed. The skin biopsy has been proposed as the gold standard. In this study, we evaluate the histopathologic characteristics and tissue culture positivity of biopsies in patients diagnosed with cellulitis seen by our inpatient dermatology consultation service. This retrospective cohort study examined patients who were hospitalized with a skin and soft tissue infection at our institution between 2011 and 2020 and underwent a skin biopsy. Those with a positive tissue culture were more likely to die within 30 days compared with those with negative tissue cultures (26% vs. 6%, P = 0.048). Patients who died within 30 days were more likely to have acute interstitial inflammation as a feature on histopathology (38%, P = 0.03). Single institutional design, unintentional exclusion of patients with organism-specific diagnosis, and selection for a medically complex patient population because of the nonroutine collection of biopsies. Positive tissue cultures and histopathology showing acute interstitial space inflammation on skin and soft tissue infection (SSTI) biopsies are associated with increased mortality and thus may serve as indicators of poor prognosis.

Document by example: resident perception of SmartPhrases for inpatient dermatology consultations.

Document by example: resident perception of SmartPhrases for inpatient dermatology consultations.

42757 Inpatient dermatology consultations in patients with connective tissue diseases

42757 Inpatient dermatology consultations in patients with connective tissue diseases

Psychiatric comorbidities on an inpatient dermatology consultation service: A cross-sectional analysis.

Despite the high prevalence of psychiatric illness in hospitalised dermatology patients, characterisation of psychiatric comorbidities on an inpatient dermatology consultation service in the United States has yet to be performed. To fill this gap in knowledge, we investigated the prevalence of and factors associated with psychiatric illness on the inpatient dermatology consultation service at the University of Southern California. Of the 429 patients seen by the dermatology consultation service between June 2021 to July 2022, 147 (34%) had psychiatric illness (defined as having at least 1 psychiatric diagnosis). Increasing age was associated with a decreased likelihood of psychiatric illness, while housing instability, chronic dermatologic disease, drug reaction, and pruritus without rash were associated with an increased likelihood of psychiatric illness. The high prevalence of psychiatric illness observed in hospitalised dermatology patients emphasises the importance of collaboration between consultant dermatologists and mental health specialists, particularly when specific sociodemographic or disease factors are present.

Palliative Care: Utilization Patterns in Inpatient Dermatology.

Palliative care (PC) focuses on improving the quality of life of patients with serious illnesses. The use of PC in the field of dermatology is limited despite the presence of severe disease. In this cross-sectional study of inpatient dermatology consultations, we aimed to evaluate PC utilization among patients hospitalized with select severe dermatologic diseases. Our results suggest that PC may be underutilized when caring for patients with serious skin diseases. Palliative care should be an integral part of caring for patients with serious illnesses, and further research characterizing ways this can be accomplished by dermatologists is needed.

Inpatient Dermatology Consultation Services in Hospital Institutions.

Inpatient dermatology plays a key role in the hospital system. Dermatology-related admissions are frequent, and the correct diagnosis and management of cutaneous conditions is crucial to improving patient outcomes and decreasing health care costs. As a dermatology resident, it can be challenging to perform inpatient consultations, especially early in residency. Focusing on pre-rounding and must-ask questions of requesting providers as well as carrying an organized toolbox will be invaluable for every dermatology resident.

Concordance of diagnostic modalities in atypical skin and soft tissue infections in hospitalized patients.

Skin and soft tissue infections (SSTIs) have high rates of morbidity and mortality worldwide but lack reliable standards for diagnostic workup. As a result, atypical infections, more prevalent among immunocompromised patients, can be missed due to deviance from classic features only to be revealed later through inconsistently performed ancillary studies. Our objectives included to evaluate the sensitivities of clinical impression, histopathology, tissue culture, and molecular and non-molecular ancillary tests in diagnosing inpatient SSTIs, as well as to qualitatively discuss the unusual features making a subset of infections "atypical." To do so, we retrospectively reviewed the histopathologic reports and charts of inpatient dermatologic consults at a single tertiary care institution over a 3-year period. We identified a total of 111 cases of SSTIs evaluated by the inpatient dermatology consultation service with concurrent skin or soft tissue biopsy, with 32.4% representing atypical infections. Among these, clinical impression suggested infection in 9(25.0%), routine histopathology in 21(58.3%), specialized stains for microorganisms in 22(68.8%), and tissue culture in 15(68.2%). Due to incomplete picture that each modality by itself creates, we conclude that clinicians and pathologists should carry a low threshold for including SSTIs in their differential diagnoses and should evaluate with skin biopsy, special stains for microorganisms, and ancillary studies, particularly in critically ill individuals who necessitate timely diagnoses.

