Effective Interventions to Improve the ED Consultation Process

Two of the most significant administrative issues presently faced in the emergency department are long lengths of stay (LOS) and extensive waiting times. A major contributor to these issues is the consultation process.

Patients whose workup is otherwise complete, and are simply waiting for disposition recommendations from consulting services or admitting teams, are occupying beds that could be used by other patients.

Recently, Voaklander et al. published a systematic review of interventions aimed at improving the consultation process in the ED.¹ Using this review as a starting point, we highlight effective interventions that have been shown to improve the consultation process in EDs across the United States.

Review of the Literature
Policies and Metrics Approach

A cost-efficient approach to improving the consultation process involves setting a time-based standard that specialists are required to meet. This type of approach requires buy-in from ED and consulting services’ leadership, as it relies heavily on their support and reinforcement of the policies and adherence to metrics.

One group instituted a hospital-wide guideline stating that the admitting or consultation service must evaluate the patient in the ED within 30 minutes of the admit or consultation order being placed and reach a disposition decision within an additional 60 minutes.² This policy was reinforced by weekly metric reports to administrators and chairs.²

Response times before and after the new guideline showed significant reductions in disposition time by 21 minutes and in LOS by 18 minutes.² However, likely due to the consultants’ attention being turned to adhering to the new guidelines, during the study period patients were discharged from the in-patient setting a statistically significant 50 minutes later.² This is a reminder that an ED-focused intervention may have unintended consequences when the same group of physicians are tasked with two different but equally important responsibilities.

Another group conducted a quality improvement project consisting of emailing performance metrics to the ED chair, ED vice chair, and the chief of acute care surgery on patients requiring surgical consultation.³ Leadership received information daily regarding the amount of time to respond to the consult order, time until recommendation, and time to final disposition.³ The hospital was able to significantly decrease LOS by almost one hour and decrease time to consultation by 25 minutes.³

Team-Based Approach
Team-based approaches are particularly effective if they target a patient population that has two separate types of needs, such as psychiatric patients who often need medical clearance and psychiatric evaluation. Collaborating with the psychiatric service to form different patient management frameworks or teams can be an effective approach to decreasing LOS for this patient population.

One study used a co-management approach between the emergency physician and the psychiatrist on the consultation service, who completely assumed care of the patient after a consult order was placed.⁴ Once the patient was medically cleared, the psychiatrist was immediately able to start managing the patient, instead of strictly being a consultant as they were in the pre-intervention phase.⁴ This team-based strategy resulted in a 22% decrease in LOS.⁴ The time to medical clearance did not change between the study periods, indicating that the co-management model significantly decreased the psychiatry portion of the visit.⁴ Despite improvement in LOS, the study did not find improvement in surrogate markers for improved patient throughput, namely the number of patients who left without being seen and hours on ambulance diversion.⁴

Another study utilized a specialized team consisting of a child psychiatrist and a mental health social worker who was solely responsible for ED consults.⁵ This team would also initiate family therapy in the ED and follow up with them while in-patient.⁵ This intervention resulted in a significant decrease in LOS of 27% and in the number of patients admitted to a psychiatric facility.⁵ The second finding was likely related to the initiation of therapy in the ED, which would not have been possible without a dedicated ED-based team.

Admission Process Interventions
To decrease time between an ED disposition and placed orders, numerous research teams have attempted to implement different strategies targeting the admission process.

At one institution, for patients suspected of acute appendicitis or acute cholecystitis, the acute care surgery team would directly admit patients to their observation unit if all criteria on a checklist completed by the ED provider was met.⁶ This process resulted in decreasing LOS by half.⁶ Although the process itself was successful in reducing LOS, only about a quarter of both acute appendicitis and acute cholecystitis patients met the criteria and were eligible for this unique pathway.⁶

One group created an ED admission holding order set and protocol that replaced the typical process of waiting for a consult to be completed prior to the ED receiving admission orders.⁷ The ED admission holding order set included a consult order to let the admitting team know about the patient, a verbal sign-out of the patient, a bed request, and orders including medications, diagnostics, diet, activity, and code status.⁷ If the admitting team disagreed with the ED team during the verbal sign-out, the admitting team needed to evaluate the patient within 30 minutes.⁷

