eTable. Surgical Procedures Performed
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Choi KJ, Kahmke RR, Crowson MG, Puscas L, Scher RL, Cohen SM. Trends in Otolaryngology Consultation Patterns at an Academic Quaternary Care Center. JAMA Otolaryngol Head Neck Surg. 2017;143(5):472–477. doi:https://doi.org/10.1001/jamaoto.2016.4056
What are the trends in otolaryngology–head and neck surgery consultations performed at a quaternary care center?
In this analysis of the medical records of 1491 patients receiving consultations from the otolaryngology–head and neck surgery, 66.7% had bedside procedures performed and 16.3% required operative intervention. Consultation requests in the emergency department were more acute than consultation requests in inpatient services.
The consultation volume of an otolaryngology–head and neck surgery service requires significant time and resources; future training curriculums can be designed to prepare for the most frequent consultation requests received.
The consultation patterns of an otolaryngology–head and neck surgery service have not previously been reported. The time, resources, and attention required to operate such a consultation service are unknown.
To assess trends in otolaryngology–head and neck surgery consultations conducted in emergency departments (EDs) and inpatient services.
Design, Setting, and Participants
A retrospective analysis was conducted of the medical records of patients at a quaternary care center receiving inpatient otolaryngology consultations from January 1 to December 31, 2014.
Clinical evaluation and bedside and operative procedures performed by the otolaryngology–head and neck surgery service.
Main Outcomes and Measures
Demographics, reason for consultation, diagnosis, bedside procedures, operative interventions, and admission variables.
A total of 1491 consultations were completed for adult (1091 [73.2%]; 854 men and 637 women; mean [SD] age 50.3 [19.3] years) and pediatric (400 [26.8%]; 232 boys and 168 girls; mean [SD] age, 4.0 [5.2] years) patients. Of the 1491 consultations, 766 (51.4%) originated from inpatient teams vs 725 (48.6%) from the ED. A total of 995 of all consultations (66.7%) resulted in a bedside procedure, and 243 (16.3%) required operative intervention. Consultations regarding airway evaluation (362 [47.3%] vs 143 [19.7%]), management of epistaxis (78 [10.2%] vs 33 [4.6%]), and rhinologic evaluation (79 [10.3%] vs 18 [2.5%]) were more frequent from inpatient teams than from the ED. Consultations regarding management of head and neck infections (162 [22.3%] vs 32 [4.2%]), facial trauma (235 [32.4%] vs 16 [2.1%]), and postoperative complications (73 [10.1%] vs 2 [0.3%]) were more frequent in the ED. Of the 725 consultations performed in the ED, 212 patients (29.2%) required hospitalization.
Conclusions and Relevance
The consultation volume of an otolaryngology–head and neck surgery service requires significant time and resources. Consultations are most often for rhinologic or laryngologic issues and are reflective of the clinical setting in which the patient is evaluated. Cost savings may be realized by increasing health care access points for nonurgent concerns that can be evaluated in an outpatient setting.
Patients with diverse otorhinolaryngologic concerns often have conditions that can be appropriately triaged and medically managed by primary care professionals. However, recent database reviews demonstrate that individuals with poor access to health care services may be more likely to present to the emergency department (ED) for evaluation and treatment of routine conditions, such as uncomplicated acute rhinosinusitis.1 Adult and pediatric patients with otologic symptoms also represent a significant care burden to the ED, presenting with acute otitis media, otitis externa, and cerumen impaction.2 Although the ED is designed to serve patients with urgent medical needs, it has become a convenient access point for many patients with nonurgent conditions, despite the extended wait times and potentially inferior clinical outcomes.3-6 Nonurgent conditions evaluated at the ED are also associated with higher hospital fees and costs owing to potentially unnecessary tests and treatments.7-10 The influx of new patients into the health care system owing to the Affordable Care Act is likely to continue to add significant burden onto emergency care professionals and those in the consulting specialties, including otolaryngology, if current trends in medicine continue.
