Pulmonary Physician Consultancy in Emergency Services in Turkiye (PuPCEST) – a cross-sectional multicenter study

Abstract

Pulmonology is one of the branches that frequently receive consultation requests from the emergency department. Pulmonology consultation (PC) is requested from almost all clinical branches due to the diagnosis and treatment of any respiratory condition, preoperative evaluation, or postoperative pulmonary problems. The aim of our study was to describe the profile of the pulmonology consultations received from emergency departments in Turkiye. A total of 32 centers from Turkiye (the PuPCEST Study Group) were included to the study. The demographic, clinical, laboratory and radiological data of the consulted cases were examined. The final result of the consultation and the justification of the consultation by the consulting pulmonologist were recorded. We identified 1712 patients, 64% of which applied to the emergency department by themselves and 41.4% were women. Eighty-five percent of the patients had a previously diagnosed disease. Dyspnea was the reason for consultation in 34.7% of the cases. The leading radiological finding was consolidation (13%). Exacerbation of preexisting lung disease was present in 39% of patients. The most commonly established diagnoses by pulmonologists were chronic obstructive pulmonary disease (19%) and pneumonia (12%). While 35% of the patients were discharged, 35% were interned into the chest diseases ward. The majority of patients were hospitalized and treated conservatively. It may be suggested that most of the applications would be evaluated in the pulmonology outpatient clinic which may result in a decrease in emergency department visits/consultations. Thus, improvements in the reorganization of the pulmonology outpatient clinics and follow-up visits may positively contribute emergency admission rates.

1. Introduction

Emergency departments receive more visits than any other clinical branches do in our country (Turkiye).^[1] The leading causes may include expectation for faster health service access, immediate treatment in emergency room, faster access to laboratory and radiological examinations, and access to a variety of specialists other than those of emergency medicine.^[2,3] However, this may also bring excessive burden for diagnostic and therapeutic workforce. Pulmonology consultation (PC) is frequently requested by the emergency department for their admitted cases, including those with underlying lung diseases or newly-emerged respiratory condition.^[4,5] Although most consultations are medically necessary consultations, a large number of PCs requested from the emergency department constitute a high burden of work for both the emergency and the pulmonology departments.

Emergency departments, operating as the critical lifeblood of health institutions, provide uninterrupted services 24/7 to a diverse array of emergency patients and injuries. The dynamic nature of these departments necessitates an interdisciplinary approach for the swift diagnosis and treatment of patients.^[6] Our study illuminates that a substantial portion of pulmonology consultations initiated from emergency departments is deemed necessary, with patients referred based on respiratory findings. Notably, the preeminence of consultations initiated by emergency medicine residents suggests that the emergency room serves as a triage point for patients with underlying diseases, rather than merely functioning as an emergency treatment unit.

However, the admission of inappropriate patients to emergency departments poses significant challenges. The resultant excessive patient volume leads to prolonged wait times, delays in providing services to genuinely emergent cases, heightened patient dissatisfaction, increased health expenditures, compromised service quality, safety concerns, and diminished efficiency among emergency staff.^[2,3,7–9] Several factors contribute to this influx, such as the rapid access to health care services, the expectation of injectable or immediate treatment, swift laboratory and imaging examination opportunities, the absence of patient-paid contribution fees for emergency visits, and access to other clinical specialists.^[2,3,7,9] Unintentionally, patients may overutilize diagnostic and therapeutic facilities through inappropriate emergency applications.^[4]

The aim of this study was to describe the profile and characteristics of consultation service by pulmonologists for emergency departments in Turkiye. This would also help to identify the extent of optimal use of PCs in emergency rooms. In addition, study findings would help to address potential problems during health care provision for patients with respiratory conditions in emergency rooms to build a base for development of further restorative or improving interventions. Furthermore, the findings from this study will serve as a foundational knowledge base for the development of restorative or improvement interventions in emergency care for respiratory issues.

2. Methods

This study included voluntary pulmonologists working in health institutions in different geographical regions of our country. The eligibility criteria for the physicians was to provide consultancy service to emergency rooms and to work in a health institution with a center evaluation form that was deemed to be appropriate. The responses obtained from the initial distribution of the form were meticulously reviewed to identify participating centers in the first stage. Specifically, emphasis was placed on selecting centers that not only accurately reflected the patient density in their respective regions but also held the status of a reference center. This criterion aimed to ensure a representative and comprehensive sampling of healthcare facilities. The chosen centers predominantly included training and research hospitals, as well as university hospitals situated in larger provinces. Nevertheless, to account for regional diversity, private hospitals in smaller provinces were also considered, given their significant role as reference centers in those areas. This inclusive approach aimed to capture a holistic representation of healthcare institutions, acknowledging the varied healthcare landscapes across both large and small provinces. At most one other physician (pulmonology specialist or resident) was able to participate in the study as a co-investigator. The study was approved by the ethics committee (Approval number: KTU 2017/161) and conducted in accordance with the principles of the Declaration of Helsinki.