The addition of this order set decreased LOS by 22% and time between the ED decision to admit and the physical departure from the ED by 57%.⁷ However, there was a 14% increase in time from patient registration to ED disposition, which perhaps indicates that patients received more comprehensive evaluations in the ED during the intervention phase.⁷

Another team established a direct admission pathway from the ED to ICU for critical trauma patients not immediately receiving operative intervention.⁸ The ED LOS for patients in this rapid admission pathway was 1.54 hours — significantly less than the 5.88 hours via the traditional pathway.⁸ Although patients in the rapid admission group had significantly higher Injury Severity Scores and significantly lower Glasgow Coma Scale scores, there was no significant increase in mortality between the rapid and traditional admission protocols.⁸

Through a collaboration with the internal medicine service, a streamlined admission process was implemented where the ED provider could send stable patients to open inpatient beds after presenting the case to the admitting team.⁹This process bypassed the need for the admitting team to see the patient in the ED and for all testing to be finished prior to admission.⁹ This intervention resulted in a decreased ED LOS of only 10.1 minutes.⁹ This intervention was likely limited by the small amount of pathologies that can be admitted prior to all of the diagnostics being completed.

Discussion
Improving the consultation process and decreasing LOS can improve patient flow. Ultimately, increasing the throughput of patients will help decrease ED crowding. One review found that overcrowding in the ED correlated with higher mortality, increased time to treatment, and increased rate of patients leaving against medical advice or without being seen.¹⁰

Interventions involving collaborations between the ED and admitting services seem to be particularly effective and would likely be practical at many institutions. Additionally, an expedited admission process where diagnostic testing is not required for patients requiring ICU admission (such as those who are mechanically ventilated) would likely be feasible and decrease ED LOS. This review highlights a variety of successful strategies focusing on different aspects of the consultation process that can be implemented within the U.S. healthcare system.

References

1. Voaklander B, Gaudet LA, Kirkland SW, Keto-Lambert D, Villa-Roel C, Rowe BH. Interventions to improve consultations in the emergency department: A systematic review [published online ahead of print, 2022 May 11]. Acad Emerg Med. 2022;10.1111/acem.14520. doi:10.1111/acem.14520
2. Geskey JM, Geeting G, West C, Hollenbeak CS. Improved physician consult response times in an academic Emergency Department after implementation of an institutional guideline. J Emerg Med. 2013;44(5):999-1006. doi:10.1016/j.jemermed.2012.11.028
3. Horng S, Pezzella L, Tibbles CD, Wolfe RE, Hurst JM, Nathanson LA. Prospective evaluation of daily performance metrics to reduce emergency department length of stay for surgical consults. J Emerg Med. 2013;44(2):519-525. doi:10.1016/j.jemermed.2012.02.058
4. Polevoi SK, Jewel Shim J, McCulloch CE, Grimes B, Govindarajan P. Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model. Acad Emerg Med. 2013;20(4):338-343. doi:10.1111/acem.12105
5. Sheridan DC, Sheridan J, Johnson KP, et al. The Effect of a Dedicated Psychiatric Team to Pediatric Emergency Mental Health Care. J Emerg Med. 2016;50(3):e121-e128. doi:10.1016/j.jemermed.2015.10.034
6. Kulvatunyou N, Zimmerman SA, Adhikhari S, et al. The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis. J Surg Res. 2021;260:293-299. doi:10.1016/j.jss.2020.11.018
7. Haydar SA, Strout TD, Baumann MR. Sustainable Mechanism to Reduce Emergency Department (ED) Length of Stay: The Use of ED Holding (ED Transition) Orders to Reduce ED Length of Stay. Acad Emerg Med. 2016;23(7):776-785. doi:10.1111/acem.12967
8. Jaffe TA, Kim J, DePesa C, et al. One-way-street revisited: Streamlined admission of critically-ill trauma patients. Am J Emerg Med. 2020;38(10):2028-2033. doi:10.1016/j.ajem.2020.06.043
9. Quinn JV, Mahadevan SV, Eggers G, Ouyang H, Norris R. Effects of implementing a rapid admission policy in the ED. Am J Emerg Med. 2007;25(5):559-563. doi:10.1016/j.ajem.2006.11.034
10. Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16(1):1-10. doi:10.1111/j.1553-2712.2008.00295