Should we call the neurologist? The value and cost of a growing neurology consultation service

Lost in translation: Telephone referrals to a tertiary neurology referral centre

BACKGROUND

Cork University Hospital acts as the tertiary referral centre for the HSE southern area, with a catchment population of 1.2 million [1]. The neurology registrars receive telephone consultations from hospitals and primary care practices in the region. While there have been a number of studies examining inpatient neurology consultations in Irish hospitals [2-6], there is a paucity of data examining the support provided by tertiary referral centres to other acute hospitals and primary care centres in their region.

AIMS

The aim of this study is to define the workload of the neurology registrar with respect to telephone consultations and to examine the quality of these referrals.

METHODS

All calls received from the 19th of October 2021 to the 25th of February 2022 were logged by the receiving registrar. Information collected pertained to the nature of the consult and completeness of the referral.

RESULTS

The average volume of calls during the study period was six per week. The median call duration was 8 min. The cumulative time spent resolving outside calls during the study period was at least 41.25 hours. Sixty-three per cent of calls were from other acute hospitals in the region. Thirty-nine per cent of referrals were deemed incomplete with respect to either history, collateral history or examination.

CONCLUSIONS

This is a necessary service in a system that is not adequately resourced to provide specialist led care in all hospitals. A greater emphasis on complete and accurate referrals, along with robust communication and documentation, could reduce the inherent risk associated with such consultations.

Improving medical consults for surgical inpatients: a quality improvement project using an e-referral system linked to clinical pathways

Surgical inpatients referred to medicine with acute medical problems represent a complex patient population, vulnerable to fragmented care and suboptimal outcomes. They can also be a source of staff dissatisfaction in busy or understaffed departments. Comanagement by surgical and medical staff may improve outcomes but requires dedicated resources and the evidence for other interventions is scarce. We aimed to assess staff experience, demographics and clinical outcomes of this patient population at our hospital and develop an intervention aiming to improve medical staff experience, without compromising clinical outcomes.

Staff were surveyed before and after the intervention to measure staff experience. Demographics and clinical outcomes were collected for 60 referrals at baseline and 29 referrals postintervention (an e-referral system linked to locally developed clinical pathways). Clinical outcomes were delay time (time from referral submission to review), length of stay, 30-day mortality and 30-day readmissions.

Medical staff experience improved from majority negative or neutral ratings to majority positive ratings postintervention and 100% of staff surveyed supported ongoing use of the intervention. There were no negative impacts on clinical outcomes, which acted as balancing measures.

Medical staff experience improved, without compromising clinical outcomes. The e-referral system doubles as a platform for ongoing quality improvement.

Seizure management in a Model Three hospital: what does specialist neurology add?

BACKGROUND

The commonest reason for admissions to hospital in Ireland annually for patients with a neurological condition is due to convulsions/epilepsy and their care is often managed by Internal Medicine physicians.

AIMS

The study aims to evaluate the care provided for patients admitted with seizures in a Model Three hospital before and after the commencement of a specialist onsite neurology service.

METHODS

Retrospective chart review of patients admitted from Emergency Department (ED) with the term "seizure" during a 4-month period in 2018 and 2019 was undertaken. Charts evaluated for patient demographics, Length of Stay (LOS), driving and lifestyle advice offered, and rescue medications prescribed upon discharge.

RESULTS

In 2018, a total of 58 patients were admitted with a seizure over a period of 4 months of audit and the mean LOS was 4.25 days (SD = 4.43). Driving advice was documented in 9 patients and Buccal midazolam (Buccalam) for rescue therapy for prolonged seizures was prescribed once. Following the appointment of a neurologist, LOS for patients admitted with seizure dropped to 2.6 days (SD = 3.44, p < 0.05) in the same time frame in 2019. Driving status/recommendations were documented in 27(42%) and buccal midazolam was prescribed for 25 (39%) patients.

CONCLUSION

Access to expert neurology review in a Model Three hospital in Ireland not only improved the provision of safe, timely, and equitable care but also significantly reduced the LOS for patients admitted with seizures.

Improving liaison neurology services

Liaison neurology (consulting with inpatient ward referrals) is the main way that most patients admitted with neurological disease will access neurology services. Most liaison neurology services are responsive, seeing referrals on request, but they also can be proactive, with a regular neurology presence in the acute medical unit. Fewer than half of hospitals in England have electronic systems, yet these can facilitate the process-allowing electronic responses to advise on investigations before seeing the patient, and arranging follow-up after-as well as prioritising referrals and documenting the process. In this time of COVID-19, there are additional benefits in providing prompt remote advice. Improving the way liaison neurology is delivered can improve patient outcomes and save money by shortening admissions. This hidden work of the neurologists needs to be recorded and recognised.