2.1. Data collection

Data from our investigators in different centers that agreed to participate in the project were collected, synthesized, and analyzed by coordinators. All data were analyzed after the project was completed. The data from all 57 participants and 32 centers from Turkiye (the PuPCEST Study Group) were collected in the 3-month period from December 2017 to February 2018 and analyzed by the study coordinators.

The study included all patients for whom PC service was provided in emergency rooms in study centers during the defined study period. Each patient was included in the study once. The data of patient who was previously included to the study was not evaluated in the study when consulted again. This was a clinical observation study, where no physical or laboratory examination, intervention, or procedure was performed with the patients. In addition, no costs were incurred for the patient or the patient’s reimbursement institution.

The demographic, clinical, laboratory, and radiological data of the consulted cases were examined with special emphasis on presence of acute or chronic pathological finding, history of chronic disease. The final result of the consultation, the justification of the PC by the consulting pulmonologist, and the need for emergency intervention or hospitalization was also recorded.

2.2. Statistical analysis

The study data were analyzed through Statistical Package for the Social Sciences (SPSS) version 22 software (IBM Corp., Armonk, NY). The variables were expressed as number and percentages.

3. Results

We identified 1712 patients who were consulted to the pulmonologists during the study period. Among them, 58.8% (n = 1007) of which applied to the emergency department by themselves and 41.4% (n = 707) were women. A total of 1052 patients (61.4%) were consulted to pulmonologists by the emergency physician and the remaining patients were consulted by the emergency service residents. There were 1445 patients (84.4%) with a previously diagnosed disease. Dyspnea was the reason for consultation in 1010 cases (59%). Pathological sounds such as rales and rhonchus were the reason for consultation in 263 patients (15.4%). The most common reason of laboratory abnormality was decreased saturation (17.8%, n = 306), followed by elevated acute phase reactants like leukocytes, C-reactive protein, and pro-calcitonin (12.5%, n = 214). The leading radiological finding was consolidation (33.2%, n = 569). A total of 475 patients (27.8%) underwent thorax computed tomography (CT), whose report was consulted to pulmonology. In total, 65.1% of patients (n = 1114) were requested to be hospitalized during consultancy.

Exacerbation of preexisting lung disease was present in 39.2% of patients (n = 671). The most commonly established diagnoses by pulmonologists were chronic obstructive pulmonary disease (COPD) (n = 455, 26.6%) and pneumonia (n = 340, 19.9%). No treatment was recommended by the pulmonologist in 284 cases (16.6%), while 128 (7.5%) patients received outpatient treatment. No invasive procedure was performed in 1569 (91.7%) patients in the emergency room. The most commonly prescribed therapies were antibiotics (n = 580, 33.9%), oxygen (n = 507, 29.6%), and bronchodilators (n = 462, 26.9%). While 27.3% of the patients (n = 467) were discharged, 27.9% (n = 478) were interned into the chest diseases ward. A total of 237 patients (13.8%) was recommended to be referred to the intensive care unit. Another 228 patients (13.3%) were hospitalized by another clinical discipline.

Three patients (0.2%) had died in the emergency room. A total of 112 patients (6.5%) was referred to another center due to lack of bed or for further investigation and management. In 1968 patients, the reason for emergency admission was primarily a respiratory disease. The pulmonologists declaring that the consultation was necessary and on-time constituted 49.8% (n = 852) of the population.

The findings of the patients consulted to pulmonologists are shown in Tables 1–3.

Table 1.

Reasons for pulmonary physician consultation in the study population.

Reasons for consultation	n	% (n/1712)
Pathological clinical findings
Cough	683	39.9
Sputum	395	23.1
Hemoptysis	87	5.1
Dyspnea	1010	59.0
Wheezing	72	4.2
Chest pain	138	8.1
Fever	257	15.0
Cyanosis	59	3.5
Laboratory abnormalities
D-dimer elevation	111	6.5
Hypoxemia	306	17.9
Hypercapnia or respiratory acidosis	149	8.7
Increased acute phase reactants, e.g. leukocytosis, CRP, procalcitonin etc.	214	12.5
Abnormal findings in thoracic imaging modality
Finding in plain chest X-ray	1028	60.1
Finding in thorax computed tomography	384	22.4

CRP = C-reactive protein.

Table 3.

