By Stacey Kusterbeck
As a surgical resident at the University of Oklahoma Health Sciences Center, Katherine Snyder, MD, wanted to know what the surgical consulting service could do to alleviate delays that were contributing to ED crowding. “Our ED, much like many others, has experienced issues with overcrowding. As providers from a consulting service to the ED, we were motivated to evaluate what we could do from a general surgery perspective,” Snyder says.
Often during surgical consults, some labs or imaging tests were not ordered yet — or if they were ordered, were not resulted yet. Snyder and colleagues analyzed the timing of consults from the ED to determine whether completing the ED workup before the surgical consultation would shorten wait times.1
Researchers analyzed 137 overnight general surgery consults over a two-month period, comparing cases where the workup was incomplete (defined as at least some baseline tests not yet ordered before the consult) or complete (defined as labs and imaging results ready before the consult) at the time of consultation.
Completion of workups, such as basic labs and imaging before consultation, resulted in the patient spending less time in the ED. Some key findings:
• Average consultant-to-decision time was 2.5 hours for patients with complete workups vs. 4.9 hours for those with incomplete workups.
• Patients with complete workups stayed in the ED an average of 7.9 hours vs. an average of 11.4 hours for patients with incomplete workups.
To ED leaders, it may seem counterintuitive that waiting on the workup to be completed before calling consulting services results in the patient spending less time in the ED. “Timing of consults can affect the efficiency of the surgery teams finalizing their plan and disposition,” Snyder explains.
The researchers suggested emergency care providers invest the time to securing a complete basic workup before consulting other services. “This leads to more efficient patient disposition,” Snyder says.
Even if specialty tests still need to be ordered, it often is helpful for the baseline studies to be finished for reference. “Having this performed prior to consult ultimately results in the patient spending less time in the emergency room,” Snyder concludes.
Emergency physicians (EPs) also must consider the fact undue delays in obtaining surgical consults pose multiple patient safety and legal risks, according to Robert W. Derlet, MD, a professor emeritus of emergency medicine at the University of California, Davis. In some cases, the EP knows a patient must be taken to the OR immediately to prevent a complication or even death. However, the surgeon asks the EP to obtain a CT scan first, then call back. Sometimes, the CT scanner is backed up, and the EP realizes it could take hours to secure a CT scan and ask a radiologist to read it. “A serious diagnosis (or suspected diagnosis) has a ‘golden hour’ in order to save the patient,” Derlet warns.
Ruptured appendix; mesenteric occlusion; serious internal bleeding; ruptured spleen; and perforation of the stomach, duodenum, bowel, or esophagus are examples of cases in which EPs can make a bedside diagnosis before lab, CT scans, or MRIs are completed. “Hospitals have set up trauma teams to take a patient immediately to the OR, but not for non-trauma emergency surgery,” Derlet notes.
As for the ideal timing for a surgical consult, it depends on how serious and how emergent the problem is. The EP is the one who should determine that, according to Derlet.
Derlet says EPs should document the time the surgeon was called, the time the surgeon called back, what the EP told the surgeon, and the surgeon’s response. This information might be missing from ED charts, in Derlet’s experience. Good documentation can help the EP’s defense if the surgeon later claims the EP did not convey key facts about the patient’s true condition.
For example, an EP might document: “I told Dr. X to come in immediately because the blood pressure was dropping. The patient was cold and clammy. Dr. X advises to get a CT scan, then call back.”
If the EP tells the surgeon to come see the patient as soon as possible, Derlet says the surgeon should be at bedside within a time frame established by the hospital policy, or face a disciplinary hearing at the hospital’s medical staff executive committee.
“Time is life, and a few surgeons may stall on going to the ED, or it takes a long time to contact them, placing the hospital at risk for a lawsuit,” Derlet says.
REFERENCE
1. Snyder KB, Ball J, Lees J, et al. Anecdotes drive attitudes, data drives decisions: Optimizing the emergency department workup prior to surgical consultations. J Surg Educ 2023; Jun 24: S1931-7204(23)00201-5. doi: 10.1016/j.jsurg.2023.05.025. [Online ahead of print].
Researchers reported completion of workups, such as basic labs and imaging before consultation, resulted in patients spending less time in the ED. Average consultant-to-decision time was 2.5 hours for patients with complete workups vs. 4.9 hours for those with incomplete workups.
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