34181 Consultation of other services delays dermatologic care for inpatient skin disease

Background: Consultation of dermatology for inpatient skin disorders enhances care by changing diagnoses, management plans, and reducing length of stay. Methods: Retrospective chart review of all inpatient dermatology consults from October 1, 2013 to December 31, 2016 at five hospitals within the Detroit Medical Center (Detroit, MI). Data collected included demographics, diagnosis and management plans from primary and consulting teams, as well as timing of initial recognition of skin problem and consult to dermatology and other specialties. Results: 873 consultations met criteria and were included for analysis. Median age was 45 years, 61% were African American, and 51% were female. Of the total, 258 (29.6%) patients had multiple specialties consulted. Comparing patients with only dermatology consults against those with other additional specialties, time to dermatology consult was 5.6 vs 17.1 hours respectively. Furthermore, 61 (7.0%) patients had another specialty consulted >24 hours prior to dermatology. Delay in dermatology consultation after other specialties was associated with an increased median length of stay of 7.0 days vs 4.0 days with no delay (P < .05). Delay was also associated with more referrals from internal medicine or pediatrics (80.3% vs 67.5%) and less from infectious disease (4.9% vs 17.3%) as the primary team. Conclusion: Delay in inpatient dermatology consultation is infrequent, but is associated with consultation of other specialties, increased length of stay, and referral from internal medicine and pediatrics.

33379 Melanophages save the day: A case of generalized bullous fixed drug eruption

A 29-year-old female was seen via inpatient dermatology consultation for acute erosive stomatitis. Upon admission for sickle cell crisis, the patient had an incidental urinary tract infection and was treated with trimethoprim-sulfamethoxazole for 3 days. On physical examination, she had painful superficial erosions of the upper and lower mucosal lips extending onto the vermillion as well as the distal and ventral tongue. Five large dusky violaceous plaques with overlying superficial erosions were seen on the bilateral proximal medial thighs, arms and on the left lateral abdomen. Punch biopsy of the violaceous plaques revealed a vacuolar interface dermatitis with full thickness necrosis overlying an inflammatory infiltrate with occasional interstitial eosinophils and many melanophages at the level of the superficial vascular plexus. While the pathologic differential diagnosis included EM as well as SJS/TEN, the melanophages, eosinophils and clinical findings favored a diagnosis of generalized bullous fixed drug eruption (GBFDE) secondary to trimethoprim-sulfamethoxazole. GBFDE is a particularly severe variant of FDE which often includes mucosal erosions. Differentiation from SJS/TEN may sometimes be clinically and histologically difficult, and patients may suffer high morbidity and mortality. In our patient, we treated aggressively and cautiously with IV methylprednisolone followed by oral prednisone with no disease progression and eventual complete resolution. The clinical findings suggestive of FDE along with dermal melanophages and eosinophils allowed a cautious but confident diagnosis of GBFDE without need for transferring our patient to a burn unit.

Use of a hybrid teledermatology model in an Australian tertiary hospital during the COVID-19 pandemic