The final results of consultation by pulmonary physician.

	n	% (n/1712)
Acute or progressive pleuro-pulmonary pathological finding
Newly emerged pleuro-pulmonary condition	575	33.6
Exacerbation of preexisting pleuro-pulmonary pathological condition	671	39.2
Stable pleuro-pulmonary pathological condition	178	10.4
No pleuro-pulmonary pathological condition	140	8.2
Diagnosis of the respiratory condition
Upper respiratory tract infection	60	3.5
Chronic obstructive pulmonary disease	455	26.6
Asthma	107	6.3
Acute respiratory failure	83	4.9
Chronic respiratory failure	111	6.5
Acute respiratory distress syndrome	4	0.2
Pneumonia	340	19.9
Hypoxemic respiratory failure	121	7.1
Hypercapnic respiratory failure	126	7.4
Lung cancer	66	3.9
Lung metastasis	18	1.1
Pulmonary nodule	13	0.8
Pulmonary thromboembolism	83	4.9
Pulmonary hypertension	15	0.9
Infiltrative lung disease	34	2.0
Pleural effusion	120	7.0
Respiratory disease of cardiac origin	147	8.5
Suggested treatment for the respiratory disease
None	284	16.6
Continuance of current treatment	204	11.9
Bronchodilator treatment by nebulization (anticholinergic/ beta-agonist/ corticosteroid)	462	27.0
Nasal oxygen therapy	507	29.6
Noninvasive mechanical ventilation	141	8.2
Low molecular weight heparin	179	10.5
Tissue plasminogen activator (for pulmonary thromboembolism)	1	0.1
Corticosteroid	532	31.1
Magnesium (for acute exacerbation of asthma)	6	0.4
Invasive mechanical ventilation	152	8.9
Antibiotherapy	580	33.9

4. Discussion

This descriptive study reveals a detailed cross-sectional view of the pulmonology consultations requested from emergency departments in Turkiye. It was observed that most of the patients who were consulted to pulmonologists applied to the emergency room in the outpatient setting. Most of these patients were asked to be hospitalized by the emergency department, implying these cases to have stable conditions. The number of patients with underlying and exacerbated COPD was also considerably high. More frequent follow-up of these patients in COPD outpatient clinics may provide more adequate control of the underlying lung disease. We observed that a substantially high number of thorax CT order was made without consultation to the pulmonology department.

Emergency departments, vital units within healthcare institutions catering to a diverse range of emergency patients and injured individuals, operate seamlessly around the clock, 24/7. These departments attend to a broad spectrum of cases, often necessitating immediate intervention. Given the varied nature of cases, an interdisciplinary approach is frequently imperative for accurate diagnosis and prompt treatment, making consultation a pivotal aspect of the emergency department.^[6] In our study, a majority of the emergency consultations requested from the pulmonology department were deemed necessary, with patients primarily seeking consultation for respiratory concerns. Notably, a substantial portion of patients was attended to by emergency medicine residents, underscoring the emergency room’s role as a triage point for admitted patients with underlying diseases, directing them to the appropriate specialized branch rather than functioning solely as an emergency treatment unit. This observation highlights the nuanced and multifaceted role that emergency departments play in facilitating the efficient and targeted delivery of healthcare services to individuals with diverse medical needs.

Admission of inappropriate patients to the emergency departments causes excessive patient volume in hospitals and therefore lead to serious problems in the implementation of health services. This excessive volume causes patients to wait for a long time, delay in providing services to those with actually emergent and serious illnesses, increased patient dissatisfaction in the emergency room, increased health expenditures, low service quality, serious problems in safety, and diminished efficiency in emergency staff.^[2,3,7–9] The number of consultations found necessary by the pulmonologists were 49.8% (n = 852) of the population. This means that half of the consultations were unnecessary.

There can be many reasons for excessive patient volume and applications in emergency departments, including rapid access to health care services,^[2,3] receiving injectable or immediate treatment in emergency departments, benefiting from rapid laboratory and imaging examination opportunities,^[7,9] lack of patient-paid contribution fee for emergency visits and prescriptions, and access to other clinical specialists. Thus, it has been shown that patients lead to overutilization of diagnostic and therapeutic facilities through their inappropriate emergency applications.^[4,10]

In our study, it was seen that those with underlying lung disease frequently applied to the emergency department with the progression of the disease, and it was shown that the ordered tests in the evaluation of these patients detected the progression of the disease. In addition, it was also observed that half of the consultations requested by emergency department was not deemed unnecessary by pulmonologists.

