Abstract & Commentary
What Makes an ICU Consultation High Quality’?
By Leslie A. Hoffman, RN, PhD
Professor Emeritus, Nursing and Clinical & Translational Science, University of Pittsburgh
SYNOPSIS: From interviews, seven key factors were identified that characterized a "high-quality consultation;"
all could be easily adopted into critical care clinical practice.
- SOURCE: Stevens JP, et al. Elements of a high-quality inpatient consultation in the intensive care unit. A qualitative study. Ann Am Thorac Soc 2013; 10:220-227.
Although consultation by specialists is common in the ICU setting, few studies
have examined characteristics that make information provided from the consult more beneficial. In this study, one-on-one interviews were held with 12 attending physicians who provided care in ICUs of two academic medical center hospitals affiliated with Harvard Medical School. Participants (10 men, 2 women) had 12 ± 10 years’ experience at this institution (range, 1-30 years). They provided 24/7 coverage for three medical ICUs (77 beds) and covered the ICU and consults on weekends. All interviews were conducted by a single investigator using a semi-structured guide. Participants were asked open-ended questions about the mechanics of consultation and past positive and negative experiences. Interviews were audiotaped, transcribed, and coded for themes with discrepancies resolved by consensus.
Two qualities were viewed as influencing consult quality from the perspective of the requesting team, e.g., "articulating a clear question" and "conveying the level of urgency." Seven characteristics were viewed as promoting high-quality input by the consulting team (see Table).
The identified elements focused on providing specific, helpful information in a timely manner and projecting a sense of interest in doing this. Barriers to a high-quality consult were in the majority the reverse, e.g., unclear question, delayed response, inability of the consultant to suggest a change without consulting his/her attending, etc. In addition, handoffs were identified as a barrier, given that the physician requesting the consult might be gone when the consultant arrived on the unit.
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Requesting
team
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• Articulate a clear and concise question.
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• Tell the consulting team when you need the consultation quickly.
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Consulting
team
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• Provide your assessment within the requested time.
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• Be decisive and provide a plan (for today and for follow-up).
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• Be thoughtful. Include new insights in the summary you offer for the case.
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• Recommend tests likely to change care, not a shotgun approach.
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• Project a high degree of helpfulness and interest in the case.
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• Engage with the family only with or after consultation with the primary team.
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• Provide an expert opinion. You have been called for your expert guidance.
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Commentary
Consults are common in the ICU and inpatient setting. Among the Medicare population alone, data suggest that more than 12 million consults occurred in 2008 at a cost of $1.9 billion. Reasons vary and include the need for assistance with a procedure, institutional protocol, and family request, as well as the need for expert opinion regarding a complex case. In addition, those interviewed for this study cited a desire to provide education to the primary care team and/or the consulting team as a reason for initiating a consult. Information provided in this study serves to highlight two important considerations on the part of the requesting team — to provide a clear rationale and clearly indicate the urgency of the request. Positive elements from the perspective of those providing the consult focused on the importance of decisiveness, responsiveness, professional behavior, and appropriate engagement with the family. Despite the range of subspecialty groups that were consulted by these ICU physicians, consistent themes emerged that could assist in providing more timely and helpful information. All were practical and should be easily implemented in practice.
Editor's Commentary
David J. Pierson, MD
Interesting information pertinent to the above study and discussion comes from a recently published article from Denver Health, a 500-bed university-affiliated urban safety-net hospital.1 This study examined whether curbside consults — the common, informal hospital interactions in which clinicians seek advice about managing individual patients without formal assessments by the persons consulted — were accurate and complete. All 18 members of the Department of Medicine’s Hospitalist Service carried out the study. Each time a curbside consult was requested, the hospitalist receiving the call proceeded with the telephone interaction as usual, documenting several aspects of the conversation and, afterwards, asking the consulting physician for permission to carry out a formal consultation on the patient addressing the issue that prompted the call. A different member of the hospitalist group then performed the formal consultation without knowledge of the details or advice provided, after which the two of them compared notes. Later, an experienced senior clinician reviewed the interactions for accuracy, consistency, and agreement with his own assessment.
Formal same-day consultations were obtained for 47 of the 50 curbside consults requested during the study period. The requests came from many different services within the hospital, with psychiatry (47%) and the emergency department (19%) providing the most. Questions dealt with all aspects of diagnosis and management, and involved a wide spectrum of organ systems and presentations. Based on information collected in the formal consultation, information was either inaccurate or incomplete in 24 of 47 (51%) of the curbside consults. Management advice after formal consultation differed from that given in the curbside consult for 28 of 47 patients (60%). When inaccurate or incomplete information was received, the advice provided in the formal vs the curbside consultation differed in 22 of 24 patients (92%, P < 0.0001).
Although it was not carried out in a critical care setting, this study’s findings should give pause to all hospital-based clinicians requesting curbside consultation in managing their patients. I would expect that the same characteristics described by Dr. Hoffman in the study by Stevens et al would apply, both for those requesting the consult and for those responding to the call.
References
1. Burden M, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med 2013;8:31-35.
