Putting the cart before the horse: Development of a de novo clinical infectious diseases service

Infectious diseases, as a specialty in Canada, traces its roots to the late 1960s (1. Following rapid growth of the specialty over the subsequent decades, infectious diseases programs were widely implemented in major centres across the country, although less so in smaller centres. In part related to career opportunities for new graduates, shifting value structures amongst trainees, and in response to patient care needs and health services planning, there has been increasing interest in expanding infectious diseases services to new sites. Little has been written about the subject of new program development. Authors EP and KL developed a new comprehensive clinical infectious diseases program in the interior of British Columbia, centred in Kamloops. In this article, we describe our program building trajectory, challenges, and successes with the hope that our experience might be helpful to others embarking on a similar pursuit.

Program development

Publicly administered health care is provided to residents of British Columbia via five health authorities, with Interior Health responsible for the southern interior region of the province (2. Interior Health is divided into four health service areas with the Thompson Cariboo Shuswap subregion serving a population of 230,000 residents over a large (120,000 km²) geographically diverse predominantly rural area (3. Tertiary care is provided at Royal Inland Hospital (RIH) in Kamloops (population 117,000), with 254 beds operating an average annual 115% occupancy (4). Most services are offered to adults at RIH, with the exceptions of invasive cardiac procedures, elective cardiothoracic surgery, organ and stem cell transplantation, and care of patients with major burns.

In 2013, Dr Kevin Laupland, a specialist in critical care medicine and infectious diseases, was hired as an intensivist at RIH. At that time, a formal infectious diseases position was neither available nor planned administratively. Infectious diseases consult requests were initially performed in an ad hoc and infrequent (<1–2 per week) manner, but gradually demand grew. The need for a coordinated outpatient program was evident with the overuse of the emergency department for the management of acute infections, particularly those requiring intravenous antibiotic therapy. Relationships were forged with the existing peripherally inserted central catheter (PICC) nurses and outpatient parenteral therapy program nurse coordinator and pharmacists culminating in the first semblance of a multidisciplinary program (5. A rudimentary clinic room was acquired in the ambulatory care unit, and a small roster of patients began to visit the clinic.

Major growth in the program ensued with an approximate doubling of clinical load every 6 months. A concomitant shift in attitudes amongst colleagues and administrative staff regarding the value of the infectious diseases consult occurred consistent with the Pavese et al survey demonstrating requesting physicians’ high level of satisfaction for the infectious diseases consultation (6. A second physician, Dr Elizabeth Parfitt, was hired in 2015 in order to meet increasing demand and to provide Internal Medicine consultation. A shared practice model was employed to ensure consistent availability for patient care support and promote the team approach. Growth continued: a modern clinic space was secured in an outpatient-focused hospital expansion, clinic hours were expanded, and by 2017 we reached a relatively steady state of outpatient patient care events (Figure 1).

Figure 1:

Infectious diseases outpatient visits per quarter, Kamloops, 2017–2019

The present-day clinical infectious diseases service

There are now three full-time infectious diseases consultants practising in a multidisciplinary team setting with pharmacists, nurses, and support staff. The general clinical practice resembles the description in Ingram et al, “What do infectious diseases physicians do?” (7. Services include weekday inpatient consultation (average 10–20 per week), outpatient clinics, regional telephone consultations, an interdisciplinary complex wound clinic with vascular surgery and advanced practice nursing, and a weekly HIV/PrEP clinic. The outpatient clinic is a fusion of a traditional general infectious diseases clinic, an outpatient parenteral antibiotic therapy clinic, and a rapid access clinic (8. A multidisciplinary viral hepatitis clinic is being implemented. Virtual care (telehealth) services are provided on an as-needed basis in order to address the needs of a geographically distributed population (9. Since 2017, region-wide after hours and weekend call is offered in collaboration with colleagues in Kelowna. Our physicians are active participants in medical education and research (10,11).

Reflections and lessons learned

Our initial development occurred in a bottom-up fashion in direct response to patient care needs rather than as a result of top-down administrative efforts. At times, our strategy was more in keeping with better to ask for forgiveness than permission due to the rapid evolution of challenges in the context of program growth. Initially, existing resources and staff (such as the outpatient parenteral therapy nurse coordinator and pharmacists) were reorganized into a coordinated unit without additional investment. Further programmatic success was supported through increased resourcing. Program expansion occurred and continues to do so in small, iterative cycles with rapid response to team members’ creative input as well as perceived patient care gaps. All efforts are made to be highly accommodating and responsive to consult requests in order to bolster the service’s reputation.

Our group has embraced the spirit of multidisciplinary care and created alliances with allied health professionals and other physicians, perhaps best represented by our complex wound program (12). Infectious diseases providers are well poised to form alliances with other disciplines since we share patients with virtually all medical and surgical specialties. The medical literature is clear regarding the value of multidisciplinary care with improved outcomes, perhaps best established in cancer care (13). Within our program, and analogous to a “tumour board” round, we meet weekly to discuss processes and agree on care plans for complex patients. Nurturing a functional team culture is taken very seriously, since team dynamics and the need for individual recognition are strong predictors of career satisfaction and resilience (14.

Engaging with our leadership team early on was very helpful in order to garner support, focusing on expected cost savings to the facility and decongesting emergency department and acute care beds. The use of tools such as business cases and decision briefs has been invaluable for affecting the desired change. Our physician group has sought out opportunities for leadership development, and durable relationships have been established with administrators.

A new infectious disease program will not be successful without a viable financial plan. In the absence of salary model availability, there will inevitably be a lean period in the start-up phase. Although each of our current three full-time infectious diseases consultants only practices that discipline, in the development phase the consultants had roles in other disciplines. In starting a new practice, it is difficult to say whether there will eventually be enough infectious diseases specific work to support a reasonable income. Our experience, echoed by an analysis of the infectious diseases workforce (15, suggests that at least one clinical full-time equivalent may be supported per 100,000 population. Infection prevention and control and antimicrobial stewardship are not served well by the fee-for-service payment model and require sessional or salaried funding. While in progress, to date our involvement with these programs has been negligible.

In summary, we provide a description of our clinical infectious diseases program development “from scratch” and share our successes and challenges. Our experiences may be illustrative to trainees in meeting the Royal College of Physicians and Surgeons of Canada’s Infectious Diseases Training Objectives surrounding practice management and program planning, budgeting, and evaluation (16. Our practice has evolved to be highly rewarding. We work with outstanding colleagues in a friendly and collaborative environment, and our unselected patient population means that we have the pleasure of managing a broad spectrum of infectious diseases not restricted to subdisciplines. Employing an iterative design strategy to respond to patient and provider needs has enabled us to adapt quickly with high provider satisfaction. Fostering relationships within our team and with other specialists has helped to create a meaningful work environment and broadened our own horizons and understanding across disciplines. Importantly no a priori plan existed for our program. This evolution may be helpful to those considering developing new programs elsewhere—that is, to take the first step, see the first patient, and the program will follow.

Competing Interests:

The authors have nothing to disclose.

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Funding:

No funding was received for this work.

Peer Review:

This article has been peer reviewed.