Pulmonology is one of the branches that receives the highest number of consultation requests from both the emergency department and other departments. PC is requested from almost all clinical branches due to the diagnosis and treatment of any respiratory condition, preoperative evaluation, or postoperative pulmonary problems.^[4,5] In our study, it can be concluded that the emergency room burden of pulmonologists is also very high.

Atamna et al reported that in 29% of the cases, the emergency department diagnosis of pneumonia was not consistent with the internal medicine ward’s diagnosis.^[11] While pneumonia constituted 33% of patients with a consolidation as a radiological finding consulted by the emergency department, only 19% of patients were decided to have pneumonia by pulmonologists.

The increasing use of imaging in the emergency department services has become a crucial problem in terms of cost and unnecessary exposure to radiation.^[12] Unnecessary utilization of chest imaging may expose patients to ionizing radiation and raise potential cancer risk especially in young adults and children, increase expenditures, and extend the time of stay in emergency department.^[13–15] In our study, thorax CT was ordered in approximately one fourth of patients consulted for chest diseases. Such unnecessarily requested examinations can be an important result of unnecessary applications to the emergency department.

A major limitation of our study was the inability to calculate the percentage of all PCs for all patients applied to the emergency department. The fact that the number of applications reached up to one thousand in some hospitals and some consultations were requested verbally or through calls compel the assessment and relative comparison of this consultation rate. In addition, as the data from different centers were not evaluated separately, we did not reveal and describe the differences between the centers, which may warrant designation of further research. Conducting a nationwide study posed challenges due to diverse provincial data, rendering comprehensive comparative analysis virtually impossible. Consequently, our study focused on fundamental descriptive analysis. Acknowledging this limitation, we recognize the need for future well-planned studies to address regional variations systematically, allowing for more nuanced and conclusive insights. Our current findings, while foundational, underscore the importance of targeted investigations for a more comprehensive understanding across provinces.

In conclusion, our study reveals that a majority of patients seeking palliative care (PC) in the emergency department were ultimately hospitalized. Notably, a significant portion of these patients either received no treatment or were managed in an outpatient setting. This implies a potential overutilization of the emergency room, leading to unnecessary laboratory and radiologic examinations, thereby contributing to the increased workload on the pulmonology department’s emergency consultations. A recommended strategy to alleviate this burden involves establishing dedicated outpatient clinics for individuals with preexisting lung conditions. Such clinics could effectively reduce the influx into the emergency room, alleviate the emergency consultation workload for pulmonologists, and mitigate the need for unnecessary investigations like tomography, especially in situations where resources permit.

Table 2.

Description of abnormal finding in thoracic imaging modality by consulting pulmonary physician.

Chest X-ray	n	% (n/1712)
Consolidation	569	33.2
Pleural effusion	174	10.2
Mass	38	2.2
Nodule	18	1.1
Reticular densities	241	14.1
Linear band	51	3.0
Blunted sinus	112	6.5
Increased cardiothoracic ratio	249	14.5
Pneumothorax	2	0.1
Hilarfullness	123	7.2
Thoraxcomputed tomography
Ground glass opacity	161	9.4
Fibrotic changes	84	4.9
Pulmonary nodules	61	3.6
Interseptal thickening	74	4.3
Mediastinal lymph node	37	2.2
Honeycomb appearance	9	0.5
Traction bronchiectasis	27	1.6
Hilar lymph node	15	0.9
Linear atelectasis	43	2.5
Peribronchial thickening	59	3.5
Bulla/cyst	16	0.9
Pleural effusion/thickening	145	8.5
Solitary pulmonary nodule/multiple nodules	22	1.3
Mass	37	2.2
Hyperinflation	29	1.7
Mosaic perfusion	27	1.6
Consolidation	569	33.2
Tree in bud	27	1.6

Author contributions

Conceptualization: Özlem Erçen Diken, Şerife Kaya, Hayriye Bektaş Aksoy, Aydanur Ekici, Aylin Çapraz, Talat Kiliç, Tarkan Özdemir, Pinar Yildiz Gülhan, Sulhattin Arslan, Nalan Ogan, Canan Doğan, Ümit Tutar, Şeyma Başlilar, Dorina Esendağli, Gamze Kirkil, Ömer Tamer Doğan, Ümran Toru Erbay, Aysun Ayvaci, Mustafa Tosun, Efsun Chousein, Elif Yelda Niksarlioğlu, Sabri Serhan Olcay, Tuncer Özkisa, İclal Hocanli, Mehmet Karadağ, Neslihan Özçelik, Nuray Oktay, Elvan Şentürk, Sertaç Arslan, Sibel Pekcan Özyurt, Ahu Cerit, Yasemin Nennicioğlu, Nurhan Atilla, İbrahim Halil Üney, Mehmet Fatih Elverişli, Serdar Berk, Ayşe Baha, Nur Erik, Hasan Ölmez, Berat Kaçmaz, Hüseyin Erzurumluoğlu, Ezgi Demirdöğen Çetinoğlu, Tevfik Özlü.

