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PubMed1992

Community hospital ethics consultation: evaluation and comparison with a university hospital service.

BACKGROUND: Ethics consultants may improve patient care by responding to physician requests for assistance with problems they identify as ethical issues. OBJECTIVE: To examine three aspects of ethics consultation: the clinical questions asked; the helpfulness of the consultation to requesting physicians; and the differences between consultations performed at a community teaching hospital and those performed at a university hospital. SETTINGS: A community teaching hospital and a university teaching hospital. SUBJECTS: Physicians who formally requested ethics consultations in both hospitals and the patients for whom they requested them. METHODS: Over 2 years (January 1, 1988, to December 31, 1989), we prospectively evaluated a newly established clinical ethics consultation service in a community teaching hospital using confidentially completed, pretested, structured questionnaires, and compared our data with previously reported university hospital data. RESULTS: During the 2-year study, 104 consultation requests were received from 68 physicians in eight departments. Requesters most often requested consultation about deciding to forego life-sustaining treatment (74%), resolving disagreements (46%), and assessing patient competence (30%). Requesters found the consultation "very helpful" or "helpful" in one or more aspects of patient care in 86% of cases, or in one or more aspects of physician education in 86% of cases. These data are similar to university hospital data.

Adolescent↗
PubMed2001

The comparative impact of video-consultation on neurosurgical health services.

This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations.

Emergencies↗
PubMed2004

[Internet physician's offices: main reasons for consultation and differences with Primary Care offices].

INTRODUCTION: Direct communication between patients and physicians through internet can represent an opportunity for medical consultation because of higher access that provides this medium. METHODS: A retrospective observational study was conducted in order to know the content and the characteristics of the consultations of a free medical physician's office by internet and its differences with the consultations in Primary Care. RESULTS: During a period of 45 days 221 consultations of which 188 corresponded to health problems were received. The average age of the consultants was very young (21.5 15.7 years; average SD), with predominance of men over women (1,4:1). In the consultations by internet, and in comparison with those of Primary Care, dermatological (relative risk: 6.1; CI 95%: 5.2-10.8), nervous system and sense organs (RR: 1.9; CI 95%: 1.3-2.8), genitourinary (RR: 2.0; CI 95%: 1.3-3.2), and digestive system (RR: 1.7; CI 95%: 1.1-2.6) consultations were carried out more frequently; less frequent consultations were those of respiratory tract (RR: 0.30; CI 95%: 0.16-0.56) and circulatory system (RR: 0.11; CI 95%: 0.03-0.33). CONCLUSIONS: The characteristics of this type of consultations and of the population group that ask for them are the reasons that their content and the grade of resolution of problems are very far from those of Primary Care.

Adolescent↗
PubMed1984

Strangers bearing gifts: a retrospective look at the early years of community mental health center consultation.

Many early community mental health center (CMHC) consultations floundered when consultants attempted to apply Gerald Caplan 's community consultation theory, which the author describes as based on a private consultation paradigm, to the very different realities of government-mandated public paradigm consultation by CMHCs to public agencies. CMHC consultants were often perceived by consultees as "strangers bearing gifts" due to the lack of clarity concerning the rationale, contracts, roles, responsibilities, evaluation, and consultant- consultee exchanges of their public paradigm consultations. The otherwise disastrous recent losses of financial support for CMHCs are beneficially forcing them to shift their community consultation practices toward the private paradigm.

Catchment Area, Health↗
PubMed2001

Consultations for holistic pediatric services for inpatients and outpatient oncology patients at a children's hospital.

