Regarding emergency department consultations with neurologists: Author's reply

Dear Editor:

We very much appreciate the comments made by Drs Busca and Miró about our study and agree with their conclusions.¹ Viewing such an important part of our workload from the perspective of an emergency department gives us the opportunity to comment on a few aspects that we did not examine in our study. Our purpose was to provide a descriptive and retrospective analysis of the in-hospital consultations (IHC) requested of our department during a 5-year period; we agree with Busca and Miró that this is an innovative approach since it shows trends in IHC use.² Consultations from emergency departments have not traditionally been considered IHCs, as we mentioned in our study. Nevertheless, we deemed it appropriate to include them in our analysis since the emergency department frequently requests formal ICHs, using the same procedure as other hospital departments, when staff have questions about how best to manage or diagnose neurological diseases. We should also point out that our hospital did not have an on-call neurology service and pagers were not used in the morning hours during this study period.

Several studies with different methodological approaches provide useful data on neurological care in emergency departments.^3–7 According to 2 different series, these emergencies account for 3% to 14% of all medical emergencies. An observational prospective study conducted several years ago in a general hospital found that 5% of all emergencies were neurological conditions, and that 90% required assessment by a neurologist. We should highlight that nearly 75% of neurological emergencies in tertiary hospitals can be considered life-threatening or potentially life-threatening, while this percentage would be 60% for all other medical specialties.⁶ Several studies have cited that these neurology-related consultations are more frequent between mid-afternoon and night-time,⁷ which points to a need for a 24-hour on-call neurology service. The overall increase in the demand for healthcare also affects emergency departments, and leads to an increased number of consultations related to neurological diseases. Studies conducted in Spain show a 2% to 4% annual increase in IHCs to the neurology department.^4,6 This marked increase in the number of IHCs, apparent in Busca and Miró’s letter to the editor¹ and in our article,² proves that consulting neurologists and/or on-call neurologists are needed in emergency departments. The explanation for such a pronounced increase lies in a number of factors, including a shift in social attitude towards diseases, increased prevalence of age-related diseases due to population ageing, easier access to hospital care, the possibility of rapid diagnosis and treatment, delays in scheduled medical appointments, and the availability of ‘free’ healthcare.⁸

Patients requiring an IHC from the emergency department have a mean age (SD) of 43 (1.6) years and are predominantly female (59%). The most common reasons for IHC are epileptic attacks, loss of consciousness, stroke, and headache. These data agree with findings from more in-depth studies of the neurological disorders most frequently managed in emergency departments.^3,7,9,10 Your results, in which cases are classified by symptoms, and not by diagnostic category, find focal neurological signs to be the most common neurological emergency. This tendency, which has also been noted in other studies,^6,11 underscores the importance of stroke care: approximately 1 out of every 3 patients receiving emergency neurological care has suffered a stroke.¹²

Several studies analysing the impact of including neurologists in emergency departments from different viewpoints have concluded that results are positive in terms of overall reduction of hospital admissions, reduction of unnecessary hospital admissions, correct diagnosis, safety, prognosis, quality of care, and coordination with other levels of care.^{3,6,7,10,12–14} In hospitals with on-call neurology services, that specialty has the second-highest number of IHCs from the emergency department,³ which highlights both the relevance of and satisfaction with emergency neurological care.

Neurology's rapid advances and increasing complexity, the increasing demand for neurological care, the rising number of neurologists, and the need for further advances and independent management of the modern specialty resulted in a paradigm shift. One of its results was the National Strategic Plan for the Integral Treatment of Neurological Diseases, which devoted a chapter to urgent care, a feature that previous neurology programmes lacked.¹⁵ The order approving the new residency training programme for the specialty of neurology was published on 20 February 2007 in Spain's official gazette (B.O.E.). We must highlight that the preamble to this ministerial order begins with a specific reference to actively involving neurologists in unconventional care areas, including non-hospital care, emergency care, and critical care. Several relevant strategies (code stroke, stroke units, reperfusion treatments) that have changed stroke management radically in the past few years have also transformed the relationship between emergency and neurology departments.¹²

According to scientific, educational, and care quality criteria, neurological emergencies should be managed by neurologists when necessary. A close, fluid, and trusting relationship between the departments involved is therefore essential. Nevertheless, although this solution may seem obvious, it does not constitute common practice in many hospitals in Spain. We are glad to learn that emergency departments are working to improve quality of care, with no influence by economic, organisational, or corporate interests.