Data curation: Özlem Erçen Diken, Şerife Kaya, Aydanur Ekici, Aylin Çapraz, Ali Tabaru, Özlem Şengören Dikiş, Hüseyin Arpağ, Hanifi Yildiz, Talat Kiliç, Tarkan Özdemir, Pinar Yildiz Gülhan, Sulhattin Arslan, Nalan Ogan, Canan Doğan, Ümit Tutar, Şeyma Başlilar, Dorina Esendağli, Gamze Kirkil, Ömer Tamer Doğan, Ümran Toru Erbay, Aysun Ayvaci, Mustafa Tosun, Efsun Chousein, Elif Yelda Niksarlioğlu, Sabri Serhan Olcay, Tuncer Özkisa, İclal Hocanli, Mehmet Karadağ, Neslihan Özçelik, Nuray Oktay, Elvan Şentürk, Sertaç Arslan, Sibel Pekcan Özyurt, Ahu Cerit, Yasemin Nennicioğlu, Nurhan Atilla, İbrahim Halil Üney, Mehmet Fatih Elverişli, Serdar Berk, Ayşe Baha, Nur Erik, Hasan Ölmez, Berat Kaçmaz, Hüseyin Erzurumluoğlu, Ezgi Demirdöğen Çetinoğlu, Tevfik Özlü, Hayriye Bektaş Aksoy.

Formal analysis: Özlem Erçen Diken, Hayriye Bektaş Aksoy, Aydanur Ekici, Hüseyin Arpağ, Hanifi Yildiz, Talat Kiliç, Tarkan Özdemir, Pinar Yildiz Gülhan, Sulhattin Arslan, Nalan Ogan, Canan Doğan, Ümit Tutar, Şeyma Başlilar, Dorina Esendağli, Gamze Kirkil, Ömer Tamer Doğan, Ümran Toru Erbay, Aysun Ayvaci, Mustafa Tosun, Efsun Chousein, Elif Yelda Niksarlioğlu, Sabri Serhan Olcay, Tuncer Özkisa, İclal Hocanli, Mehmet Karadağ, Neslihan Özçelik, Nuray Oktay, Elvan Şentürk, Sertaç Arslan, Sibel Pekcan Özyurt, Ahu Cerit, Yasemin Nennicioğlu, Nurhan Atilla, İbrahim Halil Üney, Mehmet Fatih Elverişli, Serdar Berk, Ayşe Baha, Nur Erik, Hasan Ölmez, Berat Kaçmaz, Hüseyin Erzurumluoğlu, Ezgi Demirdöğen Çetinoğlu, Tevfik Özlü, Şerife Kaya.

Investigation: Özlem Erçen Diken, Ali Tabaru, Tevfik Özlü, Şerife Kaya, Hayriye Bektaş Aksoy.

Methodology: Özlem Erçen Diken, Aylin Çapraz, Ali Tabaru, Özlem Şengören Dikiş, Hanifi Yildiz, Nalan Ogan, Tevfik Özlü, Şerife Kaya, Hayriye Bektaş Aksoy.

Project administration: Özlem Erçen Diken, Tevfik Özlü, Şerife Kaya, Hayriye Bektaş Aksoy.

Resources: Özlem Erçen Diken, Hayriye Bektaş Aksoy, Özlem Şengören Dikiş, Tevfik Özlü, Şerife Kaya.

Software: Özlem Erçen Diken, Tevfik Özlü, Şerife Kaya, Hayriye Bektaş Aksoy.

Supervision: Özlem Erçen Diken, Hayriye Bektaş Aksoy, Aydanur Ekici, Aylin Çapraz, Ali Tabaru, Hüseyin Arpağ, Tevfik Özlü, Şerife Kaya.

Validation: Özlem Erçen Diken, Şerife Kaya, Aydanur Ekici, Özlem Şengören Dikiş, Tevfik Özlü, Hayriye Bektaş Aksoy.

Visualization: Özlem Erçen Diken, Tevfik Özlü, Şerife Kaya, Hayriye Bektaş Aksoy.

Writing – original draft: Özlem Erçen Diken, Ali Tabaru, Özlem Şengören Dikiş, Tevfik Özlü, Şerife Kaya, Hayriye Bektaş Aksoy.

Writing – review & editing: Özlem Erçen Diken, Tevfik Özlü, Şerife Kaya, Hayriye Bektaş Aksoy.