Subspecialty consultations are a necessary part of comprehensive medical care. They provide an opportunity for collegial interaction between physicians and the exchange of knowledge and expertise in patient management. In both the inpatient and ED settings, appropriately placed consultations provide an opportunity for patients to receive point-of-care service and arrangement of appropriate follow-up. Although the consultation patterns of other surgical specialties, including urology, orthopedic surgery, and vascular surgery, have been previously reported,11-14 the extent of the workload imposed on a comprehensive otolaryngology service is unknown. Recent literature on consultation patterns within otolaryngology is disparate in terms of the point-of-care settings that are investigated.11,13,15 The workload of an inpatient consultation service can be derived from the otolaryngologist hospitalist model provided by Russell et al,15 while the ED data can be obtained from national claims database reviews.1,2 As we continue to move forward in an era of medicine that emphasizes optimization of health care costs, imposes restrictions on resident work hours, and underscores the need for improved documentation, further scrutiny into the volume and variety of services provided by the otolaryngology consultation service is warranted to improve patient outcomes and foster interspecialty education. In this retrospective study, we investigate the patterns of ED and inpatient consultation to the otolaryngology–head and neck surgery service at an academic quaternary care center.
The Duke Enterprise Data Unified Content Explorer was used to identify all patients who had an order placed for otolaryngology consultation during their care at Duke University Hospital. Of these patients, only those who received care from the consultation service from January 1 to December 31, 2014, were included for review, including all adult and pediatric patients from the ED and inpatient treatment teams. Patients receiving care at affiliated secondary medical centers were excluded. Those with incomplete documentation were also excluded, including those who had a consultation order placed without a corresponding consultation note from the referring team or the otolaryngology team.
Records of patients meeting the inclusion criteria were reviewed to extract the following variables: age, sex, reason for consultation, date of consultation, procedures performed, final diagnosis, and need for admission or operative intervention. Procedures performed by the consultation team were captured through the review of medical records. Inpatient vestibular and audiologic testing is provided by the audiology team and thus was excluded from review. Descriptive statistics were performed to analyze the data. This retrospective review was approved by the Duke University Health System Institutional Review Board, who waived the need for patient consent owing to the retrospective nature of the study.
Durham, North Carolina, had an estimated population of 300 952 in 2015.16 The median population age is 32.7 years, with a median annual household income of $52 038. Of the estimated population, 16.6% live below the federal poverty line. The predominant race/ethnicity is white (42.3%), followed by African American (38.4%) and Hispanic (13.4%). It is estimated that 7.4% of individuals younger than 65 years have a disability, and 15.1% of those younger than 65 years are without health insurance. Of those who are older than 25 years, 45.6% hold a bachelor’s degree or higher and 87.4% have at least a high school diploma.
Duke University Medical Center is a quaternary care referral center providing comprehensive care to adult and pediatric patients.17 There are 957 beds available, with 190 dedicated pediatric beds. The intensive care services are available for adults in the surgical, medical, cardiac, cardiothoracic, and neurologic intensive care units. The pediatric intensive care services include cardiac, neonatal, and pediatric intensive care units. A complete obstetrics service, including labor and delivery and postpartum units, is available. In 2015, a total of 40 326 patients were admitted to the hospital and 40 056 surgical procedures were performed.
The ED has 10 pediatric and 64 adult beds, including 4 resuscitation bays for patients that require an intensive care level of service. There are 13 additional beds in the clinical evaluation unit that is managed by the ED for patients who require further observation without necessitating a hospital admission. There were a total of 70 701 patient evaluations in the ED in 2015.