BACKGROUND: As demand increases for complementary and alternative medical care, pediatric institutions face the need to answer patients' and clinicians' questions about integrating these therapies in hospital settings. OBJECTIVE: To describe the first year of experience in providing holistic medicine consultations in an urban tertiary care teaching hospital. DESIGN: Prospective cohort. SUBJECTS: Patients seeking consultation from the Center for Holistic Pediatric Education and Research, Boston, Mass, from July 16, 1999, to July 15, 2000. METHODS: Review of consultation notes and medical records. RESULTS: Of the 70 physician consultations, most (n = 43) were for oncology patients. Most consultations (n = 44) were accomplished with a single visit. The most common goal for consultation was to obtain help in managing symptoms such as nausea, pain, insomnia, or agitation (n = 50). The most common questions about specific therapies had to do with herbs (n = 41) or dietary supplements (n = 42), but there were also frequent questions about diet and nutrition (n = 33) and mind-body therapies such as guided imagery and biofeedback (n = 28) and massage (n = 25). Approximately 0.3 full-time equivalents of physician time was required to provide clinical consultations, and $7315 was collected of the $26 638 billed for these services. CONCLUSIONS: The complementary medicine consultation service was primarily consulted by oncology patients requesting assistance with pain and symptom management. Patients had questions about various therapies, particularly herbs and dietary supplements. Additional research is necessary to determine the cost-effectiveness of an integrated approach to care, particularly for institutions without access to reliable community resources for complementary and alternative medical therapies.

Adolescent↗
PubMed2004

Shared decision-making--results from an interdisciplinary consulting service for prostate cancer.

Locally confined prostate cancer (PCa) can be treated by various treatment options (e.g. radical prostatectomy or radiation therapy) with comparable results but different possible side effects. Therefore, treatment recommendations can vary between urologists and radiation oncologists. In 2001 the Charite-Campus Benjamin Franklin (CBF, Berlin), established the first interdisciplinary consulting service for prostate cancer patients in Germany. The aim was to offer a comprehensive and neutral consultation on all treatment options and to make treatment recommendations. The study examines what benefits may be derived from this type of consultation. A total of 362 patients presented to the consulting service between May 2001 and April 2003. Two questionnaires were used. The first one contained epidemiological questions as well as questions covering information already available on PCa. It also examined feelings and fears about the disease and possible treatment options. The second questionnaire was completed 2 weeks after the consultation to evaluate the treatment decision, determine the patient's satisfaction with the consultation and trace the development of feelings and fears. Of the patients, 334 (92.2%) were completely assessable. All patients had already obtained information about the disease and possible treatment options and wished to be involved in the decision-making process through objective and neutral consultation. Nearly all of them had a great fear of the possible side effects of therapy. Such a comprehensive consultation is time-consuming (average of 35 min) but largely received a very positive assessment in that a total of 66% found it either helpful (n=74, 22%) or very helpful (n=147, 44%). Patients felt they had been completely informed in 92% of the cases. Only 22 (9.7%) had still failed to make a decision after 2 weeks, 115 patients had stage T1c, PSA <10 ng/ml and a Gleason score < or =7. In these cases an equivalent recommendation for radical prostatectomy, percutaneous radiotherapy or permanent seed implantation was given. Of these, 49 (43.4%) decided on the surgical intervention, 48 (42.5%) on a type of radiotherapy and only 18 (15.6%) remained undecided. The histological examination of prostatectomy specimens from patients who had decided to undergo radical surgery at CBF showed a significant decrease in the rate of extracapsular disease extension (> or =T3) from 38% to 20% during the observation period. The interdisciplinary approach has made the process of deciding on an appropriate treatment much easier for the patient. The time-consuming consultation enables better selection of individual treatment modalities and their possible side effects from the point of view of both the patients and the attending physicians. In this study, patients chose either radical surgery or radiotherapy with equal frequency.

Humans↗
PubMed1983

General medicine consultation. Lessons from a clinical service.

