Emergency room consultations: problems and solutions.
The quality of the healthcare service is one of the most important factors that determine the socioeconomic development levels of countries (1). Hospitals are one of the most important parameters that represent the quality of health services. In the quality evaluation of the hospitals, both the operation and the architecture of the emergency services (ES) have a very distinctive role. In other words, ES are accepted as the showcases of the hospitals (2).
When a patient is admitted to an ES, urgent examination of the patient and rapid completion of the procedures of diagnosis and treatment are expected. However, this is not quite possible in reality because, in ES, doctors deal with different cases that may have different problems at the same time and make life-sustaining decisions about the cases in very short time periods. Also, ES are units that have the highest mortality rate (3-5). Moreover, in the beginning, it may not be possible to understand whether or not the patient who came to an ES has an emergency situation. At this stage, every patient must be examined; the necessary laboratory tests should be performed; and in most cases, consultation from the related branches may be needed. It should not be forgotten that consultation is one of the most important stages in this procedure (1,3, 4).
Consultation is defined as the situation in which the physician primarily responsible for the patient decides which views and applications of different areas of specialty are needed or, on the patient's request, the physician consults one of his/her colleagues from another branch, takes his/her advice, and continues the follow-up of the patient according to this advice (6-8).
There are two sides in consultation. One side is the doctors working in ES, and the other is the doctors called for consultation. Communication between the two sides and the manner in which they run the consultation procedure (CP) are the factors that determine the effectiveness of this procedure. During the consultation period, if a problem occurs on one of the sides, this appears as a failure in consultation or elongated consultation periods (8-11). As a result of this situation, patients wait for longer periods, which cause patient dissatisfaction (12, 13). It is possible to say that an effective consultation process will decrease the waiting period of the patient in an ES, thereby increasing patient satisfaction.
The aim of this study was to determine the problems that are encountered during the consultation process and to determine the suggested solutions for these problems as well as to contribute to the literature because there has not been enough research on this issue.
Materials and Methods
This study was conducted between 15.04.2012 and 15.06.2012. Out of the 1349 physicians, 439 physicians working in a total of six hospitals, of which two are Medical Faculty Hospitals, two are Training and Research Hospitals, and two are Public Hospitals, joined the study. In the questionnaire, there were questions about demographic information, whether or not there are written CP, whether or not the CP is announced, and the basic problems as well as solutions for them. As a part of the study, emergency and consulting physicians filled in the questionnaire (Questionnaire 1 and 2, respectively). They were requested to give a point value according to the significance level of the problem that they experience from 1 to 10 using a numerical grade scale. Also, the doctors were asked for their solution-oriented personal ideas.
The data was analyzed using the Statistical Package for the Social Sciences version 11.0 (SPSS Inc, Chicago, IL, USA) software. Percentage distribution and mean [+ or -] standard deviation were used.
Demographic data: Demographic data of the doctors that joined the study are presented in Table 1. In total, 439 doctors joined the study. According to the data, 68.1% were male, 82.2% were consulting physicians, and 52.8% were specialists.
Consultation procedure: There was a CP in three hospitals out of six. In two hospitals, the CP was announced on the website of the institution. In only one hospital, the written announcement of the CP to all doctors had been performed, and doctors were asked to sign the papers that show they have read the CP. According to the results, the percentage of physicians who had read the CP increased as a result of the written announcement of the CP. Nevertheless, it was found that most of the doctors (62%) did not read the document that they signed (Table 2, 3).
Basic problems: The results from the point of view of the consulting physicians are shown in Table 4. According to these results, the three greatest problems are as follows: "patient who needs consultation is not sufficiently examined by an emergency physician" "not having enough information in the patients' file," and "invitation of unnecessary consultation." The results from the point of view of emergency physicians are shown in Table 5. According to the results "trying to complete the diagnostic procedure for the patients in an emergency service" was the main problem. The other two important problems are stated as follows: "Trying to treat patients in an emergency service who need hospitalization" and "not finishing the consultation with a definite statement and writing re-consultation forms"
Solution suggestions: Out of the 361 consulting physicians, 94 gave 135 different suggestions. "Before consultation, sufficient examination and medical workups must be performed" (25.5%) and "unnecessary consultation should not be requested" (22.3%) were the suggestions that were prominent (Table 6). The solution suggestions of emergency physicians to improve the consultation process are stated in Table 7.
Emergency service are the most crowded and complicated units in almost all hospitals. The crowdedness in ES originates from the examination without appointment. The major reasons for complexity include the emergency nature of cases in addition to the crowdedness of patients; having a wide clinical diagnosis range; and in most cases, the requirement of a multidisciplinary approach and coordinated work with many other departments (9, 10).