A total of 1491 unique patient consultations were performed by the otolaryngology–head and neck surgery service from January 1 to December 31, 2014. Of these patients, 1491 (57.3%) were male. The mean age of adult patients was 50.3 years (range, 19.0-88.0 years), and was 4.0 years (range, 0-17.0 years) for pediatric patients. Inpatient and ED consultations combined represented 14.5% (1491 of 10 312) of the total outpatient consultation requests received by our adult and pediatric clinic in 2014. Adult patients were evaluated more frequently than were pediatric patients. Consultation requests originated from inpatient teams more frequently than the ED for both adult and pediatric patients (766 [51.4%] vs 725 [48.6%]). The demographics of the study population are presented in Table 1. Records excluded from review included 158 requests originating from affiliated secondary medical centers and 299 discontinued consultation orders with incomplete documentation (Table 2). Other reasons (n = 29) for study exclusion included requests for an earlier operative date, frequent falls, radiographic evidence of mastoiditis, management of oral secretions, and tonsillar hypertrophy. Examples of consultations deferred to the outpatient clinic (n = 26) included ankyloglossia, chronic cough, cerumen impaction, dizziness, hearing loss, globus pharyngeus, and repair of facial lacerations performed by the ED. Consultation to incorrect surgical services occurred when the otolaryngology team was initially consulted for postoperative concerns for surgical procedures performed by endocrine surgery teams (thyroidectomies) or general surgery teams (tracheotomies). These consultations were deferred to the operative team for postoperative management. Frequently, requests for airway evaluations were received when the patient was intubated (n = 15) or tracheotomies were requested prior to the referring team holding a discussion with the health care power of attorney (n = 10).
The primary reason for the requested consultation is depicted in Table 3 and Table 4. Requests for airway evaluation were most frequently encountered for adults across all patient care settings (inpatient, 228 of 563 [40.5%]; and ED, 36 of 197 [18.3%]), while they were most frequently requested for pediatric patients in the inpatient setting (134 of 203 [66.0%]). In adults presenting to the ED, evaluations for head and neck infections (103 of 528 [19.5%]), facial traumas (179 of 528 [33.9%]), and postoperative problems (patients presenting with clinical concerns within 30 days after surgery, and included consultations, such as surgical wound checks, concerns for infection, and pain control; 51 of 528 [9.7%]) were most frequent. Management of epistaxis (72 of 563 [12.8%]) and rhinologic (65 of 563 [11.5%]) and otologic (49 of 563 [8.7%]) concerns were the most commonly requested reasons for evaluating adults in an inpatient setting. Epistaxis management was categorized independent of other rhinologic concerns in the data analysis owing to its high frequency across all patient ages and clinical settings. Craniomaxillofacial trauma consultations represented 15.1% of all service requests (225 of 1491) and occurred more frequently in adults presenting to the ED.
In pediatric patients presenting to the ED, head and neck infections (59 of 197 [29.9%]), facial lacerations (39 of 197 [19.8%]), and airway evaluations (36 of 197 [18.3%]) were the most frequent reasons for consultation. In the inpatient setting, airway evaluations (134 of 203 [66.0%]) and rhinologic (14 of 203 [6.9%]) and otologic (12 of 203 [5.9%]) concerns were the most frequent reasons for consultation.
Of the 725 consultations performed in the ED, 212 patients (29.2%) required subsequent hospital admission for further care. Only 47 of the patients who received a consultation in the ED (6.5%) were admitted to the otolaryngology–head and neck surgery service for management. The remaining admissions were most frequently to the general medicine service and the clinical evaluation unit (a 24-hour observational unit managed by the ED). Bedside procedures were performed in 995 consultations (66.7%). Flexible fiberoptic laryngoscopy was performed most frequently (554 [55.7%]), followed by repair of complex facial lacerations (110 [11.1%]), rigid nasal endoscopy (109 [11.0%]), and management of epistaxis (96 [9.6%]) (Table 5). Of all consultations performed, 243 patients (16.3%) required surgical intervention in the operative theater. A total of 416 operations were performed in these patients. Repair of facial fractures (50 [12.0%]), direct laryngoscopy (47 [11.3%]), bronchoscopy (47 [11.3%]), and tracheotomy (41 [9.9%]) were the most commonly performed operations. A complete list of surgical operations is listed in the eTable in the Supplement.
