For the successful management of a patient in the emergency department (ED) or urgent care setting, clear communication between emergency providers and ENT specialists is paramount. Working within hospital systems, it is also important to be cognizant of a system’s limitations and availability of services (eg, in-house consultants, on call physicians, telehealth providers, or no specialty backup). Understanding how to balance all these factors is the keystone of communication with consultants. As with any consultation, the usual goal is to ask for a service outside the scope of practice of the emergency provider or to obtain expert opinion. The objectives of this chapter are to provide a schema for the ENT consultation question and conversation, establish the capabilities and timing of consultation by an otolaryngologist, and clarify when to involve further services to help our patients outside of otolaryngology.
The Consultation Question and Communication
To optimize care of patients with ENT pathologies requires prompt and effective communication. Ideally, there are simple and reliable mechanisms for communication between the ED providers and consultants. Several studies have demonstrated that consults following a specific format help to convey a comprehensive description of the patient as well as a focused reason for consulting a provider (Figure 3.1
There are also tools to guide consultants’ communication with the requesting provider (Table 3.1
These schemas can clarify and anticipate issues that ENT providers will need to know in order to provide appropriate recommendations or prepare for an in-person evaluation. In general, these schemas involve identifying the consultant and consultee, identifying the patient, providing a precise and focused history of present illness, relevant studies or imaging already performed, a clinical question, or a confirmed diagnosis requiring the consultant’s expertise.
As with all ED consults, one of the most important considerations is providing the consultant with a specific actionable item for collaboration. These actionable items can be divided into questions regarding diagnosis, specific management options, and patient disposition. Framing the clinical question around what is lacking that the consultant can provide is a key factor in clear communication between services. Asking for clear procedural guidance (eg, help with locating a foreign body in the airway, laryngoscopy for evaluation of angioedema) or for help with disposition and management of a patient (eg, evaluation for admission for mastoiditis, advanced airway management, or surgical intervention for epistaxis) helps to narrow the focus of the consultant to provide optimal care.
Another important aspect of the clinical consultation is anticipating and acknowledging what needs the ENT consultant will have in order to best help you with your patient. Anticipating and performing appropriate imaging, such as computed tomography (CT) evaluation for mastoiditis or
imaging to localize foreign bodies, can help your consultants make quicker and simpler decisions on cases. ENT consultations usually focus on a wide variety of diagnoses. One study on ENT consultation at a quaternary care hospital revealed that the most common reason for consultation from the ED was facial trauma, followed by airway evaluation, neck infection, then epistaxis, as outlined in Table 3.2
Figure 3.1: A CONSULT card to facilitate consults from the emergency room. (From Podolsky A, Stern DT, Peccoralo L. The courteous consult: a CONSULT card and training to improve resident consults. J Grad Med Educ. 2015;7(1):113-117. Figure 1.)
Systems Considerations, Capability of ENT Consultants, and Telemedicine
Because healthcare facilities have variable staffing and care capabilities, it is critical to understand the resources available both for consultation and for definitive care. The scope of practice may vary for consultants available to the ED, so agreements and protocols are important to discuss between services in advance of consultation. For example, if a patient with uncontrolled epistaxis requires ligation, and the on-call ENT does not perform these, the patient may need to be transferred to another facility, or a neurosurgeon/interventional radiologist may need to be called. There are also some diagnoses that may be handled by multiple services (eg, orbital fractures may be evaluated by ENT, ophthalmology, or plastic surgery). Bedside procedures commonly performed by ENT are listed in Table 3.3
TABLE 3.1 Modified Commandments to Facilitate Communication Between Consultant and the Requesting Provider
1. Determine the question being asked
Ask the person requesting the consult what specific question they are trying to ask; sometimes this is not obvious and you may need to ask probing questions.
2. Establish urgency
Ask if the situation is emergent, urgent, or elective; this may require additional questions during the conversation.
3. See the consult in person
See the patient and perform physical exam whenever possible; “trust but verify.”
4. Be brief when appropriate
Consultant may not need to repeat every detail of the history taking and documentation, but should still verify the pertinent details.
5. Be specific
Do not assume that the requesting provider knows details of your recommendations; be as specific as possible about your recommendations.
6. Provide contingency plans
Anticipate issues with your recommendations and provide secondary backup plans.
7. Do not overstep boundaries
Remember that you are the consultant and should not overstep your boundaries (ie, change orders without notifying the requesting/primary provider).
8. Teach as appropriate
Use consultations as an opportunity to discuss patient’s case with learning points (only if the requesting provider is amenable).
9. Talk is essential
Having a conversation between requesting provider and the consultant is crucial for optimal patient care and outcomes.
10. Provide follow-up
Even if you feel that the consultation has been completed, provide means for follow-up for any concerns or issues that may arise.
(Derived from Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med. 2007 Feb 12;167(3):271-275.)
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