Despite the fact that there are too many factors that affect the patient flow in ES, the difficulties encountered during medical consultations are shown to be the major factor (14). Problems encountered during the consultation progress can sometimes be the reason for patients' death and can cause doctors to be found guilty in the eyes of the law. Thus, in recent years, an increase in the number of lawsuits because of doctors' malpractice has been drawing attention. It is imperative that doctors in both emergency and consulting services should know their duties and responsibilities (3).
In terms of consultation, the body of the current law states that an "emergency physician should request consultation in time from a consulting physician and a consulting physician should also return as soon as possible under any circumstances whatsoever" (15). In addition, it is not identified with distinct borders under which conditions consultation from a specialty physician should be requested; however, to minimize the problems faced, it is suggested to structure a CP and control system according to the operation of the hospital (3, 16-19). Three out of six examined hospitals in this study have a CP, and only one of them has announced this procedure in written form and required that the doctors sign papers that show they have read the CP, which gives rise to the idea that the hospital administrations does not display necessary sensitivity on this subject.
During the consultation procedure, the consulting physician is expected to, in respect to the consultation request, take care of the patient attentively, make suggestions about diagnosis and treatment, ensure that the suggested treatment is applied, and follow the results of the medical analysis and work collaboratively with the primary physician of the patient. In addition, it is also expected that the consulting physician should attempt to help others in his/ her own profession as may be required (15). However, this procedure cannot be conducted salubriously most of the time, and we face a set of problems as a reflection of that situation (11). Also, in our study, the major problems encountered by the emergency physicians during the consultation were stated as follows: "trying to complete the diagnostic procedure for patients in emergency services," "trying to treat patients in emergency services who need hospitalization," "not finishing the consultation with a definite statement and writing re-consultation forms," and "delay by the consulting physician".
It is a known fact that consulting physicians do not respond in the time that is anticipated by the body of law. Some of the consultants even give this service via the phone or by other methods with out seeing the patient (8, 9). When it is taken into consideration that the consulting physician is just as responsible as the emergency service physician in terms of vocational and administrative perspectives, it is an obligation for him/her to accept the consultation invitation. Leaving the consultation invitation unanswered is a crime and legally evaluated as "neglect of duty" (20). According to our study, "delay by the consulting physician" is placed fourth and "Consulting physician does not examine the patient, only gives information via the phone" is placed in the sixth place in the list of basic problems of emergency physicians.
With respect to conducting consultation responses in a shorter time period, Sahin et al. stated that forming paging systems for consulting physicians will contribute to the process (11).
In a study conducted by Sahin et al. (11), which included emergency physicians who request consultation, it was revealed that the major problems are not making a proper physical examination before the consultation invitation, not having consultation papers, not having enough information on the consultation request forms, and request for unnecessary consultations.
In other studies conducted on this subject, it was observed that an invitation of a consulting physician without the correct indication is the most serious criticism (8, 9). The results of our study corresponded to these studies and showed that a physician who requests for consultation did not examine the patient thoroughly, the patient file did not contain adequate information, and unnecessary consultation was requested.
When we look at the solution recommendations that are revealed by the survey toward all of these problems, it says that unnecessary extra consultations, consulting physician's manner and behavior, adoption of patient, and communication problems must be solved. A similar result is revealed by Sahin et al. (11), which shows that these problems are general.
As a result, it is evident that in the solutions of problems encountered during the CP, both ES and consulting physicians are responsible. In this respect, emergency service physicians must properly examine patients before requesting consultation and avoid unnecessary consultation invitations, whereas consulting physicians must not try to require diagnostic procedures to be completed in an ES and should not try to make the patients who would normally need hospitalization be treated in an ES. This will be the appropriate approach to solve the problems. In addition, having a more respectful behavior towards emergency physicians by the consulting physician is another thing that will result in the desired conditions.
Ethics Committee Approval: Our study is not required that the Ethics Committee Approval for a survey.
Informed Consent: Our study is no need for patient Informed Consent is a survey.
Peer-review: Externally peer-reviewed.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study has received no financial support.