The 564 consultations performed by a general medicine consultation service during its first year were analyzed in order to provide a concrete definition of this new academic domain. Of the consultations, 52 percent were for patients on the surgical service. Among these patients, the most common reason for consultation was the preoperative management of chronic illness, specifically, hypertension, diabetes, and angina; 47 percent of such patients had two or more chronic illnesses. The service recommended cancellation of planned surgery in 2 percent and postponement in 9 percent of the 210 patients seen preoperatively. Patients on the psychiatric service accounted for 47 percent of the consultations. In this group, diagnostic issues were the most common reasons for consultation, that is, abdominal pain, dementia, and the suspicion of thyroid disease. Only 12 percent of the patients were seen for prognostic reasons, usually related to the planned use of electroconvulsive therapy or tricyclic antidepressants. The service was evaluated by the referring physicians who rated the service favorably on its "mechanics," as well as on its qualitative performance. However, complaints of triviality were voiced when the average length of the list of recommendations seemed disproportionate to the complexity of the problems. The service was also evaluated by the residents who had provided consultations. From their perspective, the service was more successful in teaching the "art" of consultation than the "science." This experience provides an operational definition of the work facing a general medicine consultation service as well as data useful in focusing future educational programs and research efforts.

Family Practice↗
PubMed1982

Consultation and supervision in cases of non-accidental injury to children.

Consultation and supervision play an essential role in the management of the anxieties, conflicts and demands experienced by those working long-term with cases of non-accidental injury. In our setting we employ our own external staff consultant and in turn our workers offer a consultative service to workers from other agencies. It seems to us that consultation and supervision are inter-related but distinct processes: consultation is essentially experiential and non-directive; supervision is didactic and directive. A consultant may give advice from his own area of expertise (which may be different from that of the consultor), but he may also be called upon to interpret or comment on other areas, such as the conflicts between workers and their clients or workers and their organizations. A consultant may also be called on to offer a model of supervision to supervisor and worker. A supervisor, by definition, is expert in the area of work of the worker and in a position within the organization to give direction. He at times, however, will be called upon for non-directive discussion and comment--in effect consultation. He may also have to fill the role of manager and resource provider. Our experience shows it is essential to clarify this inter-relationship as a first step to exploring the skills necessary for supervisor and consultant to help workers fulfil their task.

Adult↗
PubMed2005

Critical care without walls: The role of the nurse consultant in critical care.

BACKGROUND: The nurse consultant role was first described in 1999 and has undergone little evaluation since. Critical care nurse consultant roles have developed against a background of service innovation following a review of adult critical care and have resulted in a variety of job roles and titles. There is some evidence to suggest that these posts are developing differentially and with varied role content. AIMS: To provide a profile of the nurse consultant in critical care. To identify critical care roles in practice. METHOD: A national postal survey of all 72 critical care nurse consultants in post in England by August 2003; response rate 72% (n = 52). RESULTS: The majority (54%) of critical care nurse consultants were aged between 40 and 50 years with a mean of 18.4 years post registration experience. The majority held a higher degree (71%) and at least one additional professional qualification (96%); many (44%) continue to study. Most critical care nurse consultants (69%) reported that a nurse does not manage them operationally. Nurse consultants were taking the lead in developing care outside the traditional boundaries of the Intensive Care Unit (ICU) (mean involvement score, M = 4.25) and with outreach rounds on the wards (M = 3.78). Despite having an overall high involvement (M = 3.37) with the practice and service development function, they had a lower involvement with research activities (M = 2.87). They also had a low involvement with strategic organisations such as the Department of Health (M = 1.63), Strategic Health Authorities (M = 1.54) and Primary Care Trust's (M = 1.49). CONCLUSIONS: The critical care nurse consultants who responded to this survey were clinically experienced and educated to an advanced level. They were leading the care of critically ill patients outside the traditional boundaries of the ICU, but have significantly less involvement within the ICU. Nurse consultants' restricted involvement with strategic organisations may limit the development of the role.

Adult↗
PubMed2004

Devising and establishing the face and content validity of explicit criteria of consultation competence for UK secondary care nurses.

