When is a rose not a rose?

August 2015

​​Consider the words “urgent,” “emergent” and “priority.” Do they mean the same thing? When used in consult requests, how might they affect responsiveness to either a pediatric or adult patient?

To reduce the subjectivity of health care communication, the Clinical Leadership Council (CLC) has been working to create guidelines for soliciting and providing consultations. 

Led by CLC members from four specialties (Orthopedics, Pediatrics, Emergency Medicine and Family Medicine), the goal is to ensure that the right patient receives the right care at the right time in both child- and adult-health settings. Drs. Evalina Burger-van der Walt, Michael Narkewicz, Jennifer Wiler and Colleen Conry, all recognize the value of clear consultation communication across the spectrum of care.

In March 2015 after months of preliminary work to draft tiered “Levels of Urgency”, a pilot was launched in the University of Colorado Hospital Emergency Department with Orthopedics. This pilot evaluated new Epic tools put in place to streamline electronic communication as well as how the urgency guidelines could function in real life.

The urgency guidelines standardize definitions for consult timeframes. “Level 1” for emergency and inpatient settings, for example, requests a call back from the consult service in 10 minutes and recommendations in the electronic health record in one hour; “Level 2” requests acknowledgement in one hour and documented recommendations no later than 5 p.m. the same day.

Multiple Aims

However, the urgency guidelines are just one part of the pilot, says Ben Easter, MD, fellow in Emergency Medicine Administration, Operations and Quality, and a recent graduate from the emergency medicine residency. He explains that the program also aims to ensure that all requests are clear and actionable, that responses are timely and that the patient’s needs and expectations are understood. (Dr. Easter pictured on left)

“Our main goal was to expedite patients' access to the expertise of consulting physicians and to reduce the length of stay in the emergency department. The Orthopedic Surgery department has been an incredible partner during this process. Working together, we've been able to provide care that is faster, better quality and patient-centered,” he said.

The CLC hopes that when all recommendations are actionable, timely and clearly communicated, patient care and safety will be optimized, and it will be easier for staff to meet patient and provider expectations.

Evalina Burger, vice chair of Orthopedics for Clinical Affairs and Quality and the project co-chair, explains that the CLC subcommittee has been working toward this pilot since March 2013. “We have multiple care settings in the pipeline – emergency, inpatient, ambulatory and multi-campus – but we have been up against a variety of communication and electronic medical record challenges,” she said.

Developing such a program across multiple care settings can present difficulty. “There are very different solutions and levels of patient need, depending on the service,” said Burger. “It can be a real challenge to have a specialist meet response guidelines when some of her inpatients are in different locations.”

This process also intends to provide consistent expectations. When a busy service gets overwhelmed, using the appropriate levels of consultation requests allows quicker prioritization so patients and requestor are clear on when they should have input for next steps. 

Creative Solutions

The solution for many of those circumstances may be telehealth, allowing a preliminary review and discussion with the patient remotely, and allocating time for the specialist to be onsite at a later date if needed.

Despite the obstacles, a successful outcome from this pilot promises a boon of benefits: improved patient outcomes, reduced or eliminated unnecessary testing and increased patient satisfaction.

Murray Spruiell, MD, orthopedic surgery resident and a leader during the initial pilot, explains the key role residents play in providing consistent communication with the requesting service. (Dr. Spruiell pictured on right)

“PGY2s and 3s are the orthopedic residents taking primary ED calls, listening to the questions or requests for consults asked by the ED providers, and then providing recommendations either by phone or by direct patient care in the ED. My co-residents and I helped troubleshoot issues with the new process as it was being rolled out.”

Dr. Burger acknowledges that residents perform a lot of the preliminary work in consult services. “We know it’s extra work to add a quality improvement program to an already very busy service,” she said. “Drs. Spruiell and Easter are providing leadership that really makes a difference. They have spearheaded communication with their peers and their contributions are vital in bringing us closer to what we’re trying to achieve.”