Improving Timeliness of Internal Medicine Consults in the Emergency Department: A Quality Improvement Initiative

Abstract

Introduction: Emergency department (ED) wait time is an important health system quality indicator. Prolonged consult to decision time (CTDT), the time it takes to reach a disposition decision after receiving a specialty consultation request, can contribute to increased overall length of stay in the ED. Objective: To identify delays in the consultation process for general internal medicine (GIM) and trial interventions to reduce CTDT. Methods: The study was conducted at a large tertiary teaching hospital with GIM inpatient wards at two campuses. Four interventions were trialed over sequential Plan-Do-Study-Act cycles: (1) process mapping, (2) resident education sessions, (3) audit and feedback of CTDT, and (4) adding a swing shift during peak consult volume. Measurements: The primary outcome measures were mean CTDT for patients admitted to GIM and the proportion of admitted patients with CTDT of less than 3 hours. Results: Mean CTDT decreased from 4.61 hours before intervention to 4.18 hours after intervention (p < .0001). The proportion of GIM patients with CTDT less than 3 hours increased from 25% to 33% (p < .0001). Conclusions: The interventions trialed led to a sustained reduction in CTDT over a 12-month period and demonstrated the effectiveness of education in influencing physician performance.

Interventions to improve consultations in the emergency department: A systematic review

“…The majority of the included studies were conducted in North America (United States n = 12, 16–28 Canada n = 6 29–34 ) with a smaller number of studies conducted in Asia (South Korea n = 5, 35–39 Singapore n = 2, 40,41 Thailand n = 1, 42 Taiwan n = 1, 43 India = 1 44 ) and Europe (Ireland n = 1, 45 Turkey n = 2, 46,47 ; see Table 1). The studies were mainly conducted in a single ED site 16–25,27,29–32,34–50 . The majority of studies utilized a before/after study design ( n = 25, 71%), of which one study used a controlled before/after design 39 .…”

“…In addition, five studies reported completing audits and providing feedback in regard to responding to consultation requests and timely admission decisions to the staff and health administers 17,19,20,29,31 . Two of the studies that audited physician performance also provided staff with educational sessions on ED overcrowding (Table 1).…”

“…Two of the studies that audited physician performance also provided staff with educational sessions on ED overcrowding (Table 1). 29,31 …”

“…The studies were mainly conducted in a single ED site. [16][17][18][19][20][21][22][23][24][25]27,[29][30][31][32][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50] The majority of studies utilized a before/after study design (n = 25, 71%), of which one study used a controlled before/after design. 39 Study sample sizes ranged considerably from 136 to 71,051 patients (see Table 1).…”

“…Eleven studies implemented interventions designed to reduce the response time to disposition decision among consultants (see Table 1 and Appendix S2). 17,19,20,[29][30][31]35,36,46,47,51 Some of the interventions implemented a specific time in which the consultant was expected to start or complete the consultation, 17,19,30,35,51 while another study reported setting a specific time in which consultants were expected to arrive to an admission decision. 36 Two studies implemented reminder messages sent via short messaging service (SMS) to the consultant or the residents/staff of the consulted service if the specified time target was not met.…”