AIM: The aims of this study were (a) to devise a set of prioritised criteria of consultation competence for UK secondary care nurses, and (b) to determine their face and content validity. METHOD: The criteria of consultation competence as contained in the Consultation Assessment and Improvement Instrument (CAIIN) for primary care nurses were adapted as a result of focus group discussions and observation of videotaped consultations with nurses working in secondary care. The amended criteria were sent to a sample of nurse consultants, specialist nurses and nurse practitioners (n = 394) to determine their face and content validity. RESULTS: Support for the seven categories of consultation competence varied from 96% to 99% and for the 37 component competences from 94% to 99%. There was no consensus for alternative or additional categories or components. 87% of respondents strongly agreed or agreed that the categories of consultation competence should be prioritised and 63% strongly agreed or agreed with the suggested weightings. CONCLUSION: We have devised prioritised criteria of consultation competence of UK secondary care nurses and established their face and content validity. This can now facilitate the assessment and improvement of the consultation competence of secondary care nurses for both formative and regulatory purposes.

Clinical Competence↗
PubMed2006

Patients evaluate accessibility and nurse telephone consultations in out-of-hours GP care: determinants of a negative evaluation.

OBJECTIVE: The shift towards large-scale organization of out-of-hours primary healthcare in different western countries has created an important role for the nurse telephone consultation. We explored the association between negative patient evaluation of nurse telephone consultations and characteristics of patients and GP cooperatives. METHODS: A cross-sectional study using postal patient questionnaires sent to patients receiving a nurse telephone consultation from one of 26 GP cooperatives in the Netherlands. RESULTS: The total response was 49.3% (2583/5239). Negative evaluations were most frequently encountered for the general information received on the GP cooperative (35%). When patients expected a centre consultation or home visit, but only received a nurse telephone consultation, they were more negative about the accessibility (OR 1.7, CI 1.4-2.1) and nurse telephone consultation (OR 4.2, CI 3.2-5.6). In the presence of a special supervising telephone doctor at the cooperative's call centre, nurse telephone consultation was evaluated significantly less negative (OR 0.4, CI 0.2-0.8). CONCLUSION: Expectation of care mode was most strongly associated with a negative evaluation of nurse telephone consultation. The presence of a supervising telephone doctor may lead to a better evaluation of nurse telephone consultations. PRACTICE IMPLICATIONS: More attention should be paid to the provision of patient information on the GP cooperative and discrepancies between the care expected and the care offered.

After-Hours Care↗
PubMed2003

The role of the medical consultant.

The basic concepts of medical consultation have been reviewed. The referring physician and the consultant both have responsibilities to fulfill in order to maximize the effectiveness of the consultation in improving patient care. The reasons for and urgency of the consultation need to be communicated to and understood by the consultant. The consultant needs to respond by promptly evaluating the patient, concisely documenting his findings, and communicating his recommendations to the referring physician. As described by Bates, the ideal medical consultant will "render a report that informs without patronizing, educates without lecturing, directs without ordering, and solves the problem without making the referring physician appear to be stupid". The consultant should try to support the referring physician and comfort the patient. By following these guidelines, the consultant will be more effective in providing useful, informative advice likely to result in enhanced compliance with the recommendations and improved patient outcome.

Communication↗
PubMed2001

Ophthalmology inpatient consultation.