To the Editor: The COVID-19 pandemic has led to the adoption of teledermatology by health services across the world. There is increasing support for the use of teledermatology in the outpatient setting; however, its role in inpatient and emergency settings is less established. We reported the use of teledermatology in inpatient and emergency settings at the Dermatology Department, St George Hospital, a tertiary center in Sydney, Australia. Inpatient and emergency consultations are conducted at our institution by 1 of 2 staff dermatologists per day and 1 hospital-based dermatology resident. A hybrid model of inpatient teledermatology consultations was established prior to the COVID-19 pandemic. All referrals would be seen face to face by the dermatology resident to ensure relevant history, and high-quality clinical and dermatoscopic photographs would be taken. The referrals would then be summarized and sent to the on-call dermatologist, who would provide an impression and plan for the resident to enact. For severe or life-threatening cases, the on-call dermatologist would also attend the face-to-face consultation. This system involved both synchronous and asynchronous models depending on the triaging of consultations performed by the dermatology resident. To avoid the exposure of the on-call dermatologists to COVID-19, which would subsequently shut down the provision of dermatology services to both outpatient and inpatient or emergency services, this hybrid model of inpatient teledermatology was maintained during the pandemic, and outpatient clinics were converted to teledermatology for large proportions of 2020 and 2021. Using this hybrid approach, our dermatology service avoided any shut down periods due to the exposure of the 2 on-call dermatologists to COVID-19. The main exposure site for COVID-19 was the emergency department, and this was the main source of inpatient referrals (Fig 1). There was no statistically significant difference (P > 0.05, Student t test) in the number of inpatient consultations seen between pre-COVID-19 2019 (n = 295; mean, 27 consultations per month; SD, 10.9) and 2020 (n = 305; mean, 25 consultations per month; SD, 6.3) or 2021 (n = 323; mean, 27 consultations per month; SD, 8.1).1Ho G. Blake S.C. Sheriff T. Daniel B.S. Murrell D.F. Impact of COVID-19 on inpatient dermatology consults in an Australian tertiary hospital.Australas J Dermatol. 2021; 62: 427-428Crossref PubMed Scopus (3) Google Scholar This may have been due to the establishment of the hybrid model of inpatient teledermatology. In 2021, 70% of inpatient consultations had a treatment plan provided to the referring team within the same day of referral. The role of teledermatology to increase the efficiency of inpatient consultations was described prior to the COVID-19 pandemic, with reduction in the time taken for inpatient medical teams to receive advice from dermatology consultants.2Sharma P. Kovarik C.L. Lipoff J.B. Teledermatology as a means to improve access to inpatient dermatology care.J Telemed Telecare. 2016; 22: 304-310Crossref PubMed Scopus (25) Google Scholar Concordance in investigations and treatment plans between teleconsultations and face-to-face consultations has also been described.3Keller J.J. Johnson J.P. Latour E. Inpatient teledermatology: diagnostic and therapeutic concordance among a hospitalist, dermatologist and teledermatologist using store-and-forward teledermatology.J Am Acad Dermatol. 2020; 82: 1262-1267Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,4Gabel C.K. Nguyen E. Karmouta R. Liu K.J. Zhou G. Alloo A. Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease.J Am Acad Dermatol. 2021; 84: 1547-1553Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The COVID-19 pandemic has seen wider adoption of teledermatology services.5Loh C.H. Tam S.Y. Oh C.C. Teledermatology in the COVID-19 pandemic: a systematic review.JAAD Int. 2021; 5: 54-64Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The experience of our department supports the use of teledermatology for efficient delivery of care that has been stable throughout the COVID-19 pandemic. Our experience supports use of a hybrid model of teledermatology rather than a virtual model and can be applied in other parts of the world. None disclosed.

Valuing the Inpatient Dermatology Consult Service at a Single Academic Institution

Valuing the Inpatient Dermatology Consult Service at a Single Academic Institution

The Role of Photography in Increasing Efficiency of Dermatologic Inpatient Consulting Service

Introduction: Inpatient dermatology consultations can bring a mixed bag of pathologies. Due to the highly specialized nature of dermatology and the lack of dermatologic training in medical school, the dermatologic team is consulted for matters that range from non-urgent to pressing. Pictures are a critical component of dermatology and greatly aid in the diagnosis of cutaneous diseases. In the inpatient setting, pictures can help streamline diagnosis and prevent unnecessary tests or procedures. The purpose of this study was to evaluate for the presence of pictures in patients’ chart after a dermatology consult had been placed through EPIC at the University of Nebraska Medical Center (UNMC). Methods: Baseline data was gathered for two months in regards to the presence or absence of pictures in patients’ charts upon consultation of the UNMC academic dermatology service. At the two month mark, a prompt was added to the EPIC order for dermatology consultation stating, “Are there pictures in the chart?” This prompt required the consulting team to check ‘yes’ or ‘no’ before proceeding with signing the electronic order. Data was then gathered after two months following initiation of the prompt. Results: In the baseline two months, 15/33 (45.4%) consults contained photographs. In the two months following the prompt, “Are there pictures in the chart?”, 57/71 (80.3%) of consult orders placed contained a photograph. A Chi-squared analysis was preformed and revealed a significant difference (Chi-squared statistic 12.823, p-value < 0.001) between the number of pictures placed in the chart with consult order before and after prompt. Conclusion: By adding a prompt in the EPIC order questioning picture availability, a significant increase was seen in pictures taken by consulting teams. This can help improve patient care by decreasing time to diagnosis, preventing unnecessary testing or procedures, and practicing cost-efficient medicine.

