title: Appropriateness, Reasons and Independent Predictors of Consultations in the Emergency Department (ED) of a Dutch Tertiary Care Center: A Prospective Cohort Study.
abstract: OBJECTIVE
  Consultations occur frequently in the emergency department (ED) of tertiary care centres and pose a threat for patient safety as they contribute to ED lengths of stay (LOS) and overcrowding. The aim of this study was to investigate reasons and appropriateness of consultations, and the relative impact of specialty and patient characteristics on the probability of a consultation, because this could help to improve efficiency of ED patient care.
  
  
  METHODS
  This prospective cohort study included ED patients presenting to a Dutch tertiary care centre in a setting where ED physicians mostly treat self-referred and undifferentiated patients and other specialists treat referred patients. Consultations were defined as appropriate if the reason of consultation corresponded with the final advice, conclusion or policy of the consulted specialty. Multivariable logistic regression analysis was used to assess the relative contribution of specialty and patient characteristics on consultation.
  
  
  RESULTS
  In the 344 (24% (95% CI 22 to 26%)) of the 1434 inclusions another specialty was consulted, resulting in a 55% increase of ED LOS. ED physicians more often consulted another specialty with a corrected odds ratio (OR) of 5.6 (4.0 to 7.8), mostly because consultations were mandatory in case of hospitalization or outpatient follow-up. Limited expertise of ED physicians was the reason for consultation in 7% (5 to 9%). The appropriateness of consultations was 84% (81 to 88%), similar between ED physicians and other specialists (P = 0.949). The patient characteristics age, comorbidity, and triage category and complaint predicted consultation.
  
  
  CONCLUSIONS
  In a Dutch tertiary care centre another specialty was consulted in 24% of the patients, mostly for an appropriate reason, and rarely because of lack of expertise. The impact of consultations on ED LOS could be reduced if mandatory consultations are abolished and predictors of a consultation are used to facilitate timely consultation.
authors.affiliation: Emergency Department, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Daniël
authors.initials: D
authors.lastname: van der Veen
authors.affiliation: Emergency Department, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Christian
authors.initials: C
authors.lastname: Heringhaus
authors.affiliation: Emergency Department, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Bas
authors.initials: B
authors.lastname: de Groot
mesh_terms: D015331:Cohort Studies; D004632:Emergency Medical Services; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D009426:Netherlands; D010343:Patient Admission; D011446:Prospective Studies; D012017:Referral and Consultation; D062606:Tertiary Care Centers