OBJECTIVE: To profile inpatients and eye problems evaluated and managed by the Ophthalmology Consultation Service of a large university teaching hospital. DESIGN: A hospital-based retrospective, cross-sectional study. PARTICIPANTS: One thousand four hundred seventy-two patients admitted to the University of California Los Angeles Medical Center. METHODS: We reviewed the inpatient medical records, discharge summaries, and Ophthalmology Consultation Service notes of every patient evaluated by the Service from July 1990 through January 1997. MAIN OUTCOME MEASURES: We recorded demographic information, hospitalization information, and eye examination information, including reason for consultation, type of consultation (screening examination, new eye problem, or preexisting eye problem), as well as primary and secondary ophthalmologic diagnoses. RESULTS: Internal medicine services requested 39.7% of consultations, surgery services 20.9%, and trauma services 13.5%. There were 92 different reasons why consultations were requested. The most common reason was decreased vision. Eye problems that developed either on the day of admission or some time during hospitalization accounted for 39.6% of consultations, preexisting eye problems accounted for 31.6%, and screening examinations for the remaining 28.7%. We recorded 166 unique primary ophthalmologic diagnoses and 130 unique secondary ophthalmologic diagnoses. The top five common primary ophthalmologic diagnoses were refractive error (88 patients), fungal endophthalmitis ruled out (80 patients), conjunctivitis (56 patients), diabetic retinopathy (52 patients), and corneal abrasion (52 patients). Refractive error was the most common secondary ophthalmologic diagnosis (201 patients). Inpatient diagnostic or surgical procedures were performed 7911 times. There were 947 unique primary and 1391 unique secondary hospital discharge diagnoses. The most common primary discharge diagnosis, human immunodeficiency virus infection, accounted for only 1.6% of all hospitalizations, indicating a considerable diversity of systemic disease in the study population. CONCLUSIONS: This study profiled the typical patients and eye problems an ophthalmologist may expect to encounter when inpatient consultation is requested. The information may be useful for the planning and management of consultation services in residency training programs.

Adolescent↗
PubMedDate not supplied

Six-month outcomes of hospital-based psychiatric substance use consultations.

Substance use disorders and their health complications are prevalent in general hospitals. Among intervention measures, specialized substance use consultations by a general hospital psychiatric consultation team have been described. Because outcome data are scanty, effectiveness of specialist consultations is not known. To analyze effectiveness of focused, semistructured consultations by clinically competent consultants, we conducted a prospective 6-month follow-up in a hospital-based psychiatric substance use consultation service. We aimed to measure severity of dependence and changes in substance use and to find out which variables at the consultation anticipated abstinence or reduction in substance use. Among general hospital patients referred for substance use consultation, 30% (46/155) of the male patients and 56% (35/63) of the female patients reported either abstinence or reduction in substance use at the 6-month follow-up. Changes in weekly alcohol consumption and SADD (Short Alcohol Dependence Data) scores were statistically significant (P<0.001) and clinically highly meaningful. Absence of earlier psychiatric or substance use treatment and fewer adverse substance use consequences predicted reduction in substance use. Compliance and outcomes were remarkable among female patients, and improvement was promoted by unbroken family relations. In all, hospital-based psychiatric substance use consultations seemed to be effective as the only treatment among socially adjusted substance use patients, whereas patients with psychiatric comorbidity and/or chronic substance use problems needed more vigorous help.

Adolescent↗
PubMed2003

Outcome in patients with lung cancer found on lung cancer mass screening roentgenograms, but who did not subsequently consult a doctor.

GOALS OF THE STUDY: To evaluate the outcome in patients with lung cancer found on lung cancer mass screening roentgenograms, but who did not subsequently consult a doctor. PATIENTS AND METHODS: This study enrolled 198 asymptomatic patients with lung cancer found by lung cancer mass screening during the 9-year period. Five-year survival rates in patients who did not consult a doctor or who stopped consulting a doctor in spite of abnormal shadows detected on last mass screening chest roentgenograms (n=45, delayed consultation group) and in patients who subsequently consulted a doctor when abnormal shadows were detected (n=153, control group) were evaluated by the method of Kaplan and Meier and clinical variables were examined as possible predictors of survival time by the Cox proportional-hazards model. RESULTS: There was a significant difference between the 5-year survival rates in the delayed consultation group and in the control group (21 vs. 51%, log rank: P=0.0003, Wilcoxon: P=0.0009). The risk of death increased 115.0% for the 1-year delay in consultation (hazard ratio: 2.150, 95% CI: 1.203-3.842, P=0.0097). With regard to the reason why they did not consult a doctor, many of them answered that they did not have any respiratory symptoms. CONCLUSION: The 1-year delay in consultation had a great significance in that these patients did not receive any treatment for lung cancer for 1 year, and the 1-year delay in treatment itself affected the outcome.

