Consultation outcomes in the emergency department: exploring rates and complexity

Abstract

Objective: Consultation is a common and important aspect of emergency department (ED) care. We prospectively examined the consultation rates, the admission rates of consulted patients, the emergency physician (EP) disposition prediction of consulted patients and the difficult consultations rates in 2 tertiary care hospitals. Methods: Attending EPs recorded consultations during 5 randomly selected shifts over an 8-week period using standardized forms. Subsequent computer outcome data were extracted for each patient encounter, as well as demographic data from the ED during days in which there was a study shift. Results: During 105 clinical shifts, 1930 patients were managed by 21 EPs (median 17 patients per shift; interquartile range 14-23). Overall, at least 1 consultation was requested in 38% of patients. More than one-half of the patients (54.3%) who received a consultation were admitted to the hospital. Consultation proportions were similar between males and females (51% v. 49%, p = 0.03). Consultations occurred more frequently for patients who were older, had higher acuity presentations, arrived during daytime hours or arrived by ambulance. The proportion of agreement between the EP's and consultant's opinion on the need for admission was 89% (κ = 0.77, 95% confidence interval 0.72-0.83). Overall, 92% of patents received 1 consultation. Six percent of the consultations were perceived as "difficult" by the EPs (defined as the EP's subjective impression of difficulties with consultation times, accessibility and availability of consultants, and the interaction with consultants or disposition issues). Conclusion: Consultation is a common process in the ED. It often results in admission and is predictable based on simple patient factors. Because of perceived difficulty with consultations, strategies to improve the EP consultation process in the ED seem warranted. RÉSUMÉObjectif : La consultation est un aspect courant et important des soins prodigués à l'urgence. Nous avons étudié prospectivement, dans deux centres de soins tertiaires, les taux de consultation, les taux d'admission des patients vus en consultation, les prédictions du médecin d'urgence quant à l'issue des patients vus en consultation ainsi que les taux de difficulté des consultations. Méthodes : Les médecins d'urgence traitants ont consigné, sur des formulaires normalisés, les consultations réalisées pendant cinq quarts de travail choisis au hasard sur une période de huit semaines. Subséquemment, des données informatiques des résultats ont été extraites pour chaque ORIGINAL RESEARCH • RECHERCHE ORIGINALE EM ADVANCES

Understanding the Impact of Residents' Interpersonal Relationships During Emergency Department Referrals and Consultations

“…[3][4][5][6][7][8][9][10] Research has explored nonemergent consultations by family medicine physicians 3,4 and the attitudes of consultants during telephone-only consults. 5 In the research on urgent or emergent consultations, [8][9][10][11][12][13][14][15] most studies sought to define and quantify the emergency department (ED) consultation process. [8][9][10][11][12][13] With the advent of the ACGME core competencies and Milestone Project, 16 the teaching and learning of interpersonal and teamwork skills are increasingly highlighted.…”

“…5 In the research on urgent or emergent consultations, [8][9][10][11][12][13][14][15] most studies sought to define and quantify the emergency department (ED) consultation process. [8][9][10][11][12][13] With the advent of the ACGME core competencies and Milestone Project, 16 the teaching and learning of interpersonal and teamwork skills are increasingly highlighted. To our knowledge this is the first study that has explored interpersonal factors that may influence resident communication during the referral-consultation process within the context of the ED.…”

Evaluation of Consultations Requested from Patients Admitted to the Emergency Department

“…The proportion of hospitalizations for those patients receiving specialist consultations is highly variable. Cortazzo et al (12) reported that 87% of all consulted patients were admitted, and Woods et al (13) reported that a proportion of 54% were admitted. Curry and Wang (14) reported an admission rate of 68% for the highest acuity site and 64% for the lowest acuity site.…”

Assessment of consultation impact on emergency department operations through novel metrics of responsiveness and decision-making efficiency

“…Consultations with inpatient colleagues are used for approximately one-third of patients seen in highvolume, urban tertiary care emergency departments (EDs) in Canada. [1][2][3] In the consultation process, emergency physicians contact specialty services to assist in a patient's care. Requests for consultation are made for different reasons, including hospital admission, treatment or procedure (performed by the consulting service), opinion only, and outpatient referrals.…”

“…[6][7][8][9][10] Some of the problems identified by emergency physicians include the accessibility and availability of consultants, interactions with consultants, and the disposition decision process. 2,3 Despite their importance, little is known about the causes of consultation delays and the metrics required to measure them.…”