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Halil ibrahim Cikriklar , Yusuf Yurumez , ibrahim Kelej , Serife Ozding , Fatih Selvi , Zulfu Engindeniz , Ramazan Kujarslan , Murat Yucel , Mehmet Ali Ekici , Canan Baydemir 
 Department of Emergency Medicine, Sakarya University Faculty of Medicine, Sakarya, Turkey
 Department of Urology, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar, Turkey
 Department of Emergency Medicine, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar, Turkey
 Department of Emergency Medicine, Agri State Hospital, Agri, Turkey
 Department of Emergency Medicine, Muradiye State Hospital, Bursa, Turkey
 Clinic of General Surgery, Ministry of Health istanbul Bagcilar Training and Research Hospital, istanbul, Turkey
 Clinic of Neurosurgery, Ministry of Health Jevket Yilmaz Training and Research, Bursa, Turkey
 Department of Biostatistics, Eskijehir Osmangazi University Faculty of Medicine, Eskijehir, Turkey
Correspondence to: Halil ibrahim Qkriklar e-mail: firstname.lastname@example.org
Table 1. Demographic features n % Min-Max Average Age Male 299 68.1 24-62 36.1 [+ or -] 8.1 Female 140 31.9 24-53 33.3 [+ or -] 6.2 Subject Emergency 78 17.8 Medicine Other subjects 361 82.2 Degree Academic 37 8.4 Senior physician 232 52.8 Research 139 31.6 assistant General 31 7.0 practitioner Min: minimum; Max: maximum Table 2. Answers of physicians related to existence of a CP in hospitals that have a CP n % Emergency Number of physicians answering 17 39.5 Physicians "I do not know" Number of physicians answering 26 60.5 "Yes" Number of physicians answering 0 0 "No" Number of Physician that have 6 13.9 read the written "Consultation Procedure" Total 43 1 00 Consulting Number of physicians answering 97 45.7 48.0 Physicians "I do not know" Number of physicians answering 92 43.4 45.5 "Yes" Number of physicians answering 13 6.1 6.4 "No" Number of Physician that have 41 19.3 20.3 read the written "Consultation Procedure" Total 212 100 CP: consultation procedures Table 3. Answers of physicians who work at the hospital in which the written announcement of a CP is done n % Number of physicians answering "I do not 5 11.9 know" 15.6 Number of physicians answering "Yes" 24 57.1 75 Number of physicians answering "No" 3 7.1-9.4 Number of Physician that have read the 16 38-50 written "Consultation Procedure" Total 42 1 00 Table 4. Problems from the point of view of consulting physicians Score (Mean [+ or -] SD) Patient who needs consultation is not 7.00 [+ or -] 2.78 sufficiently examined by an emergency physician Not having enough information in the 6.63 [+ or -] 2.86 patients' file Invitation of unnecessary consultation 6.43 [+ or -] 2.78 Insufficiently completed consultation 6.43 [+ or -] 2.98 request forms Physician who wants consultation cannot 6.35 [+ or -] 3.13 be found beside the patient Diagnostic approaches are not performed 6.14 [+ or -] 2.94 for the patient who needs consultation Consultation request is not made in an 5.45 [+ or -] 3.25 appropriate time period Procedure given by consulting physicians 5.20 [+ or -] 3.48 are not fulfilled Patient who needs consultation could not 4.81 [+ or -] 3.35 be found in an emergency service SD: standard deviation Table 5. Problems from the point of view of emergency physicians Score (Mean [+ or -] SD) Trying to complete the diagnostic 8.47 [+ or -] 2.30 procedure for patients in an emergency service Trying to treat patients who need 8.35 [+ or -] 2.16 hospitalization in an emergency service Not finishing the consultation with a 7.38 [+ or -] 2.68 definite statement and writing re-consultation forms Delay by the consulting physician 7.33 [+ or -] 2.66 Unnecessary extra consultation request 7.32 [+ or -] 2.59 Consulting physician does not examine 6.62 [+ or -] 2.66 the patient, only gives information via the phone Cannot reach the consulting physician 6.53 [+ or -] 2.95 Unnecessary medical workup request 6.13 [+ or -] 2.96 Consulting physician does not fill in 6.09 [+ or -] 3.12 the consultation paper Completed consultation paper is not 6.00 [+ or -] 2.97 legible and understandable Nonstandard abbreviations are being used 4.74 [+ or -] 2.90 in consultation papers Table 6. Suggestion of consulting physicians to improve the consulting process n % Prior to consultation, sufficient 24 17.8 examination and medical workups must be conducted Unnecessary consultation should not be 21 15.5 requested Other 90 66.7 Total 135 100 Table 7. Suggestion of emergency physicians to improve the n % There should not be unnecessary extra 4 8.3 consultation requests Consulting physicians must be kept 4 8.3 informed about having a more appropriate and respectful attitude Consulting physician must be in contact 4 8.3 with other subject physicians and make an effort to conclude on the patient's situation Consulting physician must take care of 4 8.3 the patient Consulting physician must be easily 4 8.3 accessible and communication obstacles must be overcome Consulting physician must respond to the 3 6.2 consultation invitation on time Other 25 52.1 Total 48 1 00
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|Title Annotation:||Original Article|
|Author:||Cikriklar, Halil ibrahim; Yurumez, Yusuf; Kelej, Ibrahim; Ozding, Serife; Selvi, Fatih; Engindeniz,|
|Publication:||Eurasian Journal of Emergency Medicine|
|Date:||Dec 1, 2015|
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