Objectives: Requests for   specialty consultation are common in emergency departments (EDs) and often   contribute to delays in throughput. Our objectives were to describe the   contribution of the consultation process to total ED length of stay (LOS)   through novel metrics and illustrate causes of delay. 

Methods: We conducted a prospective   cross-sectional study at three Canadian tertiary care centres. Adult ED   patients with requested medical/surgical consultations were enrolled. We   created original metric intervals: total consultation time (TCT) defined as   the interval from the initial consultation request to the disposition   decision, consult response time (CRT) from the request to the consultant   arrival, and decision-making interval (DMI) from arrival to the disposition   decision. The consultation impact index (CII) was defined as the percentage   of ED LOS consumed by the TCT. Reasons for delay were documented if time   stamps exceeded preset benchmarks. 

Results: The median TCT for 285 patients was 138 minutes   (interquartile range [IQR]: 82-239 minutes), whereas the median total ED LOS   was 778 minutes (IQR 485-1,274 minutes). The median CRT was 55 minutes (IQR   21-115 minutes), and the median DMI was 58 minutes (IQR 25-126 minutes). The   CII measured 26% (95% CI 23-28). Major contributors to consultation delay   included urgent ward issues, simultaneous ED consultations, and the need for   additional laboratory or radiographic investigations.

Conclusion: The consultation process   is highly variable and has an important impact on ED LOS. We describe novel   measures related to consultation performance and provide an analysis of what   causes delays. These results can be used to seek improvements in the consulting   process.

Authors: Patricia A. Lee, Brian H. Rowe, Grant Innes, Eric Grafstein, Renee Vilneff, Dongmei Wang, Susan van Rheenen, Eddy Lang