The Role of Inpatient Dermatology Consultations.

Inpatient dermatology has been shown to have profound effects on the care of hospitalized patients. However, dermatology consultations remain an underutilized resource. The purpose of this study was to demonstrate how dermatology affects the hospitalization of inpatients while highlighting the breadth of services provided. This cross-sectional retrospective study included all inpatient dermatology consultations completed at a large tertiary-care facility in an urban setting. It aimed to investigate the reasons for consultation, as well as the effects on diagnosis, management, disposition, and cutaneous condition by time of discharge. This study provides evidence supporting the integration of the dermatologist into the care of hospitalized patients by illuminating lesser-known areas of impact.

28644 Inpatient training modules increase dermatology resident confidence for hospital consults

Inpatient dermatology consults are an integral aspect of dermatology resident training. These cases allow for managing acute and life-threatening dermatologic disorders, exploring complex medical dermatology in an acute care setting, and working in interdisciplinary teams to promote patient care. Residents often feel unprepared to care for such complicated patients due to lack of specific training for the inpatient setting. We outline one program’s approach to logging inpatient cases and the creation of training modules given to PGY-2 residents prior to seeing inpatient dermatology consults.

27971 Single institution experience with a dermatology hospitalist service

The dermatology hospitalist model was first defined by the Society of Dermatology Hospitalists in 2009; however, scant evidence exists to demonstrate its institutional benefit. Dartmouth-Hitchcock Medical Center established a formal dermatology consult service in early 2019, for which we named a director, ensured faculty continuity, and enacted earlier rounding times to communicate with primary teams. Here, we examine the value of an inpatient dermatology consult service at our institution. Both utilization and value of the service were determined for the year 2019 through analysis of the number of consults, consulting team, provisional diagnosis of primary team, final diagnosis of the dermatology service, performance of inpatient biopsy, and scheduled follow-up for hospitalized patients.

27165 Virtual teledermatopathology clinicopathologic correlation rounds for inpatient skin biopsies: A quality improvement project

Three-quarters of dermatology programs have dermatopathology (DP) rotations, but these largely occur in the final year of residency. Standard teaching with microscopes and glass slides is limited by available space, inconvenient locations, and new need for social distancing during the COVID-19 pandemic. These barriers are particularly salient for inpatient consultative dermatology services, which biopsy a broad range of pathologies and provide value in rapid clinicopathologic correlation. Several studies have assessed modifying curricula with digital platforms and online databases of virtual slides, but the use of live interactive teledermatopathology (TDP) to actively review skin biopsies performed by the dermatology inpatient consult service has not been systematically evaluated. In this study, a retrospective chart review of a representative baseline 3-month period found that only 2 out of 36 (6%) biopsy slides were personally reviewed by the consultative dermatology team. Our intervention uses live-interactive video slide TDP rounds to review skin biopsies performed by the inpatient dermatology consult service, sampled during a 3-month study period. The primary outcome is proportion of slides reviewed by the inpatient consultative team compared with the historical control period. We use slide capture software in combination with a secure HIPAA compliant platform that integrates chat, video conferencing, and clinical images. One and a half months into the intervention, 25/27 (92.6%) biopsies have been reviewed by the inpatient consult team. Conference discussion and clinicopathologic correlation has likely led to a change in clinical and pathologic interpretation in at least three cases.

Predictors of postdischarge follow-up attendance among hospitalized dermatology patients: Disparities and potential interventions

Predictors of postdischarge follow-up attendance among hospitalized dermatology patients: Disparities and potential interventions

Analysis of inpatient dermatology consultations in a veterans affairs hospital

To the Editor: The John D. Dingell Veterans Affairs (VA) Medical Center includes an onsite inpatient dermatology consult service that provides a unique opportunity to identify skin conditions associated with inpatient dermatologic requests. The aim of this study was to describe dermatology inpatient consultations in a VA hospital.