Consultation requests allow for open communication and improved patient care when additional expertise is required. Although the burden of consultation services has previously been reported in various surgical subspecialties, it has not been measured in otolaryngology–head and neck surgery. This review of ED and inpatient consultations at our quaternary care center demonstrates that patient volume is significantly higher than those reported for vascular11 and orthopedic surgery,13 while comparable with the volume reported for urology in health centers of similar size.14 Similar to the otolaryngology hospitalist model, the most frequent reasons for consultations among the inpatient services included airway and rhinologic evaluations.15 Laryngoscopy, functional endoscopic sinus surgery, and tracheotomy represented the most frequent operations from consultations originating from the inpatient setting. Our findings reinforce the notion that laryngologic and rhinologic processes are most prevalent among critically ill patients requiring hospitalization.15 Similarly, the review of consultations originating from the ED is reflective of the acute nature of the disease processes encountered in this clinical setting. Requests for airway evaluation owing to respiratory distress in the setting of infections and head and neck malignant neoplasms remained common, but the most frequently requested reasons for consultation were for management of facial trauma and acute infections involving the head and neck.
Compared with the national average, the population of Durham, North Carolina, includes a lower percentage of persons younger than 65 years with a disability (8.5% vs 7.4%) but a greater percentage of persons younger than 65 years without health insurance (10.5% vs 15.1%).16 Because our study does not account for geographic differences in access, race/ethnicity, and socioeconomic status of the patient base, it poses multiple confounding variables to the results that may be too specific for generalization to most practicing otolaryngologists. Although it can be surmised that the acuity of consultations performed in the ED vs the inpatient setting may be applicable to other quaternary care centers of similar size, the specifics of variations among consultations are likely to be influenced by the strengths and weakness of the medical specialties of the hospital. This variation is also likely to be influenced by the demographics of the population within the immediate catchment area, as those of lower socioeconomic status have been shown to use preventive care less than their more affluent counterparts, and are more likely to access the ED for management of acute illnesses.18
Identification of the most commonly requested ED and inpatient consultations allows for strategic targeting of educational concepts in resident education to improve knowledge and skills regarding acute issues in otolaryngology–head and neck surgery. Early in residency, the curriculum should emphasize proper techniques for performing a thorough head and neck examination, inclusive of findings relevant to patients with facial trauma, such as the Glasgow Coma Scale score, Angle classification of malocclusion, and assessment for midface mobility. Residents must also be well versed in the appropriate use of instruments, such as the flexible laryngoscope and rigid endoscope, to ensure efficient, precise, and accurate assessment of patients. As the knowledge base of otolaryngology–head and neck surgery is broad, the curriculum can be tailored to the most common consultation requests encountered in each clinical setting, with emphasis on rhinologic and laryngologic emergencies, such as angioedema, airway obstruction, and acute invasive fungal sinusitis. The skill and knowledge to appropriately triage and manage patients with acute postoperative concerns are also important, given the frequency of these consultations in the ED. At our institution, these patients are most often triaged via telephone and directed to the ED as determined by the acuity of the concern and the need for an after-hours evaluation. To ensure that these encounters are clinically meaningful and cost-effective, it is imperative for residents to quickly learn the potential postoperative pitfalls of the most common surgical procedures performed in otolaryngology–head and neck surgery.