Adult↗
PubMed1998

Analysis and impact of infectious disease consultations in a general hospital.

During an 18-month period, data from all patients in whose care our infectious diseases (ID) service was involved, were recorded in a computerized database. A total of 4184 new consultations was recorded. The consultations were solicited by the patients' physicians in 3326 cases (80%) and initiated by the ID service in the remainder. The purpose of the consultations was diagnosis (14%), therapy (39%), both diagnosis and therapy (40%), and prophylaxis (6%). Two thousand and ninety-four consultations (50%) were performed at the bedside, and the others by personal or telephone discussion. ID consultation was given in more than 10% of admitted patients in six departments, 46% of the admissions in the ICU, and 6.9/100 hospitalized patients. Recommendations included: antibiotic manipulation (i.e., initiation, change or discontinuation of antibiotic treatment) (51%); performance of tests (13%); performance of diagnostic or therapeutic procedures (5%); prophylaxis (4%) or no change in management (26%). Analysis of the solicited vs unsolicited consultations and of the bedside vs telephone consultations revealed that sub-groups of consultations differ significantly from each other in many aspects. Recording of consultations enables the ID service to evaluate its activity and to direct efforts to departments with high rates of infectious diseases and/or antimicrobial usage.

Communicable Diseases↗
PubMed2000

Consultation with another physician on euthanasia and assisted suicide in the Netherlands.

Consultation with another physician is considered to be an important safeguard of the practice of euthanasia and physician-assisted suicide. The objective is to describe the frequency and characteristics of consultation in cases of euthanasia or physician-assisted suicide (EAS) in the Netherlands. Data from two cross-sectional descriptive nationwide surveys, carried out in 1995, were used. Questionnaires were mailed to physicians attending 6060 deaths, identified from death certificates, and a stratified sample of 405 physicians were interviewed. In 1990, a cross-sectional descriptive postal survey of a random sample of 1042 general practitioners took place. Consultation took place in 63% of cases of EAS in the Netherlands, in 99% of the cases reported to the public prosecutor and in approximately 37% of unreported cases. In almost half of the unreported cases the decision had been discussed less formally with at least one colleague. In 1990, 7% of general practitioners met all 8 criteria for good consultation; this increased to 64% in 1995. Of the respondents, 26% had at some time advised against performing euthanasia or assisted suicide when acting as a consultant. This study shows that approximately two thirds of all cases of EAS are safeguarded by consultation. Although in the majority of these cases the consultation is of good quality, there is certainly still room for improvement. The quality of consultation could be improved, for instance, by appointing independent and specifically trained consultants.

Euthanasia↗
PubMed2004

An assessment of the feasibility of telephone and email consultation in a chest clinic.

One hundred and sixty-four consecutive patients attending a busy respiratory outpatient service were asked how acceptable was the concept of alternating face to face consultation with consultation by either telephone or email. The patients were then assessed as to their suitability for such non-traditional methods of consultation. Thirty patients (18.3%) were not agreeable to other forms of consultation and five could not speak English. One hundred and thirty-three (84%) had a suitable daytime telephone number for consultation purposes, but only 34 (21%) had email access, with this being commoner in the younger ages. One hundred and five patients were not thought to be suitable for alternative methods of consultation because of: the severity of their condition, the difficulty of assessing it over the telephone, or because they needed to attend the hospital for investigations. However, even in a clinic where the policy was already to return as many patients as possible to the care of their primary care physicians, and in a clinic where much work was already shared with respiratory nurse specialists, over one-third of patients were thought to be suitable for alternating face to face with telephone consultation. The diagnoses in those cases included asthma, suspected obstructive sleep apnoea, chronic obstructive pulmonary disease (COPD), unexplained cough, and some patients with respiratory malignancy being visited at home by the palliative medicine services. However, for those with asthma and for those awaiting results of investigations especially, use of telephone consultation appears to be an acceptable and convenient way of reducing the pressure upon time available for face to face consultations.

Computer Literacy↗