The educational opportunities inherent in commonly requested consultations from otolaryngologists must extend beyond the context of resident trainees. The hospital system is an environment of dynamic interplay that is dependent on clear and concise communication between physicians. A review of referrals made by primary care physicians demonstrates that otolaryngology consultations are a common part of practice, involving up to 25% of adults and 50% of pediatric patients.19-21 Otolaryngology is the third most common specialty to which family physicians referred patients, with referral diagnoses, including hearing loss, otitis media, and sinusitis.22 As nearly half of our consultation requests originated from the ED, it becomes imperative that the focus of attention extend to this group of physicians to ensure that appropriate triage and medical evaluations are performed to maximize patient care and health system efficiency. Equipment, such as functional otoscopes, must be available to ensure that objective examinations can be confidently performed. As with the education of junior otolaryngology residents, the ability to perform a comprehensive head and neck examination and differentiate normal from abnormal findings must be emphasized to front-line health care professionals. Education can then incorporate a review of the most common scenarios for patient presentation to ensure that emergency situations are not overlooked and appropriate evaluations are performed before consultation. Such examples include the availability of computed tomographic imaging for facial fractures or laboratory results in patients with acute infections. A survey performed by Whitcroft et al23 demonstrated that there is a significant knowledge gap and lack of confidence among ED residents in the management of otolaryngologic and airway emergencies. This knowledge gap may be attributed to the reported lack of exposure to otolaryngology in undergraduate medical education,24 but efforts have been made to develop an undergraduate curriculum to address this concern.25 A similar education model can be applied to graduate medical education to provide concise and informative modules on common otolaryngologic problems to trainees for whom such information would be most beneficial. Because real-time education of referring clinicians can be challenging in an academic setting where multiple specialties rotate through the ED and inpatient teams, an education curriculum has been established at Duke University Medical Center. The ED residents participate in hands-on workshops to develop skills in flexible laryngoscopy, complex wound closure, and cricothyrotomy, in addition to attending conferences to review the management of epistaxis and otolaryngologic infections as well as acute airway management algorithms alongside otolaryngology residents.
There are several limitations to our study. Our data collection was limited to the perspective of an otolaryngology consultation service and excluded the services provided by the ED and inpatient teams. Thus, we were unable to determine the potential cost savings if appropriate consultations were reallocated to an outpatient setting. Consultations that were performed without orders from the ED or inpatient teams were not captured in our review. The review also does not capture the entire breadth of services provided by our consultation team, as subsequent visits in follow-up of the initial consultations were not reviewed, nor were patient telephone calls that were triaged after hours. In addition, our study is not reflective of the variations in the socioeconomic status of the patient base, resulting in data that are institution specific and not generalizable. This study should be expanded to a multi-institutional level to identify common trends and patterns to improve educational efforts across specialties and to determine the workload of the consultation service given the resident work hour restrictions in this current era of medicine.
The clinical volume of an otolaryngology service at a quaternary medical center is significant. The variety of consultations performed is similar to those in prior reports of the otolaryngology hospitalist model and is most frequently for rhinologic or laryngologic conditions. The consultations evaluated in the ED were more acute, including head and neck infections, facial trauma, and airway evaluations. This review reinforces the procedural nature of the specialty and identifies targets of educational topics that may be used to develop a relevant curriculum for junior otolaryngology residents and primary care professionals, including emergency medicine physicians. The significant time, resources, and attention required to operate a consultation service should be considered in the organization of an otolaryngology residency program.
Accepted for Publication: October 25, 2016.
Corresponding Author: Kevin J. Choi, MD, MS, Division of Head and Neck Surgery & Communication Sciences, Department of Surgery, Duke University Medical Center, Box 2824, Durham, NC 27710 (firstname.lastname@example.org).
Published Online: January 5, 2017. doi:10.1001/jamaoto.2016.4056
Author Contributions: Drs Choi and Kahmke had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Choi and Kahmke contributed equally to the study.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Choi, Kahmke, Crowson, Puscas, Cohen.
Drafting of the manuscript: Choi, Crowson, Puscas, Cohen.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Choi, Crowson.
Administrative, technical, or material support: Choi, Crowson.
Study supervision: Kahmke, Puscas, Scher, Cohen.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Previous Presentation: This study was presented at the 2016 Triological Society at Combined Otolaryngology Spring Meeting; May 21, 2016; Chicago, Illinois.
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